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Management of multidrug-resistant TB (MDR-TB) patients co-infected with human immunodeficiency virus (HIV) is highly challenging. Such patients are subject to long and potentially toxic treatments and may develop a number of different psychiatric illnesses such as anxiety and depressive disorders. A mental health assessment before MDR-TB treatment initiation may assist in early diagnosis and better management of psychiatric illnesses in patients already having two stigmatising and debilitating diseases. To address limited evidence on the baseline psychiatric conditions of HIV-infected MDR-TB patients, we aimed to document the levels of depressive symptoms at baseline, and any alteration following individualized clinical and psychological support during MDR-TB therapy, using the Patient Health Questionnaire-9 (PHQ-9) tool, among HIV-infected patients. This was a retrospective review of the medical records of an adult (aged >15 years) HIV/MDR-TB cohort registered for care during the period of August 2012 through to March 2014. A total of 45 HIV/MDR-TB patients underwent baseline assessment using the PHQ-9 tool, and seven (16%) were found to have depressive symptoms. Of these, four patients had moderate to severe depressive symptoms. Individualized psychological and clinical support was administered to these patients. Reassessments were carried out for all patients after 3 months of follow-up, except one, who died during the period. Among these 44 patients, three with baseline depressive symptoms still had depressive symptoms. However, improvements were observed in all but one after 3 months of follow-up. Psychiatric illnesses, including depressive symptoms, during MDR-TB treatment demand attention. Routine administration of baseline mental health assessments by trained staff has the potential to assist in determining appropriate measures for the management of depressive symptoms during MDR-TB treatment, and help in improving overall treatment outcomes. We recommend regular monitoring of mental health status by trained counsellors or clinical staff, using simple, validated and cost-effective tools. [ABSTRACT FROM AUTHOR]

Background: In Mozambique, antiretroviral therapy (ART) scale-up has been successfully implemented. However, attrition in care remains a major programmatic challenge. In 2009, an intermediary-level HIV referral center was created in Maputo to ensure access to specialized care for HIV-infected patients with complications (advanced clinical-immunological stage, Kaposi sarcoma, or suspected ART failure). Objective: To determine the attrition from care and to identify risk factors that lead to high attrition among patients referred to an intermediary-level HIV referral center. Design: This was a retrospective cohort study from 2009 to 2011. Results: A total of 1,657 patients were enrolled, 847 (51%) were men, the mean age was 36 years (standard deviation: 11), the mean CD4 count was 27 cells/μl (interquartile range: 11–44), and one-third were severely malnourished. The main reasons for referral were advanced clinical stages (WHO stages 3 and 4, and CD4 count <50 cells/μl) in 70% of the cases, and 19% had Kaposi sarcoma. The overall attrition rate was 28.7 per 100 person-years (PYs) – the mortality rate was 5.0 (95% confidence interval [CI]: 4.2–5.9) per 100 PYs, and the loss-to-follow-up rate was 23.7 (95% CI: 21.9–25.6) per 100 PYs. There were 793 attritions – 137 deaths and 656 lost to follow-up (LTFU); 77% of all attrition happened within the first year. The factors independently associated with attrition were male sex (adjusted hazard ratio [aHR]: 1.15, 95% CI: 1.0–1.3), low body mass index (aHR: 1.51, 95% CI: 1.2–1.8), WHO clinical stage 3 or 4 (aHR: 1.30, 95% CI: 1.0–1.6; and aHR: 1.91, 95% CI: 1.4–2.5), later year of enrollment (aHR 1.61, 95% CI 1.3–1.9), and ‘being already on ART’ at enrollment (aHR 13.71, 95% CI 11.4–16.4). Conclusions: Attrition rates among HIV-infected patients enrolled in an intermediary referral center were high, mainly related to advanced stage of clinical disease. Measures are required to address this, including innovative strategies for HIV-testing uptake, earlier ART initiation and nutritional supplementation, and special attention to men and those who are already on ART at enrolment. Qualitative research is required to understand the reasons for being LTFU and design informed evidence-based interventions. [ABSTRACT FROM AUTHOR]

The Structured Operational Research Training Initiative (SORT-IT) has been shown to be very effective in strengthening capacity for conducting operational research, publishing in scientific journals and fostering policy and practice change. The 'classic' model includes three face-to-face modules during which, respectively, a study protocol, a data analysis plan, and a manuscript are elaborated. Meanwhile, the lectures of the SORT-IT are available online as YouTube videos. Given the availability of this online material and the experiences with online mentorship of the faculty, we piloted a first blended distance/residential SORT-IT. To inform future implementers of our experience with blended operational research courses, we summarize the model, successes, and challenges of this approach in this perspective paper. The blended SORT-IT consisted of an online phase, covering modules 1 and 2, followed by a face-to-face writing module 3. Four out of six participants successfully completed the course, and submitted a manuscript to a peer-reviewed journal within four weeks of completing module 3. A blended approach may make the SORT-IT course more accessible to future participants and may favour the adoption of the course by other institutions, such as national Ministries of Health. [ABSTRACT FROM AUTHOR]

Countries in the different stages of pre-elimination, elimination, and prevention of reintroduction are required to report the number of indigenous and imported malaria cases to the World Health Organization (WHO). However, these data have not been systematically analysed at the global level. For the period 2007 to 2013, we aimed to report on 1) the proportion of countries providing data on the origin of malaria cases and 2) the origin of malaria cases in countries classified as being in the stages of pre-elimination, elimination and prevention of reintroduction. An observational study using annual data reported through routine health information systems to the WHO Global Malaria Programme between 2007 and 2013. For all countries classified as being in pre-elimination, elimination, and prevention of reintroduction in the year 2013, there has been a substantial decrease in the total number of indigenous malaria cases, from more than 15,000 cases reported in 2007 to less than 4,000 cases reported in 2013. However, the total number of imported malaria cases has increased over that time period, from 5,600 imported cases in 2007 to approximately 6,800 in 2013. Vigilant monitoring of the numbers of imported and indigenous malaria cases at national and global levels as well as appropriate strategies to target these cases will be critical to achieve malaria eradication. [ABSTRACT FROM AUTHOR]