Search

Introduction Adolescent girls and young women, including adolescent mothers, in Southern Africa have high HIV seroconversion and transmission. We need to know which risks drive HIV infections, and what can reduce these risks. Methods We interviewed 1712 adolescent girls and young women (11–23 years), including 1024 adolescent mothers who had conceived before age 20 and had a living child, from two health municipalities of South Africa's Eastern Cape Province between March 2018 and July 2019. Recruitment was through multiple community, school and health facility channels. Associations between adolescent motherhood and seven HIV risk behaviours (multiple sexual partners, transactional sex, age-disparate sex, condomless sex, sex on substances, alcohol use and not in education or employment) were investigated using the generalized estimating equations method for multiple outcomes specified with a logit link and adjusting for nine covariates. Using the same model, we investigated associations between having enough food at home every day in the past week (food security) and the same seven HIV risk behaviours. When we found evidence of moderation by HIV status, we report stratum-specific odds ratios. Results Mean age was 17.51 years (SD: 2.54), 46% participants were living with HIV. Compared to non-mothers, adolescent mothers had lower odds of alcohol use (AOR = 0.47, 95% CI = 0.29–0.75), but higher odds of multiple sexual partners (AOR = 1.93, 95% CI = 1.35–2.74), age-disparate sex (HIV-uninfected AOR = 1.73, 95% CI = 1.03–2.91; living with HIV AOR = 5.10, 95% CI = 2.98–8.73), condomless sex (AOR = 8.20, 95% CI = 6.03–11.13), sex on substances (AOR = 1.88, 95% CI = 1.10–3.21) and not in education/employment (HIV-uninfected AOR = 1.83, 95% CI = 1.19–2.83; living with HIV AOR = 6.30, 95% CI = 4.09–9.69). Among non-mothers, food security was associated with lower odds of multiple sexual partners (AOR = 0.45, 95% CI = 0.26–0.78), transactional sex (AOR = 0.32, 95% CI = 0.13–0.82) and not in education/employment (AOR = 0.48, 95% CI = 0.29–0.77). Among adolescent mothers, food security was associated with lower odds of transactional sex (AOR = 0.17, 95% CI = 0.10–0.28), age-disparate sex (AOR = 0.66, 95% CI = 0.47–0.92), sex on substances (AOR = 0.51, 95% CI = 0.32–0.82), alcohol use (AOR = 0.45, 95% CI = 0.25–0.79) and not in education/employment (AOR = 0.56, 95% CI = 0.40–0.78). Conclusions Adolescent motherhood is associated with multiple vulnerabilities to HIV infection and transmission. Social protection measures that increase food security are likely to reduce HIV risk pathways for adolescent girls and young women, especially adolescent mothers.

There is limited evidence around the cost-effectiveness of interventions to prevent violence against children in low- and middle-income countries. We developed a decision-analytic model to estimate the cost-effectiveness of 1) a community outreach intervention to link eligible households to anti-poverty cash grants, and 2) a group-based parenting support intervention, and 3) a group-based parenting support ‘plus’ linkage of eligible households to anti-poverty cash grants intervention for preventing adolescent violence victimisation in Mpumalanga province, South Africa.The target population was families with an adolescent living below the national food poverty line. Modelled violence outcomes were emotional, physical, and sexual abuse. Intervention effectiveness was conditional on interventions’ effect on two evidence-based protective factors for adolescent violence: food security and caregiver supervision. Cost-effectiveness ratios were expressed per DALY averted and evaluated against a South Africa-specific willingness-to-pay threshold. We varied model parameters to consider routine service delivery versus trial-based costing, and population-average versus high prevalence of violence.For routine service delivery costing, both community grant outreach and parenting support interventions were cost-effective at population-average prevalence (ACER=USD2,650, and ACER=USD2,830 per DALYs averted, respectively), and high prevalence of violence (ACER=USD1,330 and ACER=USD2,305 per DALYs averted, respectively). The incremental cost-effectiveness of adding grant linkage to parenting support was USD271 and USD177 at population-average and high prevalence of violence, respectively. For trial-based costing, none of the interventions were cost-effective at population-average prevalence of violence, and only community grant outreach was cost-effective at high prevalence of violence (ACER=USD2400 per DALY averted). Cost-effectiveness estimates are expected to be conservative based on our only modelling intervention effects on three violence outcomes via two protective factors.Findings indicate that investments in community grant outreach, and parenting support interventions are likely to be cost-effective for preventing adolescent violence. Adding a grant linkage component to parenting support would enhance this approaches cost-effectiveness.

Tuberculosis is the leading cause of deaths from an infectious disease worldwide. WHO's End TB Strategy is falling short of several 2020 targets. Undernutrition is the leading population-level risk factor for tuberculosis. Studies have consistently found that undernutrition is associated with increased tuberculosis incidence, increased severity, worse treatment outcomes, and increased mortality. Modelling studies support implementing nutritional interventions for people living with tuberculosis and those at risk of tuberculosis disease to ensure the success of the End TB Strategy. In this Personal View, we highlight nutrition-related immunocompromisation, implications of undernutrition for tuberculosis treatment and prevention, the role of nutritional supplementation, pharmacokinetics and pharmacodynamics of antimycobacterial medications in undernourished people with tuberculosis, and the role of social protection interventions in addressing undernutrition as a tuberculosis risk factor. To catalyse action on this insufficiently addressed accelerant of the global tuberculosis epidemic, research should be prioritised to understand the immunological pathways that are impaired by nutrient deficiencies, develop tools to diagnose clinical and subclinical tuberculosis in people who are undernourished, and understand how nutritional status affects the efficacy of tuberculosis vaccine and therapy. Through primary research, modelling, and implementation research, policy change should also be accelerated, particularly in countries with a high burden of tuberculosis.

Adolescents exposed to high levels of adversity are vulnerable to developing mental health challenges, with long-lasting adverse consequences. Promoting the psychological well-being of adolescents and protecting them from adverse experiences is crucial for their quality of life. There is a need for evidence on which combinations of protective factors can improve the wellbeing of adolescents to inform future programming efforts. We used data from a longitudinal study that took place in Khayelitsha, South Africa, a semi-urban impoverished community in Cape Town. Data were collected from adolescents when they were 12–14 years of age (n = 333) and again at follow-up when they were aged 16–19 years (n = 314). A path analysis was used to estimate associations between access to service, food security, safe environment, family support, and social support and five outcomes related to adolescent mental health and risky behaviours. The fitted model was used to calculate adjusted mean differences comparing different combinations of risk factors. Two protective factors (food security and safe environment) were positively associated with three outcomes relating to mental health and the absence of risky behaviours. Further investigation revealed that the presence of high food security and safer environments was associated with higher adjusted mean scores: +16.2% (p < .0001) in no substance use; +16.5% (p < .0001) in no internalising behaviour, +19.5% (p < .0001) in self-esteem; +12.2% (p < .0001) in positive peer relationships; and +11.4% (p < .0001) in no suicidal ideation. Interventions targeting adolescents, that aim to improve food security together with improving the safety of their environment, are likely to impact their well-being.

This study aimed to identify possible entry points for interventions that can act as development accelerators for children and adolescents in South Africa and Malawi.This study was a secondary data analysis. Data were sourced from the Child Community Care longitudinal study which tracked child well-being outcomes among 989 children (4-13 years) and their caregivers affected by HIV and enrolled in community-based organizations in South Africa and Malawi. We examined associations between five hypothesized accelerating services/household provisions-measured as access at baseline and follow-up and 12 child outcomes that relate to indicators within the Sustainable Development Goals (SDGs) framework. We calculated the adjusted probabilities of experiencing each SDG aligned outcome conditional on receipt of single, combined or all identified accelerators.The results show household food security is associated with positive child education and cognitive development outcomes. Cash grants were positively associated with nutrition and cognitive development outcomes. Living in a safe community was positively associated with all mental health outcomes. Experiencing a combination of two factors was associated with higher probability of positive child outcomes. However, experiencing all three accelerators was associated with better child outcomes, compared with any of the individual factors by themselves with substantial improvements noted in child education outcomes.Combined delivery of specific interventions or services may yield greater improvements in child outcomes across different developmental domains. It is recommended that multiple support avenues in combination like improving food security and safe communities, as well as social protection grants, should be provided for vulnerable children to maximize the impact.

Recent evidence has shown support for the United Nations Development Programme (UNDP) accelerator concept, which highlights the need to identify interventions or programmatic areas that can affect multiple sustainable development goals (SDGs) at once to boost their achievement. These data have also clearly shown enhanced effects when interventions are used in combination, above and beyond the effect of single interventions. However, detailed knowledge is now required on optimum combinations and relative gain in order to derive policy guidance. Which accelerators work for which outcomes, what combinations are optimum, and how many combinations are needed to maximise effect? The current study utilised pooled data from the Young Carers (n = 1402) and Child Community Care (n = 446) studies. Data were collected at baseline (n = 1848) and at a 1 to 1.5- year follow-up (n = 1740) from children and young adolescents aged 9–13 years, living in South Africa. Measures in common between the two databases were used to generate five accelerators (caregiver praise, caregiver monitoring, food security, living in a safe community, and access to community-based organizations) and to investigate their additive effects on 14 SDG-related outcomes. Predicted probabilities and predicted probability differences were calculated for each SDG outcome under the presence of none to five accelerators to determine optimal combinations. Results show that various accelerator combinations are effective, though different combinations are needed for different outcomes. Some accelerators ramified across multiple outcomes. Overall, the presence of up to three accelerators was associated with marked improvements over multiple outcomes. The benefit of targeting access to additional accelerators, with additional costs, needs to be weighed against the relative gains to be achieved with high quality but focused interventions. In conclusion, the current data show the detailed impact of various protective factors and provides implementation guidance for policy makers in targeting and distributing interventions to maximise effect and expenditure. Future work should investigate multiplicative effects and synergistic interactions between accelerators.

Ethiopia has registered remarkable achievements in reaching global development goals, including reducing child marriage. Policymakers are keen to understand which investments have contributed to this. We evaluated the association between Ethiopia's Health Extension Program (HEP) and 12 adolescent health and wellbeing outcomes.We used Young Lives Ethiopia cohort data between 2002 and 2013. We evaluated associations between household support from HEP at age 15 and 12 adolescent outcomes spread across health, gender-based violence, education, and employment at age 19 using the inverse probability of treatment weighting propensity score approach, stratifying by sex. Adjusted probability differences (APDs) and adjusted mean differences (AMDs) were used to contrast exposure to HEP versus no exposure.Of 775 adolescents with complete follow-up, 46% were female. Sixty-six percent of adolescents reported support from HEP, with higher rates of support in poorer, less educated, and rural households, particularly in Tigray Province. In boys, HEP was positively associated with education enrolment (APD: +20 percentage points [ppts], 95% confidence interval [CI]: +9 ppts, +31 ppts) and literacy (AMD: +6 ppts, 95% CI: +0.2, +11), and negatively associated with4 hours in income-generating activities per day (APD: -19 ppts, 95% CI: -30 ppts, -9 ppts). In girls, HEP was positively associated with no child marriage (APD: +16 ppts, 95% CI: +4 ppts, +27 ppts), no adolescent pregnancy (APD: +17 ppts, 95% CI: +6 ppts, +28 ppts), education enrolment (APD: +27 ppts, 95% CI: +15 ppts, +39 ppts), literacy (AMD: +5 ppts, 95% CI: +0.2, +11), and numeracy (AMD: +8 ppts, 95% CI: +3; +13).Policies promoting HEP are likely to have supported improvements in multiple areas of adolescents' lives in Ethiopia.

Background: \ud \ud Identifying risk and protective factors for adolescent antiretroviral therapy (ART) adherence is a public health priority, given high HIV-related mortality in this population. An area that merits further investigation is the relationship between bullying victimization, mental health problems, and ART nonadherence among adolescents living with HIV (ALHIV). However, no known studies assess effects of bullying on adolescent nonadherence or risk and protective factors that could moderate this relationship.\ud Setting: \ud \ud This study investigates (1) the direct longitudinal relationship between bullying exposure and ART nonadherence, and the indirect relationship via psychological distress, and (2) potential risk and modifiable protective factors moderating these pathways, among vertically and horizontally infected ALHIV who initiated treatment across 53 public health care facilities in a South African health district.\ud Methods: \ud \ud Survey data were collected at 2 time points, between 2014 and 2017, with 1046 ALHIV (94% retention). Various mediation and moderated mediation models were run as part of a staged analysis approach.\ud Results: \ud \ud A significant longitudinal relationship was found between bullying victimization and nonadherence, operating indirectly through psychological distress [B = 0.07; 95% confidence interval (CI): (0.03 to 0.13)]. Moderation analyses indicated that older adolescents exposed to bullying are more at risk of nonadherence [B = 0.52; 95% CI: (0.07 to 0.97) P < 0.05], and parental monitoring is a potential protective factor buffering indirect effects of bullying on nonadherence [B = −0.22; 95% CI: (−0.42 to −0.02) P < 0.05].\ud Conclusions: \ud \ud These findings underscore the importance of interventions that address bullying and psychological distress, and strengthen parental monitoring, particularly among older ALHIV.

Background. Scalable interventions are needed to support adolescents thrive. Since 2003, the Ethiopian Government’s Health Extension Programme (HEP) has reached millions of households. We evaluated the relationship between household support from HEP and eleven indicators of adolescent health and wellbeing. Methods. We used Young Lives Ethiopia cohort data between 2002 and 2013. Outcomes were: not underweight, self-reported very good health, education enrolment, domestic tasks, paid work, fertility knowledge, sexually transmitted infection knowledge, no child marriage, no early pregnancy, literacy, and numeracy. We evaluated associations between household support from HEP at age 15 and study outcomes at age 19 using propensity score weighted regression, stratifying by sex, and adjusting for receipt of the Productive Safety Net Programme, and economic shocks. Adjusted probability differences (APDs) and adjusted mean differences (AMDs) were used to contrast exposure to HEP vs. no exposure. Findings. Of 775 adolescents with complete follow-up, 46% were female, with baseline mean age 7.87 years (SD: 0.29). Sixty-six percent of adolescents reported household support from HEP. Baseline predictors of support included lower household wealth, lower caregiver education, rural location, and residence in Tigray. Propensity score weighting yielded good balance. In boys, HEP was positively associated with education enrolment (APD: +17ppts, 95% CIs: +6ppts; +27ppts), and negatively associated with paid work (APD: -16ppts, 95% CIs: -27ppts; -4ppts). In girls, HEP was positively associated with fertility knowledge (APD: +14ppts, 95% CIs: 2ppts; 25ppts), no child marriage (APD: +19ppts, 95% CIs: +9ppts; +29ppts), no early pregnancy (APD: +18ppts, 95% CIs: +9ppts; +28ppts), education enrolment (APD: +23ppts, 95% CIs: +11ppts; +34ppts), literacy (AMD: +7ppts, 95% CIs: +2; +11), and numeracy (AMD: +10ppts, 95% CIs: +5; +14). Interpretation. Policies promoting HEP will substantially support multiple areas of adolescent health and wellbeing, and help their transition to adulthood.

Supplemental Digital Content is available in the text, Objective: Adolescent antiretroviral treatment (ART) adherence remains critically low. We lack research testing protective factors across both clinic and care environments. Design: A prospective cohort of adolescents living with HIV (sample n = 969, 55% girls, baseline mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline and 18-month follow-up (2014–2015, 2015–2016). We traced all adolescents ever initiated on treatment in 52 government health facilities (90% uptake, 93% 18-month retention, 1.2% mortality). Methods: Clinical records were collected; standardized questionnaires were administered by trained data collectors in adolescents’ language of choice. Probit within-between regressions and average adjusted probability calculations were used to examine associations of caregiving and clinic factors with adherence, controlling for household structure, socioeconomic and HIV factors. Results: Past-week ART adherence was 66% (baseline), 65% (follow-up), validated against viral load in subsample. Within-individual changes in three factors were associated with improved adherence: no physical and emotional violence (12.1 percentage points increase in adjusted probability of adherence, P

Background The INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource-limited contexts. Consequently, governments are requesting additional evidence to inform which ‘accelerator’ provisions can simultaneously reduce multiple types of violence against children. Methods and findings We pooled data from two prospective South African adolescent cohorts including Young Carers (2010–2012) and Mzantsi Wakho (2014–2017). The combined sample size was 5,034 adolescents. Each cohort measured six self-reported violence outcomes (sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking) and seven self-reported INSPIRE-aligned protective factors (positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services). Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics and correcting for multiple-hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARDs) and adjusted risk ratios (ARRs) with 95% confidence intervals (CIs) were also calculated. The sample mean age was 13.54 years, and 56.62% were female. There was 4% loss to follow-up. Positive parenting, parental monitoring and supervision, and food security at home were each associated with lower odds of three or more violence outcomes (p < 0.05). For girls, the adjusted probability of violence outcomes was estimated to be lower if all three of these factors were present, as compared to none of them: sexual abuse, 5.38% and 1.64% (ARD: −3.74% points, 95% CI −5.31 to −2.16, p < 0.001); transactional sexual exploitation, 10.07% and 4.84% (ARD: −5.23% points, 95% CI −7.26 to −3.20, p < 0.001); physical abuse, 38.58% and 23.85% (ARD: −14.72% points, 95% CI −19.11 to −10.33, p < 0.001); emotional abuse, 25.39% and 12.98% (ARD: −12.41% points, 95% CI −16.00 to −8.83, p < 0.001); community violence victimisation, 36.25% and 28.37% (ARD: −7.87% points, 95% CI −11.98 to −3.76, p < 0.001); and youth lawbreaking, 18.90% and 11.61% (ARD: −7.30% points, 95% CI −10.50 to −4.09, p < 0.001). For boys, the adjusted probability of violence outcomes was also estimated to be lower if all three factors were present, as compared to none of them: sexual abuse, 2.39% to 1.80% (ARD: −0.59% points, 95% CI −2.24 to 1.05, p = 0.482); transactional sexual exploitation, 6.97% to 4.55% (ARD: −2.42% points, 95% CI −4.77 to −0.08, p = 0.043); physical abuse from 37.19% to 25.44% (ARD: −11.74% points, 95% CI −16.91 to −6.58, p < 0.001); emotional abuse from 23.72% to 10.72% (ARD: −13.00% points, 95% CI −17.04 to −8.95, p < 0.001); community violence victimisation from 41.28% to 35.41% (ARD: −5.87% points, 95% CI −10.98 to −0.75, p = 0.025); and youth lawbreaking from 22.44% to 14.98% (ARD −7.46% points, 95% CI −11.57 to −3.35, p < 0.001). Key limitations were risk of residual confounding and not having information on protective factors related to all seven INSPIRE strategies. Conclusion In this cohort study, we found that positive and supervisory caregiving and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one or none of these factors. Policies promoting action on positive and supervisory caregiving and food security at home are likely to support further efficiencies in the delivery of INSPIRE., Lucie D. Cluver and colleagues explore associations of protective interventions with reducing violence against children., Author summary Why was this study done? A billion children are victims of violence each year. Governments need solutions that impact across not one but multiple childhood violence targets simultaneously—'development accelerators’. The World Health Organization’s INSPIRE package of seven strategies for ending violence against children is our best starting point to test for these. What did the researchers do and find? We pooled two South African cohorts including 5,034 10- to 19-year-olds. We tested seven INSPIRE-aligned protective factors against six violence types: sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence, and youth lawbreaking. Positive parenting, parental monitoring and supervision, and food security were each associated with lower likelihood of three or more types of violence. Experiencing all three of these factors was associated with lower likelihood of six types of violence for girls and boys, with up to 50% reductions. What do these findings mean? Caution should be taken, as observational studies cannot demonstrate causality. In the context of the COVID-19 economic crisis, strategic approaches to preventing violence are needed. Effective interventions to address positive and supervisory parenting and food security, such as parenting support and economic support, might reduce multiple forms of violence against children. When combined, these ‘development accelerators’ might have wider and stronger effects on multiple forms of violence.

Objective To explore amateur endurance athletes’ use and views about non-steroidal anti-inflammatory drugs (NSAIDs). Methods An online cross-sectional survey of amateur athletes at four athletic clubs. Key findings Of a sample of 129 of amateur athletes, 68% (n = 88) reported using NSAIDs in the previous 12 months (84.4% in triathletes, 70.9% in runners and 52.5% in cyclists). Overall, ibuprofen was the most popular drug (n = 48). There was a lack of knowledge of adverse drug reactions, with only 26% of use advised by a doctor or pharmacist. Conclusions There is high usage of NSAIDs in amateur athletes, including before and during events, largely without professional health advice. Informational needs of amateur athletes are not being met.

Background Illness-related costs for patients with tuberculosis (TB) ≥20% of pre-illness annual household income predict adverse treatment outcomes and have been termed “catastrophic.” Social protection initiatives, including cash transfers, are endorsed to help prevent catastrophic costs. With this aim, cash transfers may either be provided to defray TB-related costs of households with a confirmed TB diagnosis (termed a “TB-specific” approach); or to increase income of households with high TB risk to strengthen their economic resilience (termed a “TB-sensitive” approach). The impact of cash transfers provided with each of these approaches might vary. We undertook an economic modelling study from the patient perspective to compare the potential of these 2 cash transfer approaches to prevent catastrophic costs. Methods and findings Model inputs for 7 low- and middle-income countries (Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen) were retrieved by literature review and included countries' mean patient TB-related costs, mean household income, mean cash transfers, and estimated TB-specific and TB-sensitive target populations. Analyses were completed for drug-susceptible (DS) TB-related costs in all 7 out of 7 countries, and additionally for drug-resistant (DR) TB-related costs in 1 of the 7 countries with available data. All cost data were reported in 2013 international dollars ($). The target population for TB-specific cash transfers was poor households with a confirmed TB diagnosis, and for TB-sensitive cash transfers was poor households already targeted by countries’ established poverty-reduction cash transfer programme. Cash transfers offered in countries, unrelated to TB, ranged from $217 to $1,091/year/household. Before cash transfers, DS TB-related costs were catastrophic in 6 out of 7 countries. If cash transfers were provided with a TB-specific approach, alone they would be insufficient to prevent DS TB catastrophic costs in 4 out of 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $3.8 million (95% CI: $3.8 million–$3.8 million) and $75 million (95% CI: $50 million–$100 million) per country. If instead cash transfers were provided with a TB-sensitive approach, alone they would be insufficient to prevent DS TB-related catastrophic costs in any of the 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between $298 million (95% CI: $219 million–$378 million) and $165,367 million (95% CI: $134,085 million–$196,425 million) per country. DR TB-related costs were catastrophic before and after TB-specific or TB-sensitive cash transfers in 1 out of 1 countries. Sensitivity analyses showed our findings to be robust to imputation of missing TB-related cost components, and use of 10% or 30% instead of 20% as the threshold for measuring catastrophic costs. Key limitations were using national average data and not considering other health and social benefits of cash transfers. Conclusions A TB-sensitive cash transfer approach to increase all poor households’ income may have broad benefits by reducing poverty, but is unlikely to be as effective or affordable for preventing TB catastrophic costs as a TB-specific cash transfer approach to defray TB-related costs only in poor households with a confirmed TB diagnosis. Preventing DR TB-related catastrophic costs will require considerable additional investment whether a TB-sensitive or a TB-specific cash transfer approach is used., In this modelling study, William Rudgard of the London School of Hygiene and Tropical Medicine and colleagues compare two cash-transfer strategies to avert catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries., Author summary Why was this study done? Household costs related to active drug-susceptible (DS) or drug-resistant (DR) tuberculosis (TB) disease include costs for consultations, transport to and from clinics, increased food needs and lost income. If these costs are greater than or equal to one-fifth (20%) of the household’s annual income, then the patient is at risk of unsuccessful TB treatment and these high costs are termed “catastrophic costs.” The World Health Organization’s End TB Strategy prioritises preventing TB-affected households from facing catastrophic costs and proposes cash transfers as one way to achieve this. However, there are at least 2 approaches by which cash transfers could be provided to TB-affected households. In the first, they are provided to defray/reimburse households’ TB-related costs (termed a “TB-specific” approach). In the second, they are provided to increase households’ pre-illness income to prevent poverty and strengthen their economic resilience (termed a “TB-sensitive” approach). Lack of available individual-level data sources has meant that no studies have compared a TB-specific versus a TB-sensitive cash transfer approach. A literature review combined with a secondary data analysis was an effective way to bring together relevant data from several different sources and model the potential of cash transfers provided by these 2 approaches to prevent catastrophic costs. What did the researchers do and find? We performed a rigorous review of public data sources available on the internet, extracting national average data published between 2005 and 2013 for the 7 low- and middle-income economy countries of Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen. The data values we extracted included the countries’ mean value of TB patient costs, mean household income, mean cash transfers, and the expected size of the population that would be targeted with either TB-specific or TB-sensitive cash transfers. In all 7 countries these analyses were completed for DS TB, and in 1 of the 7 countries we were also able to complete these analyses for DR TB. Expressing TB patient costs as a percentage of household income, we found that average DS TB costs were catastrophic in 6 out of the 7 countries included in the study. In these 6 countries, TB-specific cash transfers prevented DS TB catastrophic costs in only 2, whilst TB-sensitive cash transfers did not prevent DS TB catastrophic costs in any of them. In the 1 country with available data, average DR TB costs were catastrophic, and neither TB-specific nor TB-sensitive cash transfers were sufficient to prevent this. For both TB-specific and TB-sensitive approaches, we then estimated the total value that cash transfers would need to be increased to in order to prevent the countries’ average DS or DR TB costs from being catastrophic for DS or DR TB-affected household. Based on this, we also estimated the average budget that each country would need to prevent catastrophic costs for all DS or DR TB-affected households. We found that a TB-specific approach was much more affordable than a TB-sensitive approach. What do these findings mean? The potential of cash transfers to prevent TB-related catastrophic costs is greater if they are provided to defray/reimburse poor households’ costs (TB-specific approach) rather than to increase the income and strengthen the economic resilience of poor households with high TB risk (TB-sensitive approach). Where cash transfers are insufficient to prevent catastrophic costs, it will be cheaper to supplement their value to achieve this objective using a TB-specific approach rather than a TB-sensitive approach. Important study limitations were that the study was at the country-level, so we might have underestimated the potential of cash transfers to prevent catastrophic costs. Also, we did not assess other health and social benefits of cash transfers, so the impact of TB-specific versus TB-sensitive cash transfers was only judged from the perspective of preventing catastrophic costs.

Leptospirosis is an important zoonosis worldwide, with infections occurring after exposure to contaminated water. Despite being a global problem, laboratory diagnosis remains difficult with culture results taking up to 3 months, serology being retrospective by nature, and polymerase chain reaction showing limited sensitivity. Leptospira have been shown to survive and multiply in blood culture media, and we hypothesized that extracting DNA from incubated blood culture fluid (BCF), followed by quantitative real-time polymerase chain reaction (qPCR) could improve the accuracy and speed of leptospira diagnosis. We assessed this retrospectively, using preincubated BCF of Leptospira spp. positive (N= 109) and negative (N= 63) febrile patients in Vientiane, Lao PDR. The final method showed promising sensitivities of 66% (95% confidence interval [CI]: 55-76) and 59% (95% CI: 49-68) compared with direct or direct and indirect testing combined, as the respective reference standards (specificities > 95%). Despite these promising diagnostic parameters, a subsequent prospective evaluation in a Lao hospital population (N= 352) showed that the sensitivity was very low (∼30%) compared with qPCR on venous blood samples. The disappointingly low sensitivity does suggest that venous blood samples are preferable for the clinical microbiology laboratory, although BCF might be an alternative if leptospirosis is only suspected postadmission after antibiotics have been used.

Governmental social protection contributes to preventing household financial hardship from drug-resistant tuberculosis in Brazil http://ow.ly/jxZL30iPqOo

To the Editor: We read with great interest the article by Diel et al. [1], which analysed the total average cost of tuberculosis (TB) per case for the current 27 member states of the European Union (EU-27). The average combined direct and indirect cost of TB in the original EU-15 (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden and the UK), plus Cyprus, Malta and Slovenia (EU-18), was calculated to be €10 282 for drug-susceptible TB, €57 213 for multidrug-resistant TB (MDR-TB) and €170 744 for extensively drug-resistant TB (XDR-TB). According to differences in the gross domestic product, the total average cost in the remaining nine countries was extrapolated to be one-third of the mean cost in the EU-18: €3427 for drug-susceptible TB and €24 166 for …