Search

ObjectivesWe assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia. MethodsWe conducted a retrospective cohort study among adults (18years) starting ART during 2003-2010. We purposefully selected six health facilities per country and randomly selected 250 patients from each facility. Patients who visited clinics at least once during the 90days before data abstraction were defined as retained. Data on individual and programme level risk factors for attrition were obtained through chart review and clinic manager interviews. Kaplan-Meier curves for retention across sites were created. Predictors of attrition were assessed using a multivariable Cox-proportional hazards model, adjusted for site-level clustering. ResultsFrom 17 facilities, 4147 patients were included. Retention ranged from 52.0% to 96.2% at 1year to 25.8%-90.4% at 4years. Multivariable analysis of ART initiation characteristics found the following independent risk factors for attrition: younger age [adjusted hazard ratio (aHR) and 95% confidence interval (95%CI)=1.30 (1.14-1.47)], WHO stage 4 ([aHR (95% CI): 1.56 (1.29-1.88)], >10% bodyweight loss [aHR (95%CI)=1.17 (1.00-1.38)], poor functional status [ambulatory aHR (95%CI)=1.29 (1.09-1.54); bedridden aHR1.54 (1.15-2.07)], and increasing years of clinic operation prior to ART initiation in government facilities [aHR (95%CI)=1.17 (1.10-1.23)]. Patients with higher CD4 cell count were less likely to experience attrition [aHR (95%CI)=0.88 (0.78-1.00)] for every log (tenfold) increase. Sites offering community ART dispensing [aHR (95%CI)=0.55 (0.30-1.01) for women; 0.40 (0.21-0.75) for men] had significantly less attrition. ConclusionsPatient retention to an individual programme worsened over time especially among males, younger persons and those with poor clinical indicators. Community ART drug dispensing programmes could improve retention. ObjectifsNous avons evalue la retention et les predicteurs de l'attrition (deces ou pertes au suivi enregistres) dans le traitement antiretroviral (ART) dans des cliniques en Tanzanie, en Ouganda et en Zambie. MethodesNous avons mene une etude de cohorte retrospective chez les adultes (18 ans) ayant debute l'ART au cours de 2003-2010. Nous avons deliberement choisi six etablissements de sante par pays et avons choisi au hasard 250 patients dans chaque etablissement. Les patients qui ont visite les cliniques au moins une fois au cours des 90 jours avant l'extraction des donnees ont ete definis comme retenus. Les donnees sur les facteurs de risque individuels et a l'echelle du programme pour l'attrition ont ete obtenues par l'examen des dossiers et des entrevues avec les directeur des cliniques. Les courbes de Kaplan-Meier pour la retention a travers les sites ont ete creees. Les predicteurs de l'attrition ont ete evalues a l'aide d'un modele multivarie des risques proportionnels de Cox, corriges par le regroupement au niveau du site. ResultatsDe 17 etablissements, 4147 patients ont ete inclus. La retention variait de 52,0% a 96,2% a un an et de 25,8% a 90,4% a 4 ans. L'analyse multivariee des caracteristiques a l'initiation de l'ART a trouve les facteurs independants de risque pour l'attrition suivants: le plus jeune age [Hazard Ratio ajuste (aHR) et intervalle de confiance a 95% (IC 95%)=1,30 (1,14 a 1,47)], le stade 4 de l'OMS ([aHR (IC 95%): 1,56 (1,29 a 1,88)], > 10% de perte de poids corporel [aHR (IC 95%)=1,17 (1,00 a 1,38)], un mauvais etat fonctionnel [aHR ambulatoire=1,29 (1,09-1,54); aHR alite=1,54 (01,15 a 02,07)] et de plus en plus d'annees d'operations en clinique avant le debut de l'ART dans les etablissements publics [aHR(IC 95%)=1,17 (1,10 a 1,23)]. Les patients avec un taux plus eleve de cellules CD4 etaient moins susceptibles a l'attrition [aHR (IC 95%) = 0,88 (0,78 a 1,00)] pour chaque augmentation logarithmique. Les sites offrant la distribution communautaire de l'ART [aHR (IC 95%)=0,55 (0,30 a 1,01) pour les femmes; =0,40 (0,21 a 0,75) pour les hommes] avaient significativement moins d'attrition. ConclusionsLa retention des patients dans un programme individuel empirait au fil du temps surtout chez les hommes, les personnes plus jeunes et ceux avec de mauvais indicateurs cliniques. Les programmes de distribution communautaire de l'ART pourraient ameliorer la retention. ObjetivosHemos evaluado la retencion y los vaticinadores de abandono (muerte registrada o perdida durante el seguimiento) en centros de tratamiento antirretroviral (TAR) en Tanzania, Uganda y Zambia. MetodosHemos realizado un estudio retrospectivo de cohortes con adultos (18 anos) en TAR durante el 2003-2010. Seleccionamos seis centros sanitarios por pais, y de forma aleatoria a 250 pacientes de cada centro. Los pacientes que visitaron los centros al menos una vez durante los 90 dias anteriores a la fecha de obtencion de los datos se definieron como retenidos. Se obtuvieron datos sobre los factores de riesgo de abandono de los individuos y el nivel del programa mediante la revision de graficos y entrevistas con el gestor del centro. Se realizaron curvas de Kaplan-Meier para la retencion en los distintos centros. Los vaticinadores de abandono se evaluaron utilizando un modelo de riesgos proporcionales de Cox, ajustado para agrupacion a nivel de centros. ResultadosSe incluyeron 4147 pacientes de 17 centros. La retencion estaba entre 52.0%-96.2% al ano y 25.8%-90.4% a los 4 anos. En un analisis multivariante de las caracteristicas presentes en el momento de iniciar TAR, se encontraron los siguientes factores de riesgo de abandono independientes: ser mas joven [razon de riesgo ajustada (RRa) and IC 95=1.30 (1.14-1.47)], estadio 4 de la OMS ([RRa(IC 95%): 1.56 (1.29-1.88)], > 10% perdida de peso corporal [RRa (IC 95%)=1.17 (1.00-1.38)], un estatus funcional pobre [RRa ambulatorio (IC 95%)=1.29 (1.09-1.54); estar en cama RRa 1.54 (1.15-2.07) ], y un mayor numero de anos en clinicas privadas antes de comenzar TAR en un centro gubernamental [RRa (IC 95%)=1.17 (1.10-1.23)]. Los pacientes con un mayor conteo de CD4 tenian una menor probabilidad de experimentar abandono [RRa (IC 95%)=0.88 (0.78-1.00)] para un aumento logaritmico (x10). Los centros que ofrecian dispensarios comunitarios de TAR [aHR (IC95%)=0.55 (0.30-1.01) para mujeres; 0.40 (0.21-0.75) para hombres] tenian significativamente menos abandono. ConclusionesLa retencion de pacientes en un programa individual empeoro a lo largo del tiempo, especialmente entre los hombres, personas jovenes y aquellos con indicadores clinicos pobres. Los programas comunitarios de dispensacion de TAR podrian mejorar la retencion.

Background.Of the 13 US vancomycin-resistant Staphylococcus aureus (VRSA) cases, 8 were identified in southeastern Michigan, primarily in patients with chronic lower-extremity wounds. VRSA infections develop when the vanA gene from vancomycin-resistant enterococcus (VRE) transfers to S. aureus. Incl8-like plasmids in VRE and pSK41-like plasmids in S. aureus appear to be important precursors to this transfer.Objective.Identify the prevalence of VRSA precursor organisms.Design.Prospective cohort with embedded case-control study.Participants.Southeastern Michigan adults with chronic lower-extremity wounds.Methods.Adults presenting to 3 southeastern Michigan medical centers during the period February 15 through March 4, 2011, with chronic lower-extremity wounds had wound, nares, and perirectal swab specimens cultured for S. aureus and VRE, which were tested for pSK41-like and Incl8-like plasmids by polymerase chain reaction. We interviewed participants and reviewed clinical records. Risk factors for pSK41-positive S. aureus were assessed among all study participants (cohort analysis) and among only S. aureus-colonized participants (case-control analysis).Results.Of 179 participants with wound cultures, 26% were colonized with methicillin-susceptible S. aureus, 27% were colonized with methicillin-resistant S. aureus, and 4% were colonized with VRE, although only 17% consented to perirectal culture. Six participants (3%) had pSK41-positive S. aureus, and none had Incl8-positive VRE. Having chronic wounds for over 2 years was associated with pSK41-positive S. aureus colonization in both analyses.Conclusions.Colonization with VRSA precursor organisms was rare. Having long-standing chronic wounds was a risk factor for pSK41-positive S. aureus colonization. Additional investigation into the prevalence of VRSA precursors among a larger cohort of patients is warranted.

BACKGROUND The World Health Organization recommends viral load (VL) as the preferred method for diagnosing antiretroviral therapy failure; however, operational challenges have hampered the implementation of VL monitoring in most resource-limited settings. This study evaluated the accuracy of dried blood spot (DBS) VL testing under field conditions as a practical alternative to plasma in determining virologic failure (VF). METHODS From May to December 2013, paired plasma and DBS specimens were collected from 416 adults and 377 children on antiretroviral therapy for ≥6 months at 12 clinics in Kenya. DBSs were prepared from venous blood (V-DBS) using disposable transfer pipettes and from finger-prick capillary blood using microcapillary tubes (M-DBS) and directly spotting (D-DBS). All samples were tested on the Abbott m2000 platform; V-DBS was also tested on the Roche COBAS Ampliprep/COBAS TaqMan (CAP/CTM) version 2.0 platform. VF results were compared at 3 DBS thresholds (≥1000, ≥3000, and ≥5000 copies/mL) and a constant plasma threshold of ≥1000 copies/mL. RESULTS On the Abbott platform, at ≥1000-copies/mL threshold, sensitivities, specificities, and kappa values for VF determination were ≥88.1%, ≥93.1%, and ≥0.82%, respectively, for all DBS methods, and it had the lowest percentage of downward misclassification compared with higher thresholds. V-DBS performance on CAP/CTM had significantly poorer specificity at all thresholds (1000%-33.0%, 3000%-60.9%, and 5000%-77.0%). No significant differences were found between adults and children. CONCLUSIONS VL results from V-DBS, M-DBS, and D-DBS were comparable with those from plasma for determining VF using the Abbott platform but not with CAP/CTM. A 1000-copies/mL threshold was optimal and should be considered for VF determination using DBS in adults and children.

BACKGROUND In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access for HIV-infected children (

Objectives To identify the reasons patients miss taking their antiretroviral therapy (ART) and the proportion who miss their ART because of symptoms; and to explore the association between symptoms and incomplete adherence. Methods Secondary analysis of data collected during a cross-sectional study that examined ART adherence among adults from 18 purposefully selected sites in Tanzania, Uganda, and Zambia. We interviewed 250 systematically selected patients per facility (>= 18 years) on reasons for missing ART and symptoms they had experienced (using the HIV Symptom Index). We abstracted clinical data from the patients' medical, pharmacy, and laboratory records. Incomplete adherence was defined as having missed ART for at least 48 consecutive hours during the past 3 months. Results Twenty-nine percent of participants reported at least one reason for having ever missed ART (1278/4425). The most frequent reason was simply forgetting (681/1278 or 53%), followed by ART-related hunger or not having enough food (30%), and symptoms (12%). The median number of symptoms reported by participants was 4 (IQR: 2-7). Every additional symptom increased the odds of incomplete adherence by 12% (OR: 1.1, 95% CI: 1.1-1.2). Female participants and participants initiated on a regimen containing stavudine were more likely to report greater numbers of symptoms. Conclusions Symptoms were a common reason for missing ART, together with simply forgetting and food insecurity. A combination of ART regimens with fewer side effects, use of mobile phone text message reminders, and integration of food supplementation and livelihood programmes into HIV programmes, have the potential to decrease missed ART and hence to improve adherence and the outcomes of ART programmes.

To achieve global targets for universal treatment set forth by the Joint United Nations Programme on human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (UNAIDS), viral load monitoring for HIV-infected persons receiving antiretroviral therapy (ART) must become the standard of care in low- and middle-income countries (LMIC) (1). CDC and other U.S. government agencies, as part of the President's Emergency Plan for AIDS Relief, are supporting multiple countries in sub-Saharan Africa to change from the use of CD4 cell counts for monitoring of clinical response to ART to the use of viral load monitoring, which is the standard of care in developed countries. Viral load monitoring is the preferred method for immunologic monitoring because it enables earlier and more accurate detection of treatment failure before immunologic decline. This report highlights the initial successes and challenges of viral load monitoring in seven countries that have chosen to scale up viral load testing as a national monitoring strategy for patients on ART in response to World Health Organization (WHO) recommendations. Countries initiating viral load scale-up in 2014 observed increases in coverage after scale-up, and countries initiating in 2015 are anticipating similar trends. However, in six of the seven countries, viral load testing coverage in 2015 remained below target levels. Inefficient specimen transport, need for training, delays in procurement and distribution, and limited financial resources to support scale-up hindered progress. Country commitment and effective partnerships are essential to address the financial, operational, technical, and policy challenges of the rising demand for viral load monitoring.

BACKGROUND: In 2007 Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access. Decentralization was facilitated through (1) down-referral of stable ART patients from overburdened central facilities (hubs) to primary health care clinics (spokes) and (2) ART initiation at spokes (spoke initiation). METHODS: We conducted a nationally representative retrospective cohort study among adult ART enrollees during 2004-2010 to assess the effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU) death and attrition (death or LTFU). Sixteen of 31 hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated the hub-and-spoke model by study start. At these facilities 1149 of 24782 hub-initiated and maintained and 878 of 7722 down-referred or spoke-initiated patient records were randomly selected and analyzed. At the 9 hub-only facilities 483 of 6638 records were randomly selected and analyzed. Multivariable proportional hazards regression was used to assess effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes. RESULTS: At ART initiation median age was 35 65% were female and median CD4 count was 147 cells per microliter. Controlling for known confounders down-referral was strongly protective against LTFU [adjusted hazard ratio (AHR) 0.38; 95% confidence interval (CI): 0.29 to 0.50] and attrition (AHR = 0.50; 95% CI: 0.34 to 0.76) but not mortality. Compared with hub-initiated and maintained patients spoke-initiated patients had lower LTFU (AHR 0.59; 95% CI: 0.45 to 0.77) and attrition rates (AHR 0.60; 95% CI: 0.47 to 0.77) but not mortality. CONCLUSIONS: Down-referral and spoke-initiation within a hub-and-spoke ART decentralization model were protective against LTFU and overall attrition and could facilitate future ART program expansion.

Background Nigeria had the most AIDS-related deaths worldwide in 2014 (170,000), and 46% were associated with tuberculosis (TB). Although treatment of people living with HIV (PLHIV) with antiretroviral therapy (ART) reduces TB-associated morbidity and mortality, incident TB can occur while on ART. We estimated incidence and characterized factors associated with TB after ART initiation in Nigeria. Methods We analyzed retrospective cohort data from a nationally representative sample of adult patients on ART. Data were abstracted from 3,496 patient records, and analyses were weighted and controlled for a complex survey design. We performed domain analyses on patients without documented TB disease and used a Cox proportional hazard model to assess factors associated with TB incidence after ART. Results At ART initiation, 3,350 patients (95.8%) were not receiving TB treatment. TB incidence after ART initiation was 0.57 per 100 person-years, and significantly higher for patients with CD4

INTRODUCTION: Children are important transmitters of influenza in the community and a number of non-pharmaceutical interventions (NPIs), including hand washing and use of hand sanitizer, have been recommended to mitigate the transmission of influenza, but limited information is available regarding schools' ability to implement these NPIs during an influenza outbreak. We evaluated implementation of NPIs during fall 2009 in response to H1N1 pandemic influenza (pH1N1) by New York City (NYC) public schools. METHODS: From January 25 through February 9, 2010, an online survey was sent to all the 1,632 NYC public schools and principals were asked to participate in the survey or to designate a school nurse or other school official with knowledge of school policies and characteristics to do so. RESULTS: Of 1,633 schools, 376(23%) accessed and completed the survey. Nearly all respondents (99%) implemented at least two NPIs. Schools that had a Flu Response Team (FRT) as a part of school emergency preparedness plan were more likely to implement the NPI guidelines recommended by NYC public health officials than schools that did not have a FRT. Designation of a room for isolating ill students, for example, was more common in schools with a FRT (72%) than those without (53%) (p

To improve early enrollment in HIV care, the Swaziland Ministry of Health implemented new linkage procedures for persons HIV diagnosed during the Soka Uncobe male circumcision campaign (SOKA, 2011–2012) and the Swaziland HIV Incidence Measurement Survey (SHIMS, 2011). Abstraction of clinical records and telephone interviews of a retrospective cohort of HIV-diagnosed SOKA and SHIMS clients were conducted in 2013–2014 to evaluate compliance with new linkage procedures and enrollment in HIV care at 92 facilities throughout Swaziland. Of 1,105 clients evaluated, within 3, 12, and 24 months of diagnosis, an estimated 14.0%, 24.3%, and 37.0% enrolled in HIV care, respectively, after adjusting for lost to follow-up and non-response. Kaplan-Meier functions indicated lower enrollment probability among clients 14–24 (P = 0.0001) and 25–29 (P = 0.001) years of age compared with clients >35 years of age. At 69 facilities to which clients were referred for HIV care, compliance with new linkage procedures was low: referral forms were located for less than half (46.8%) of the clients, and few (9.6%) were recorded in the appointment register or called either before (0.3%) or after (4.9%) their appointment. Of over one thousand clients newly HIV diagnosed in Swaziland in 2011 and 2012, few received linkage services in accordance with national procedures and most had not enrolled in HIV care two years after their diagnosis. Our findings are a call to action to improve linkage services and early enrollment in HIV care in Swaziland.

Staphylococcus aureus organisms vary in the function of the staphylococcal virulence regulator gene agr. To test for a relationship between agr and transmission in S. aureus, we determined the prevalence and genetic basis of agr dysfunction among nosocomial methicillin-resistant S. aureus (MRSA) in an area of MRSA endemicity. Identical inactivating agr mutations were not detected in epidemiologically unlinked clones within or between hospitals. Additionally, most agr mutants had single mutations, indicating that they were short lived. Collectively, the results suggest that agr dysfunction is adaptive for survival in the infected host but that it may be counteradaptive outside infected host tissues.

Understanding the underlying variables that contribute to the economic impact of large scale disasters is crucial to mitigating the effects on regions and businesses. However, depending on the approach used – secondary research on regions, using macroeconomic variables, vs. primary, survey-based business research – contradictions exist on the extent and nature of the recovery, and on the contributing variables. Further research is needed on characterisation of long-term recovery of regions and businesses in the wake of catastrophic disasters, to better pinpoint relevant factors and to inform the planning, response and mitigation efforts of communities and businesses in disaster-prone regions. This empirical work reviews and incrementally advances the literature in this area, by examining disaster recovery periods using a conceptual framework, broad-based economic indicators, and results from select case studies. Factors influencing business continuity and economic recovery of businesses are highlighted, and some best practices are discussed.

It is common knowledge that having an individual or family disaster plan is vital for saving lives and property before, during and after a disaster. First responders have the daunting task of helping many people during a disaster. It would make their jobs easier if people had disaster plans before a disaster. However, for a variety of reasons, few people have a disaster plan. People often do not develop disaster plans due to the time required to devise a plan, a lack of knowledge of the benefits of having a plan, or the effort required for the primarily manual process of developing a disaster plan. Wilberforce University has designed a solution called Wilberforce's Information Library Boosting Emergency Recovery (WILBER) which is a customized, online tool to quickly and automatically generate disaster plans to help save lives and property as well as mitigate the impacts of a potential disaster. WILBER utilizes an interdisciplinary approach to automatically generate a basic disaster preparedness plan. The system addresses a wide range of disasters but focuses on floods, earthquakes and technological disasters such as terrorism and nuclear disasters. WILBER automatically processes locally relevant data intelligently and combines mathematical analysis; distributed computing; individual and business risk management; current and historical information from a comprehensive Geographical Information Systems (GIS) that includes imagery, infrastructure, demographic, and environmental data; and wireless sensors for real time condition assessment. Not planning for a disaster only increases the potential magnitude of a disaster. WILBER allows citizens to quickly establish immediate procedures in the event of an emergency which in turn can lessen the burden on first responders and reduces the likelihood of loss of life. This research is funded by the Department of Energy's National Nuclear Security Administration and conducted by the Wilberforce University Disaster Recovery Center in Wilberforce, Ohio, USA.