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Background: In resource‐poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse‐based rapid assessment clinic for high‐risk individuals initiating cART in a resource‐constrained setting. Methods: The USAID‐AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi‐weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm[sup.3]. All HIV‐infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm[sup.3] were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods. Results: Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm[sup.3]. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45‐0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55‐0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57‐0.67). Conclusions: Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high‐risk patients initiating treatment in resource‐constrained settings., Background Combination antiretroviral treatment (cART) has proven itself to be an effective therapeutic mechanism for suppressing viral replication and enabling reconstitution of the immune system, thus allowing patients to recover [...]

The structure of softwoods, which confers resistance to degradation through hydrolysis and decay, currently limits their use for the production of biofuels. However, since wood is very heterogeneous, it is possible that differences in wood properties within and between trees could differentially affect its process ability. In this research, heartwood (inner) and sapwood (outer) from Norway spruce (Picea abies (L.) Karst.) clones were enzymatically hydrolyzed by Trichoderma viride cellulases after concentrated acid pretreatment. Wood sections with two particle sizes were compared based on their susceptibility to enzymatic hydrolysis, evaluated by assaying the formation of hydrolysis products and measured as reducing sugar yield (RSY). We also studied the relationship between RSY and the susceptibility to Heterobasidion parviporum wood decay and whether these traits are reflected in wood density and yield. Wood from the outer section produced more RSY with higher glucan but lower lignin content than wood from the inner section. Furthermore, susceptibility to enzymatic hydrolysis was positively correlated with H. parviporum wood decay, while both processes were negatively correlated with wood density. Our results revealed the importance of clonal trials for identifying suitable lignocellulosic biomass when considering wood properties and indicate that potential genotypes for the production of biofuels are not necessarily the most productive. Resume: La structure du bois des resineux qui leur confere une resistance a la degradation par hydrolyse et par la carie limite presentement leur utilisation pour la production de biocarburants. Cependant, etant donne que le bois est tres heterogne, il est possible que les differences de proprietes du bois a l'interieur du meme arbre ou entre differents arbres puissent avoir des effets differents sur sa transformabilite. Dans cette recherche, du bois de coeur (interne) et du bois d'aubier (externe) de clones d'epicea commun (Picea abies (L.) Karst.) ont ete hydrolyses enzymatiquement a l'aide de cellulases de Trichoderma viride apres un pretraitement avec un acide concentre. Les sections de bois avec deux dimensions de particules ont ete comparees sur la base de leur susceptibilite a l'hydrolyse enzymatique qui a ete evaluee en dosant la formation des produits de l'hydrolyse et mesuree sous forme de rendement en sucres reducteurs (RSR). Nous avons egalement etudie la relation entre le RSR et la susceptibilite a la carie du bois causee par Heterobasidion parviporum et verifie si ces caracteristiques sont refletees dans le rendement et la densite du bois. Le bois d'aubier a eu un meilleur RSR, avec une teneur en glucane plus elevee mais une teneur en lignine plus faible que le bois de coeur. De plus, la susceptibilite a l'hydrolyse enzymatique etait positivement correlee avec la carie du bois causee par H. parviporum tandis que les deux processus etaient negativement correles avec la densite du bois. Nos resultats ont fait ressortir l'importance des tests clonaux pour identifier la biomasse lignocellulosique convenable lorsqu'on considere les proprietes du bois et montrent que les genotypes potentiels pour la production de biocarburants ne sont pas necessairement les plus productifs. [Traduit par la Redaction], Introduction Combating climate change through renewable energy and ensuring energy security are major drivers of the increasing utilization of lignocellulosic biomass for the production of second-generation transport fuels. In general, [...]

A study was conducted to evaluate the efficacy of different antiretroviral therapies in women who were given peripartum single-dose nevirapine. Results indicated that in the case of women with such peripartum exposure, ritonavir-boosted lopinavir plus tenofovir-emtricitabine was found to be far superior as a form of initial antiretroviral therapy.

Introduction Approximately 33 million people worldwide are living with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS), and the majority are in sub-Saharan Africa. (1) The use of [...], Objective To determine the incidence of loss to follow-up in a treatment programme for people living with human immunodeficiency virus (HIV) infection in Kenya and to investigate how loss to follow-up is affected by gender. Methods Between November 2001 and November 2007, 50 275 HIV-positive individuals aged > 14 years (69% female; median age: 36.2 years) were enrolled in the study. An individual was lost to follow-up when absent from the HIV treatment clinic for > 3 months if on combination antiretroviral therapy (cART) or for > 6 months if not. The incidence of loss to follow-up was calculated using Kaplan-Meier methods anal factors associated with loss to follow-up were identified by logistic and Cox multivariate regression analysis. Findings Overall, 8% of individuals attended no follow-up visits, and 54% of them were lost to follow-up. The overall incidence of loss to follow-up was 25.1 per. 100 person-years. Among the 92% who attended at least one follow-up visit, the incidence of loss to follow-up before and after starting CART was 27.2 and 14.0 per 100 person- years, respectively. Baseline factors associated with loss to follow-up included younger age, a long travel time to the clinic, patient disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV disease, and rural clinic location. Men were at an increased risk overall and before and after starting cART. Conclusion The risk of being lost to follow-up was high, particularly before starting cART. Men were more likely to become lost to follow-up, even after adjusting for baseline sociodemographic and clinical characteristics. Interventions designed for men and women separately could improve retention. Objectif Determiner l'incidence de perte de suivi dans un programme de traitement pour les personnes vivant avec l'infection par le virus de l'immunodeficience humaine (VIH) au Kenya, et investiguer comment la perte de suivi est influencee par le sexe. Methodes Entre novembre 2001 et novembre 2007, 50 275 individus seropositifs d'age [is greater than or equal to] 14 ans (69% de sexe feminin; age median: 36,2 ans) ont participe a l'etude. Le suivi a ete perdu lorsque les individus ont ete absents de la clinique de traitement du VIH pendant > 3 mois lorsqu'ils etaient sous combinaison therapeutique antiretrovirale (TARV), et pendant > 6 mois dans le cas contraire. L'incidence de perte du suivi a ete calculee au moyen des methodes Kaplan-Meier, et les facteurs associes a la perte du suivi ont ete identifies par la regression logistique et l'analyse multivariable par regression du modele de Cox. Resultats Globalement, 8% des individus ne se sont jamais presentes a unevisite de suivi, et 54% d'entre eux ont perdu le suivi. L'incidence totale de perte du suivi etait de 25,1 par 100 personnes-annees. Parmi les 92% qui ont assiste a une visite de suivi au moins, l'incidence de perte du suivi avant et apres le debut du TARV a ete de 27,2 et 14,0 par 100 personnes-annees, respectivement. Parmi les facteurs de la ligne de base associes a la perte du suivi, ont ete constates le jeune age, la longueur du temps de trajet pour se rendre a la clinique, la revelation de l'etat VIH positif du patient, un nombre eleve de lymphocytes CD4+, un stade avance de la maladie a VIH et la ruralite de la clinique. Les hommes ont presente un risque plus eleve en general et ce, avant et apres le debut du TARV. Conclusion Le risque de perte du suivi a ete eleve, particulierement avant le debut du TARV. Les hommes ont ete plus enclins a perdre le suivi, meme apres ajustement pour base sociodemographique et caracteristiques cliniques. Des interventions concues separement pour les hommes et les femmes pourraient ameliorer la retention. Objetivo Determinar la incidencia de bajas en el seguimiento de un programa terapeutico de personas portadoras del virus de la inmunodeficiencia humana (VIH) en Kenya, e investigar si el sexo de dichas personas influye en las bajas en el seguimiento. Metodos Entre noviembre de 2001 y noviembre de 2007 se inscribieron en el estudio 50 275 personas VIH-positivas de mas de 14 anos de edad (69% mujeres; edad media: 36,2 anos). Se considero Una baja en el seguimiento cuando la persona se ausento de la clinica de tratamiento del VIH durante mas de tres meses si estaba en tratamiento antirretroviral combinado (TARC) o, en el caso contrario, durante mas de seis meses. La incidencia de bajas en el seguimiento se ha calculado utilizando los metodos de Kaplan-Meier, y los factores asociados con las bajas en el seguimiento se han identificado mediante un analisis de regresion logistica y de regresion multifactorial de Cox. Resultados En terminos generales, el 8% de las personas no acudieron a las visitas de seguimiento, de las que el 54% se consideraron como bajas en el seguimiento. La incidencia total de bajas en el seguimiento fue de 25,1 por 100 anos-persona. Dei 92% que acudio al menos a una visita de seguimiento, la incidencia de baja en el seguimiento, antes y despues de comenzar el TARC fue de 27,2 y 14,0 por 100 anos persona, respectivamente. Los factores iniciales asociados a la baja en el seguimiento incluyeron: la juventud, la lejania de la clinica, la revelacion dei paciente de su estado de VIH-positivo, el recuento linfocitico CD4+ elevado, enfermedades debidas al VIH en fase avanzada y la ubicacion de la clinica rural. El riesgo general en hombres fue elevado, antes y despues de iniciar el TARC. Conclusion El riesgo de baja en el seguimiento dei paciente fue elevado, sobre todo antes de iniciar el TARC. Hubo una tendencia de mas bajas en el seguimiento entre los hombres, aun despues dei ajuste de las caracteristicas sociodemograficas y clinicas iniciales. Las intervenciones especificas e individuales para hombres y mujeres podrian mejorar la permanencia en el programa.

Purpose: To develop a set of actionable quality indicators for critical care suitable for use in low- or middle-income countries (LMICs).Methods: A list of 84 candidate indicators compiled from a previous literature review and stakeholder recommendations were categorised into three domains (foundation, process, and quality impact). An expert panel (EP) representing stakeholders from critical care and allied specialties in multiple low-, middle-, and high-income countries was convened. In rounds one and two of the Delphi exercise, the EP appraised (Likert scale 1-5) each indicator for validity, feasibility; in round three sensitivity to change, and reliability were additionally appraised. Potential barriers and facilitators to implementation of the quality indicators were also reported in this round. Median score and interquartile range (IQR) were used to determine consensus; indicators with consensus disagreement (median < 4, IQR ≤ 1) were removed, and indicators with consensus agreement (median ≥ 4, IQR ≤ 1) or no consensus were retained. In round four, indicators were prioritised based on their ability to impact cost of care to the provider and recipient, staff well-being, patient safety, and patient-centred outcomes.Results: Seventy-one experts from 30 countries (n = 45, 63%, representing critical care) selected 57 indicators to assess quality of care in intensive care unit (ICU) in LMICs: 16 foundation, 27 process, and 14 quality impact indicators after round three. Round 4 resulted in 14 prioritised indicators. Fifty-seven respondents reported barriers and facilitators, of which electronic registry-embedded data collection was the biggest perceived facilitator to implementation (n = 54/57, 95%) Concerns over burden of data collection (n = 53/57, 93%) and variations in definition (n = 45/57, 79%) were perceived as the greatest barrier to implementation.Conclusion: This consensus exercise provides a common set of indicators to support benchmarking and quality improvement programs for critical care populations in LMICs. [ABSTRACT FROM AUTHOR]

Hepatitis C virus (HCV) is a viral pandemic and a leading cause of chronic liver disease. This review highlights the epidemiology and management of Hepatitis C in Africa. We searched for articles on medline using the terms, "Hepatitis C", "Prevalence", "Epidemiology", "Africa" and "Treatment". The bibliographies of the articles found were used to find other references. We included articles published after 1995 only. The data was summarized and presented in tables and figures. Africa has the highest WHO estimated regional HCV prevalence (5.3%). Egypt has the highest prevalence (17.5%) of HCV in the world. Genotypes commonly found in Africa are 1, 4 and 5. Genotype 3 is found in Egypt and parts of Central Africa. Blood transfusion is a major means of acquisition of HCV infection. While treatment with peginterferon and ribavirin is recommended for patients with chronic HCV, no data were found on their use in Africa. Neither were there any data on definitive management (liver transplantation) for those with end stage disease. Data on HCV infection in Africa are scarce. This suggests that hepatitis C is still a neglected disease in many countries. Limited data exist in literature on HCV in Africa

This cohort study utilized data from a large HIV treatment program in western Kenya to describe the impact of active tuberculosis (TB) on clinical outcomes among African patients on antiretroviral therapy (ART).We included all patients initiating ART between March 2004 and November 2007. Clinical (signs and symptoms), radiological (chest radiographs) and laboratory (mycobacterial smears, culture and tissue histology) criteria were used to record the diagnosis of TB disease in the program's electronic medical record system.We assessed the impact of TB disease on mortality, loss to follow-up (LTFU) and incident AIDS-defining events (ADEs) through Cox models and CD4 cell and weight response to ART by non-linear mixed models.We studied 21,242 patients initiating ART-5,186 (24%) with TB; 62% female; median age 37 years. There were proportionately more men in the active TB (46%) than in the non-TB (35%) group. Adjusting for baseline HIV-disease severity, TB patients were more likely to die (hazard ratio--HR = 1.32, 95% CI 1.18-1.47) or have incident ADEs (HR = 1.31, 95% CI: 1.19-1.45). They had lower median CD4 cell counts (77 versus 109), weight (52.5 versus 55.0 kg) and higher ADE risk at baseline (CD4-adjusted odds ratio = 1.55, 95% CI: 1.31-1.85). ART adherence was similarly good in both groups. Adjusting for gender and baseline CD4 cell count, TB patients experienced virtually identical rise in CD4 counts after ART initiation as those without. However, the overall CD4 count at one year was lower among patients with TB (251 versus 269 cells/µl).Clinically detected TB disease is associated with greater mortality and morbidity despite salutary response to ART. Data suggest that identifying HIV patients co-infected with TB earlier in the HIV-disease trajectory may not fully address TB-related morbidity and mortality.

HIV protease inhibitors (PIs) show antimalarial activity in vitro and in animals. Whether this translates into a clinical benefit in HIV-infected patients residing in malaria-endemic regions is unknown. We studied the incidence of malaria, as defined by blood smear positivity or a positive Plasmodium falciparum histidine-rich protein 2 antigen test, among 444 HIV-infected women initiating antiretroviral treatment (ART) in the OCTANE trial (A5208; ClinicalTrials.gov: NCT00089505). Participants were randomized to treatment with PI-containing vs. PI-sparing ART, and were followed prospectively for ≥48 weeks; 73% also received cotrimoxazole prophylaxis. PI-containing treatment was not associated with protection against malaria in this study population.

Mycobacteria leprae(leprosy) and HIV coinfection are rare in Kenya. This is likely related to the low prevalence (1 per 10,000 of population) of leprosy. Because leprosy is no longer a public health challenge there is generally a low index of suspicion amongst clinicians for its diagnosis. Management of a HIV-1-leprosy-coinfected individual in a resource-constrained setting is challenging. Some of these challenges include difficulties in establishing a diagnosis of leprosy; the high pill burden of cotreatment with both antileprosy and antiretroviral drugs (ARVs); medications’ side effects; drug interactions; scarcity of drug choices for both diseases. This challenge is more profound when managing a patient who requires second-line antiretroviral therapy (ART). We present an adult male patient coinfected with HIV and leprosy, who failed first-line antiretroviral therapy (ART) and required second-line treatment. Due to limited choices in antileprosy drugs available, the patient received monthly rifampicin and daily lopinavir-/ritonavir-based antileprosy and ART regimens, respectively. Six months into his cotreatment, he seemed to have adequate virological control. This case report highlights the challenges of managing such a patient.

Background. There was a 6-month shortage of antiretrovirals (cART) in Kenya. Methods. We assessed morbidity, mortality, and loss to follow-up (LTFU) in this retrospective analysis of adults who were enrolled during the six-month period with restricted cART (cap) or the six months prior (pre-cap) and eligible for cART at enrollment by the pre-cap standard. Cox models were used to adjust for potential confounders. Results. 9009 adults were eligible for analysis: 4,714 pre-cap and 4,295 during the cap. Median number of days from enrollment to cART initiation was 42 pre-cap and 56 for the cap (P