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Background Asthma is the most common chronic respiratory disease among children and adolescents worldwide. However, the burden of severe asthma is highest in Sub-Saharan Africa. This study aimed to explore teachers' perceptions of asthma care across six African countries. Methods We conducted focus group discussions (FGDs) using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and analysed thematically. FGDs were conducted in Accra (Ghana), Blantyre (Malawi), Lagos (Nigeria), Durban (South Africa), Kampala (Uganda), and Harare (Zimbabwe) between 01 November 2020 and 30 June 2021. Results We identified two key themes related to asthma care: (1) barriers to asthma care and (2) suggestions to improve the care of asthma learners. Teachers reported a lack of knowledge and skills among themselves, learners, and caregivers. Some teachers believed that myths about asthma and restrictions on themselves administering care exacerbated challenges faced by learners with asthma. Most teachers identified a need for all-inclusive asthma training programmes for teachers, learners and caregivers, focusing on acute episodes and mitigating triggers. Utilising teachers with personal experiences with asthma to advocate and support these initiatives was suggested. Recommendations were made for annual screening to enable early identification of learners with asthma and clarity on restricting teachers administering asthma medications. Conclusions Teachers across African schools identify multiple barriers to asthma care. Structured school education programs and annual asthma screening are key to addressing some barriers to care.

Background Exclusive breastfeeding for 6 months and breastfeeding with complementary feeds until 12 months for HIV exposed and uninfected (HEU) infants or 24 months for HIV unexposed (HU) infants is the current World Health Organisation (WHO) recommendation for low and middle income countries (LMICs) to improve clinical outcomes and growth trajectories in infants. In a post-hoc evaluation of HEU and HU cohorts, we examine growth patterns and clinical outcomes in the first 9 months of infancy in association with breastfeeding duration. Methods Two cohorts of infants, HEU and HU from a low-socioeconomic township in South Africa, were evaluated from birth until 9 months of age. Clinical, anthropometric and infant feeding data were analysed. Standard descriptive statistics and regression analysis were performed to determine the effect of HIV exposure and breastfeeding duration on growth and clinical outcomes. Results Included in this secondary analysis were 123 HEU and 157 HU infants breastfed for a median of 26 and 14 weeks respectively. Median WLZ score was significantly (p p p p p Conclusion Our study has generated additional evidence that HEU infants are at substantial risk of infectious morbidity and decreased growth trajectories however we have further demonstrated that these adverse outcomes were independent of breastfeeding duration.

Veena S Singaram,1 Kimesh L Naidoo,2 Shenuka Singh3 1Clinical and Professional Practice, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; 2Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; 3Discipline of Dentistry, School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South AfricaCorrespondence: Veena S Singaram Email singaram@ukzn.ac.zaPurpose: Self-directed learning (SDL) has been advocated for effective training of final-year health professions students. COVID-19 challenges conventional teaching, learning, and assessment in the clinical environment. This study aimed to identify and explore enablers and barriers to SDL among final-year health professions students training during the COVID-19 pandemic.Methods: Adopting the SWOT (strengths, weaknesses, opportunities and threats) framework, this study explored the clinical learning and training experiences of final-year health professions students during the pandemic. A survey was conducted via online platforms. Data from 155 respondents were thematically analyzed.Results: Personal attributes such as reflection, self-determination, motivation, resilience, and positive learning behaviors and skills were identified as SDL enablers. Collaborative learning networks and online learning platforms facilitate learning needs and goals. Fear and anxiety, untrusted learning sites, uncertainty about graduation, financial issues and challenges in the learning environments were the major themes related to barriers to SDL.Conclusion: The importance of SDL as a skill for uncertain times warrants further investigation in the training of future healthcare professionals. Inclusive planning and engagement with final-year health professions students to address identified stressors, as well as the creation of shared platforms where students are part of the decision-making processes for clinical learning and training are recommended. Responsive curricula that optimize unpredictable disruptions in clinical training are needed to equip students to diagnose their own learning needs and implement appropriate learning strategies.Keywords: undergraduate medical students, learning environment, clinical training, medical curriculum, self-directed learning, COVID-19, health professions students

Background Newly qualified medical practitioners (interns) in South Africa (SA) are part of the frontline healthcare workers who face Africa’s most severe COVID-19 pandemic within an environment already burdened with tuberculosis, HIV and trauma epidemics. The experiences of interns during the pandemic reflect SA’s preparedness to respond in a crisis and inform strategies that could be adopted to balance training and service in resource-challenged contexts. This study explored the strengths, weaknesses, opportunities and threats posed by the COVID-19 pandemic as reflected on by interns within clinical training platforms in SA.Methods An online survey tool consisting of ten open-ended questions based on the SWOT framework related to personal and professional perspectives to clinical training during the COVID-19 pandemic was developed using SurveyMonkey. Due to lockdown restrictions, all data were collected remotely with the survey instrument being distributed via the social media platform WhatsApp. Three coders thematically analysed data until consensus was reached.Results Forty-six first- and second-year interns reflected on personal and systemic challenges as the major threats and weaknesses in intern training during the COVID-19 pandemic. Extrapolating on strengths and opportunities, there were three overarching learnings interns reflected on. These related to being a medical professional, being in a learning environment, and specific learnings realised. Existing challenges in the environment exacerbated the threats posed by COVID-19 and innovative strategies related to improving support, feedback and broadening the intern curriculum were identified. In addition, the use of online training around holistic care and intern evaluation was mooted as an innovation to develop out of this pandemic.Conclusion Although the clinical environment where interns learn and work is often stressful and overpowered by high service burdens, there are unique opportunities to enhance self-directed learning and graduate competencies, even in the midst of the COVID-19 pandemic.

BackgroundNeglected sexual side effects are a group of less common sexual side effects after Prostate that may present after Prostate Cancer treatment. There is currently no valid and reliable tool to identify these side effects. A modified Delphi study is an effective way of developing and validating such a screening tool.MethodsA modified Delphi study was used to obtain consensus from a multi-disciplinary group of experts over three rounds. Ten statements were presented containing 8 close ended statements on individual NSSEs, and 2 open ended statements on Psychosocial impact related to NSSE. Consensus was defined as a 75% strongly agree achievement on each statement, or the final statement evolution at the end of 3 rounds. Statement support in each round was determined by mean, standard deviation and range, after a numerical value was allocated to each statement during specific rounds. All three rounds were structured and suggestions and additions were incorporated in the statement evolution of the three rounds.ResultsThirty five participants were invited, and 27 completed Round 1(RD 1), 23 participants completed RD2, and 20 participants completed RD3. All 3 rounds were completed in 12 weeks. Statement 1(sexual arousal incontinence), statement 2(climacturia) and statement 3 (orgasm intensity) reached consensus after RD2, and statement 9 (sexual dysfunction impact) and statement 10 (experiences) were removed after RD3. Statement 4 (orgasmic pain), statement 5 (anejaculation), statement 6(sensory disturbances), statement 7 (penile length shortening) and statement 8 (penile curvature) were finalised after the conclusion of RD3. Statement 1-3 were the most stable statements with the most support and least amount of disagreement. Statements 4-8 were less stable, but support for them improved over the 3 rounds. Statement 9-10 both had good stability, but the support indicated that they needed to be removed from the set of statements. Statement 5 had the poorest range due to an outlier opinion.ConclusionsConsensus was reached on the statements making up the NSSE screening tool. Health care practitioners will be able to use this tool to identify NSSE after prostate cancer treatment. Further reliability testing on this tool is needed.

Background Neglected sexual side effects (NSSE) are a group of less common sexual side effects that may present after Prostate Cancer (PCa) treatment. There is currently no valid and reliable tool to identify these side effects. A modified Delphi study is an effective way of developing the content of such a screening tool. Methods A modified Delphi study was used to obtain consensus from a multi-disciplinary group of experts over 3 rounds during a 12 week period. Ten statements were presented containing 8 closed-ended statements on individual NSSEs, and 2 open-ended statements on psychosocial impact related to NSSE. Consensus was defined as a 75% strongly agree achievement on each statement, or the final statement evolution at the end of 3 rounds. Statement support in each round was determined by mean, standard deviation and range, after a numerical value was allocated to each statement during specific rounds. All three rounds were structured and suggestions and additions were incorporated in the statement evolution of the three rounds. Results Thirty-five participants were invited, and 27 completed Round 1 (RD 1), 23 participants completed RD2, and 20 participants completed RD3. All 3 rounds were completed in 12 weeks. Statement 1 (sexual arousal incontinence), statement 2 (climacturia) and statement 3 (orgasm intensity) reached consensus after RD2, and statement 9 (sexual dysfunction impact) and statement 10 (experiences) were removed after RD3. Statement 4 (orgasmic pain), statement 5 (anejaculation), statement 6 (sensory disturbances), statement 7 (penile length shortening) and statement 8 (penile curvature) were finalised after the conclusion of RD3. Statements 1–3 were the most stable statements with the most support and least amount of disagreement. Statements 4–8 were less stable, but support for them improved over the 3 rounds. Statements 9–10 both had good stability, but the support indicated that they needed to be removed from the set of statements. Statement 5 had the poorest range due to an outlier opinion. Conclusions Consensus was reached on the items making up the NSSE screening tool. Health care practitioners will be able to use this tool to identify the evidence of NSSE after PCa treatment. Further testing will be undertaken to confirm the reliability and validly of the tool.

Background: Recently graduated South African medical practitioners (interns) are expected to be efficient and resilient in limited resource contexts that face multiple disease burdens. Work-based assessment in SA internship focuses on clinical skills and neglects the evaluation of non-clinical skills. This sub-optimal assessment process creates a daunting task for clinician supervisors who are expected to certify these interns for independent practice. Methods: Using a mixed methodological approach, the study sampled a cross section of 411 interns in seven hospitals in KwaZulu-Natal and their intern supervisors . Data collection methods included focus groups discussions and surveys. A 4-round modified Delphi-process was followed to reach consensus on the set of core competencies required. The assessment tool that resulted in the process included a variety of competencies and the tool was validated through factor analysis and internal consistency was measured with Cronbach’s alpha. Results : A competency-based assessment tool was developed that allows for the assessment of both clinical and non-clinical skills. This tool was found to be very reliable, with an overall Cronbach alpha of 0.927. Factor analysis for the instrument revealed 61 observable clinical activities aggregated into entrustable professional activities and these measured four major factors. The factors correspond with procedural clinical skills; holistic-care skills; and emotional skills related to social competence and self-management. Conclusion: A locally relevant competency-based assessment tool was developed in SA to assess local paediatric interns. The validated tool’s function as a multidimensional instrument to assess both clinical and non-clinical skills included the assessment of emotional skills which are largely neglected. Validated work-based assessment instruments can be developed that are responsive to local needs and support the development of holistic clinicians in high disease-burdened contexts.

Prevention of HIV transmission from mother to child (PMTCT) has transformed the paediatric HIV epidemic. Understanding the complex transmission of HIV in-utero, intra-partum and post-partum remains a challenge but this holds the possibility of further innovative advances in PMTCT strategies. Universal HIV testing, and the careful usage and choice of antiretroviral drugs and infant nutritional practices forms the core of PMTCT strategies to ensure a healthy mother and a HIV uninfected child Pre-conceptual, antepartum and postpartum care of HIV infected women needs to encompass evidence based PMTCT strategies into accessible, comprehensive programmes and this holds the potential for the elimination of mother to child transmission in all contexts.

Background. Resource constraints and a high disease burden impact on the work-based assessment (WBA) of medical interns in South Africa (SA). Objectives. To review the use of workplace-based assessment frameworks in intern practice in SA and to compare these with international practices. Methods. A systematic review using a thematic analysis was performed to analyse 97 articles selected from an initial scoping of 360 sources of evidence on WBA in internship between 2000 and 2017. This process informed a synthesis of descriptive and analytic themes related to competency-based assessment practices relevant to internship in SA. Results. There was an overall dearth of studies on assessment of medical interns in lower-middle-income countries (LMICs). The context in which the assessment of interns in SA occurs has many challenges related to resources, workload and supervision. SA intern assessment is largely focused on core clinical competency, and this occurs without using competency-based frameworks. This focus was reflected in the finding that most studies in SA have dealt with the assessment of core procedural skills related to acute clinical care, while the assessment of non-clinical competencies and non-procedural skills was poorly addressed. Self-assessment by interns was the predominant strategy used in the SA context. The review revealed limitations in the use of multiple assessment strategies and direct observation in the local context, in contrast to practices in most high-income countries. Conclusions. A shift in focus to assess both procedural and non-procedural skills within a competency-based framework is advocated for SA internship, together with the use of multiple assessment tools and strategies that rely on direct observation of performance.

Background. The introduction of medicine pricing policies in South Africa (SA) in the form of single exit pricing (SEP) provided a mechanism to improve medicine price transparency and reduce the medicine price and inflation. However, regulation of medicine prices may have further unforeseen effects on the availability of medicine. This research presents the impact of SEP on discontinuation of medicine products on the private healthcare market in SA. Objectives. To evaluate the impact of SEP legislation on the availability of medicines in the SA private health sector in terms of withdrawal of medicines from the market. Methods. A descriptive, quantitative analysis of all registered medicines on the SA market by stock-keeping units (SKUs) was done to establish medicine products that were withdrawn from the market by SKUs during a 14-year period (2001 - 2014). Results. A total of 152 manufacturers discontinued 3 691 SKUs between 2001 and 2014. The mean number of discontinuations per generic manufacturer was 22.34 (standard deviation (SD) 58.11), while innovator manufacturers discontinued a mean of 27.61 (41.89). The largest number of SKUs were commercially withdrawn in 2002 ( n =603), followed by discontinuations in 2003 ( n =463) and 2004 ( n =407). There was a negative correlation between number of discontinued SKUs per year and SEP increase (Pearson’s correlation coefficient r ‒0.414; p =0.14). The results showed that SEP and a transparent pricing policy may have had an impact on SKU withdrawal from the market prior to SEP implementation. Conclusions. The result of reduced product availability on the market and its impact on the cost and quality of healthcare to the patient need to be regularly monitored and evaluated to ascertain if direct price regulations achieve the intended outcomes. Other intended or unintended effects on pharmaceutical market dynamics should also be evaluated.

Background . The population in South Africa is ageing rapidly. However, health professionals are reportedly unprepared to provide quality care for the elderly population. A situational analysis of curricula is required to identify the extent to which current training addresses the needs of elderly populations. Objectives. To investigate the undergraduate medical and nursing curricula at a South African university regarding geriatric care training, and explore possible learning opportunities to enhance health professions education in geriatric care. Methods. This descriptive exploratory study was conducted through document review and semi-structured interviews with health professions educators. Results. In both curricula, a problem-based learning approach was combined with classroom and bedside teaching. A wide range of geriatric topics was covered in each programme, four of which were common to both, i.e. falls, urinary incontinence, dementia and chronic non-communicable diseases. Nursing students were exposed to geriatric patients in multiple settings, while medical students saw geriatric patients mainly in hospitals and community clinics. Geriatric content in both programmes was integrated into other modules, and there was no independent assessment of geriatric competencies. Conclusion. Although a multitude of geriatric learning objectives were included in both nursing and medical training programmes, there was limited coverage and a lack of discrete assessment in this field. Opportunities to enhance the current curricula include discrete assessment of geriatric care competencies, and increased interprofessional education. However, faculty development and additional resources would be required in both programmes.

Background. The focus is usually on organisational issues when reporting factors influencing the perceptions of South African (SA) medical interns regarding their learning environment (LE). Individual demographic factors are now being recognised as equally important in influencing these perceptions. Objective. To determine whether individual demographic factors influence interns’ perceptions of the LE during their paediatrics rotation in hospitals burdened with high disease in SA. Methods. Perceptions of the LE among interns in KwaZulu-Natal, SA, were assessed in December 2015, using a validated version of the Postgraduate Hospital Educational Environmental Measure (PHEEM). Overall and subscale PHEEM scores were calculated using Likert scales. The association of these scores with various sociocultural factors relevant to the SA context, previous educational exposure and year of internship were examined using ANOVA or Student t -tests. Results. A total of 209 interns (59.3%) was sampled. The ethnic breakdown of sampled interns reflected the changing demographic profile of SA junior doctors. Statistically significant associations of overall and teaching subscale PHEEM scores were found with ethnicity ( p =0.024), urban/rural status ( p =0.023), year of internship ( p =0.0047) and university origin ( p =0.015). These factors corroborated characteristics that reflect both past disadvantage in the SA context, and those of being an ‘outsider’ in an established group. Conclusions. Intern training programmes in SA need to recognise that individual demographic factors influence interns’ perceptions in the context of teaching and mentoring in a discipline. With rapid changes in the demographic profiles of junior doctors, SA intern trainers need to enable a ‘sense of belonging’ in LEs.

Background: Hospital acquired infections are on the increase worldwide. A possible source for transmission is the presence of microorganisms on mobile phones which are carried by increasing numbers of medical and nursing staff, students, and caregivers.Methods: A cross-sectional study was performed. Samples were obtained from medical and nursing staff, students, and caregivers from the paediatric wards (85 beds), and the neonatal unit (40 beds) at King Edward VIII Hospital (KEH), Durban. Mobile phones of participants were sampled, with sterile swabs, without prior warning. The swabs were transported promptly to the laboratory and cultured onto colistin, nalidixic acid agar and MacConkey agar plates. All positive cultures were identified using standard laboratory tests.Results: Of the 100 mobile phones sampled, 30 were contaminated with bacteria. Gram-positive microorganisms were more frequently cultured than Gram-negative microorganisms (29 vs. 7). Significantly more caregivers had contaminated phones (54.17% vs. 22.37%, p value = 0.003). Caregivers’ phones were predominantly contaminated with Staphylococcus spp. (41.67%). More phones in the general wards (37.5%) and nursery (32.5%) were contaminated compared to the gastroenteritis ward (10%).Conclusions: Our results indicate that one third of the mobile phones carried in the paediatric wards are contaminated. Caregivers had the highest likelihood of carrying mobile phones that were contaminated, with the lowest rate among the nursing staff. Caregivers’ phones were also more likely to have multiple microorganisms. The lowest rate of contamination was found in the gastroenteritis ward, possibly due to a heightened awareness of the need for handwashing.

Background South African (SA) paediatric interns (recently qualified medical graduates) work in a high disease burdened and resource deficient environment for two years, prior to independent practice. Perceptions of this learning environment (LE) influences their approaches to training as well as the outcomes of this period of development. Obstacles to creating a supportive LE and supervisor interaction affects the quality of this training. Measuring perceptions of the LE with validated instruments can help inform improvements in learning during this crucial period of medical education. Methods The aims of this study was to determine the psychometric qualities of the Postgraduate Hospital Educational Environment Measure (PHEEM) amongst paediatric interns across four hospital complexes in South Africa and to measure the LE as perceived by both interns and their supervisors. Construct validity was tested using factor analysis and internal consistency was measured with Cronbach’s alpha. Results A total of 209 interns and 60 supervisors (69% intern response rate) responded to the questionnaire. The PHEEM was found to be very reliable with an overall Cronbach’s alpha of 0.943 and 0.874 for intern and supervisors respectively. Factor analysis using a 3-factor solution accounted for 42% of the variance with the teaching subscale having the best fit compared with the other sub-scales of the original tool. Most interns perceived the learning environment as being more positive than negative however, their perceptions differed significantly from that of their supervisors. Poor infrastructural support from institutions, excessive workloads and inadequate supervision were factors preventing optimal training of paediatric interns. Conclusions The SA version of the PHEEM tool used was found to be a reliable and valid instrument for use in interns amongst high disease burdened contexts. Various obstacles to creating an ideal learning environment for paediatric interns were identified to be in need of urgent review. Key differences in perceptions of an ideal learning environment between interns and their supervisors need to be fully explored as these may result in sub-optimal supervision and mentoring. Electronic supplementary material The online version of this article (10.1186/s12909-017-1080-3) contains supplementary material, which is available to authorized users.

BACKGROUND: The South African dietary supplement market will undergo a period of transition within the next few years due to the establishment of the South African Health Products Regulatory Authority (SAHPRA), which has superseded the former Medicines Control Council (MCC). While regulatory steps are yet to be fully outlined, products such as whey protein, regarded as food, will be governed by the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Foods. The guideline provides for the minimum value of essential amino acids (plus cysteine and tyrosine) per gram of protein that products claiming to contain protein will be required to comply with. Determining the compliance levels of whey protein products currently available will assist in establishing the readiness of the dietary supplement industry for regulation, and provide an indication of the overall state of the industry.OBJECTIVES: To determine the amino acid profile of whey protein powder and compare analysed content to manufacturer stated content.To compare analysed amino acid content to the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Food template amino acid profile.METHOD: 15 of the best-selling whey protein products available in South Africa were selected for amino acid analysis. Tested amino acid content were compared to the label stated claim and the amino acid reference pattern, as stated in the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Foods.RESULTS: Sixty percent (60%) of products tested were non-compliant with the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Foods. Of the 15 products tested, 11 were manufactured in South Africa, with 8 being non-compliant to the guideline amino acid profile. Considerable variance was noted in the manufacturer stated and the tested amino acid content (ranging from 16–48% variance).CONCLUSION: Many of the whey protein products available in South Africa are not compliant to proposed industry guidelines. The considerable variance noted highlights the need for greater oversight of the industry with clearly defined regulatory procedures.

The South African sport supplement industry has experienced rapid growth in recent years. Despite the massive market demand, this industry remains poorly regulated. From raw ingredient contamination to label compliance discrepancies, the sport supplement industry is an area of growing concern and warrants further public debate.

The HIV pandemic is the most pressing public health emergency in the world today. Most infected individuals live in Sub-Saharan Africa. However, experience with antiretroviral treatment is concentrated in the developed world, where relatively small numbers of children benefit from the latest advances in the field, and are cared for in long-established specialist chronic care clinics. Antiretroviral therapy is now being rolled out throughout the developing world. Although many of the clinical lessons learned in the developed world setting can be usefully translated from it, there are considerations beyond the medical that must be taken into account to make treatment in the developing world truly accessible and sustainable. This review compares and contrasts the UK and KwaZulu-Natal experiences to explore these issues.

Isolation of New Delhi Metallo-seta- lactamase-1(NDM-1) producing Klebsiella pneumoniae in a neonate in KwaZulu-Natal, South Africa. Carbapenems have been a last line of defence in the treatment of infections caused by antimicrobialresistant Enterobacteriaceae. The emergence of resistance in Enterobacteriaceae mediated via carbapenemases is a major concern as these isolates show resistance to antibiotics commonly used to treat Gram-negative infections. The first documented case of NDM-1-producing Enterobacteriaceae in a neonate within 24 hours of birth is reported here. This is a case report of a neonate with New Delhi Metallo-Beta-lactamse-1 producing Klebsiella pneumoniae in Kwazulu Natal South Africa. Emergence of this organism is worrisome in the neonatal unit, since treatment options are restricted. Active surveillance is required to prevent spread of this organism. Strict infection control and rationale use of antimicrobials is required, to prevent acquisition of these organisms.

Summary Background Zinc deficiency is associated with impaired immune function and an increased risk of infection. Supplementation can decrease the incidence of diarrhoea and pneumonia in children in resource-poor countries. However, in children with HIV-1 infection, the safety of zinc supplementation is uncertain. We aimed to assess the role of zinc in HIV-1 replication before mass zinc supplementation is recommended in regions of high HIV-1 prevalence. Methods We did a randomised double-blind placebo-controlled equivalence trial of zinc supplementation at Grey's Hospital in Pietermaritzburg, South Africa. 96 children with HIV-1 infection were randomly assigned to receive 10 mg of elemental zinc as sulphate or placebo daily for 6 months. Baseline measurements of plasma HIV-1 viral load and the percentage of CD4+ T lymphocytes were established at two study visits before randomisation, and measurements were repeated 3, 6, and 9 months after the start of supplementation. The primary outcome measure was plasma HIV-1 viral load. Analysis was per protocol. Findings The mean log 10 HIV-1 viral load was 5·4 (SD 0·61) for the placebo group and 5·4 (SD 0·66) for the zinc-supplemented group 6 months after supplementation began (difference 0·0002, 95% CI −0·27 to 0·27). 3 months after supplementation ended, the corresponding values were 5·5 (SD 0·77) and 5·4 (SD 0·61), a difference of 0·05 (−0·24 to 0·35). The mean percentage of CD4+ T lymphocytes and median haemoglobin concentrations were also similar between the two groups after zinc supplementation. Two deaths occurred in the zinc supplementation group and seven in the placebo group (p=0·1). Children given zinc supplementation were less likely to get watery diarrhoea than those given placebo. Watery diarrhoea was diagnosed at 30 (7·4%) of 407 clinic visits in the zinc-supplemented group versus 65 (14·5%) of 447 visits in the placebo group (p=0·001). Interpretation Zinc supplementation of HIV-1-infected children does not result in an increase in plasma HIV-1 viral load and could reduce morbidity caused by diarrhoea. Relevance to Practice Programmes to enhance zinc intake in deficient populations with a high prevalence of HIV-1 infection can be implemented without concern for adverse effects on HIV-1 replication. In view of the reductions in diarrhoea and pneumonia morbidity, zinc supplementation should be used as adjunct therapy for children with HIV-1 infection.

Background. High childhood disease burdens in South Africa (SA) prioritise the need for careers in paediatrics. Experiences of junior doctors during internship may influence career trajectories in a direction that is discordant with national health priorities. Objective. To explore the influence of the learning environment and demography on career intentions of SA paediatric interns. Methods. This cross-sectional study involved sampling intern groups at the start and completion of internship in paediatrics to determine their career intentions. A validated version of the Postgraduate Hospital Educational Environmental Measure was used to measure perceptions of the learning environment (LE) in the post-paediatric internship cohort. Measures of the LE in combination with demographic factors were compared with career intentions. Associations were determined by t -tests or analysis of variance and χ 2 tests. Results. A total sample size of 422 was obtained from two separate cohorts, which were demographically similar except for age. Most interns (88.4%) intended to remain in SA, with 72.6% indicating an intention to practise in the public healthcare sector. There was a high intention to specialise (85.9%), and 60.2% were keen on a career that involved children. Previous educational exposure and demographic factors other than gender did not significantly influence career intentions. Perceptions of the LE significantly influenced decisions to stay in SA’s public sector and to care for children. The decision to specialise, however, was not influenced by demographic variables or perceptions of the LE. Conclusions. Paediatric interns from diverse sociocultural and educational backgrounds had similar career intentions. Most interns were keen to work with children in SA’s public sector. However, learning experiences during internship significantly influence these intentions and have the potential to drive young doctors away from SA, its public health service and paediatric care. Ensuring that training and support of interns are optimised is essential if SA is to align its healthcare needs with the aspirations of its future healthcare workers.

Background Extensively drug-resistant (XDR) tuberculosis (TB) and HIV coinfection is associated with low cure rates and high mortality. Clofazimine has shown activity in vitro against Mycobacterium tuberculosis, but clinical experience with clofazimine in XDR-TB and HIV coinfection is limited. Methods This was a retrospective cohort study of adult XDR-TB patients in KwaZulu-Natal, South Africa, treated with either a clofazimine- or non-clofazimine-containing XDR-TB treatment regimen. The primary outcome measure was TB culture conversion at 6 months. Survival analysis and multivariate logistic regression compared time to event in different strata and identified risk factors for TB culture conversion. Results Between August 2009 and July 2011, eligible XDR-TB patients (n = 85) were initiated on treatment for XDR-TB. Most patients (86%) were HIV-infected and receiving antiretroviral therapy (90%). Patients receiving a clofazimine-containing regimen (n = 50) had a higher percentage of culture conversion (40%) compared with patients (n = 35) receiving a non-clofazimine regimen (28.6%). On multivariate analysis, there was a 2-fold increase in TB culture conversion at 6 months (hazard rate ratio 2.54, 95% CI 0.99-6.52, P = 0.05) in the group receiving a clofazimine-containing regimen. Adverse effects due to clofazimine were minor and rarely life-threatening. Conclusions Clofazimine was associated with improved culture conversion in the treatment of XDR-TB/HIV. Adverse effects were minor and non-life-threatening. Based on these preliminary data, further study of clofazimine in XDR-TB/HIV treatment is warranted. Given the present low rates of culture conversion in XDR-TB treatment, we recommend empirical inclusion of clofazimine in treatment regimens for XDR-TB.

Objectives: The objective of this study was to assess the dietary intake and metabolic control of children with type 1 diabetes. Design: A cross-sectional observational study was carried out. Subjects: A total of 30 subjects whose ages ranged from six to ten years were included in the study. Setting: The study was conducted at the Paediatric Diabetic Clinics at Grey’s Hospital, Pietermaritzburg and Inkosi Albert Luthuli Central Hospital (IALCH), Durban, in KwaZulu-Natal. Outcome measures: Dietary intake was assessed using a three-day dietary record. Metabolic control was assessed using glycosylated haemoglobin (HbA1c). Results: The mean percentage contributions of macronutrients to total energy as determined by the three-day dietary records were as follows: carbohydrate – 52%; added sucrose – 2%; protein – 16%; fat – 32%. The mean intakes were similar to the recommendations of the International Society for Pediatric and Adolescent Diabetes (ISPAD) Consensus Guidelines (2002). Micronutrient intake was generally adequate. The mean latest glycosylated haemoglobin (HbA 1c ) for the sample as at the time of the study was 9.7%. Five of the thirty subjects had HbA 1c values that were within the recommended levels for children with type 1 diabetes. Conclusions: The macronutrient intake in this sample was found to be similar to the ISPAD Consensus Guidelines (2002) while micronutrient intake was adequate in most cases. Overall the sample had poor metabolic control.

BACKGROUND: While the impact of HAART on growth in children is well established the influence of prior nutritional status on the response to HAART is not well known. METHODS: A retrospective study was conducted on 120 children in South Africa. Patients were divided into 3 groups (normal moderately underweight and severely underweight) based on weight-for-age z-scores (WAZ). Age weight height CD4 cell percentage and viral load were recorded at initiation of HAART and after 24 months of therapy. Data were analyzed using t-tests chi tests and one-way ANOVA. RESULTS: At baseline 58% of children were normal weight 18% moderately underweight and 23% severely underweight. After 24 months of HAART WAZ improved significantly in moderately and severely underweight patient groups compared with the normal group. Height-for-age z-scores (HAZ) increased in all 3 groups with severely underweight children gaining more height than normal weight counterparts. Weight-for-height z-scores (WHZ) normalized in the severely underweight group. Mean CD4 cell percentages increased significantly in all 3 groups while viral loads decreased significantly in all groups with no differences among the groups at the end of 24 months of therapy. Of the entire cohort 75% achieved undetectable HIV RNA viral loads. CONCLUSIONS: Underlying malnutrition does not adversely affect growth immunologic or virologic response to HAART in HIV-infected children. Underweight children exhibit an equally robust response to treatment as their well-nourished peers.