Evaluation of the impact of immediate versus WHO recommendations-guided antiretroviral therapy initiation on HIV incidence: the ANRS 12249 TasP (Treatment as Prevention) trial in Hlabisa sub-district, KwaZulu-Natal, South Africa: study protocol for a cluster randomised controlled trial

Background: Antiretroviral therapy (ART) suppresses HIV viral load in all body compartments and so limits the risk of HIV transmission. It has been suggested that ART not only contributes to preventing transmission at individual but potentially also at population level. This trial aims to evaluate the effect of ART initiated immediately after identification/diagnosis of HIV-infected individuals, regardless of CD4 count, on HIV incidence in the surrounding population. The primary outcome of the overall trial will be HIV incidence over two years. Secondary outcomes will include i) socio-behavioural outcomes (acceptability of repeat HIV counselling and testing, treatment acceptance and linkage to care, sexual partnerships and quality of life); ii) clinical outcomes (mortality and morbidity, retention into care, adherence to ART, virologic failure and acquired HIV drug resistance), iii) cost-effectiveness of the intervention. The first phase will specifically focus on the trial's secondary outcomes.Methods/design: A cluster-randomised trial in 34 (2 × 17) clusters within a rural area of northern KwaZulu-Natal (South Africa), covering a total population of 34,000 inhabitants aged 16 years and above, of whom an estimated 27,200 would be HIV-uninfected at start of the trial. The first phase of the trial will include ten (2 × 5) clusters. Consecutive rounds of home-based HIV testing will be carried out. HIV-infected participants will be followed in dedicated trial clinics: in intervention clusters, they will be offered immediate ART initiation regardless of CD4 count and clinical stage; in control clusters they will be offered ART according to national treatment eligibility guidelines (CD4 <350 cells/μL, World Health Organisation stage 3 or 4 disease or multidrug-resistant/extensively drug-resistant tuberculosis). Following proof of acceptability and feasibility from the first phase, the trial will be rolled out to further clusters.Discussion: We aim to provide proof-of-principle evidence regarding the effectiveness of Treatment-as-Prevention in reducing HIV incidence at the population level. Data collected from the participants at home and in the clinics will inform understanding of socio-behavioural, economic and clinical impacts of the intervention as well as feasibility and generalizability. © 2013 Iwuji et al.; licensee BioMed Central Ltd

Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa

Prompt uptake of antiretroviral treatment (ART) is essential to ensure the success of universal test and treat (UTT) strategies to prevent HIV transmission in high-prevalence settings. We describe ART initiation rates and associated factors within an ongoing UTT cluster-randomized trial in rural South Africa. HIV-positive individuals were offered immediate ART in the intervention arm vs. national guidelines recommended initiation (CD4≤350 cells/mm3) in the control arm. We used data collected up to July 2015 among the ART-eligible individuals linked to TasP clinics before January 2015. ART initiation rates at one (M1), three (M3) and six months (M6) from baseline visit were described by cluster and CD4 count strata (cells/mm3) and other eligibility criteria: ≤100; 100–200; 200–350; CD4>350 with WHO stage 3/4 or pregnancy; CD4>350 without WHO stage 3/4 or pregnancy. A Cox model accounting for covariate effect changes over time was used to assess factors associated with ART initiation. The 514 participants had a median [interquartile range] follow-up duration of 1.08 [0.69; 2.07] months until ART initiation or last visit. ART initiation rates at M1 varied substantially (36.9% in the group CD4>350 without WHO stage 3/4 or pregnancy, and 55.2–71.8% in the three groups with CD4≤350) but less at M6 (from 85.3% in the first group to 96.1–98.3% in the three other groups). Factors associated with lower ART initiation at M1 were a higher CD4 count and attending clinics with both high patient load and higher cluster HIV prevalence. After M1, having a regular partner was the only factor associated with higher likelihood of ART initiation. These findings suggest good ART uptake within a UTT setting, even among individuals with high CD4 count. However, inadequate staffing and healthcare professional practices could result in prioritizing ART initiation in patients with the lowest CD4 counts

Bringing financial literacy and education to low and middle income countries : the need to review, adjust, and extend current wisdom

This paper presents a World Bank led and Russia trust fund financed work program to measure financial capability and the effectiveness of financial education in low and middle income countries. The two activities and their staging have been motivated by the lessons of high income countries with financial literacy programs and the deviating characteristics of low and middle income countries. While progress has been made in high-income countries to measure financial capability, there is little robust empirical evidence thatfinancial education can improve it. While applying the financial capability concept in low and middle-income countries looks promising it will need to be adjusted to their characteristic and supported by innovative interventions and rigorous impact evaluation to improve it.Financial Literacy,Access to Finance,Access&Equity in Basic Education,Education For All,Poverty Impact Evaluation

Pass it on: towards a political economy of propensity

The paper argues that the work of Gabriel Tarde on imitation provides a fertile means of understanding how capitalism is forging a new affective technology which conforms to a logic of propensity rather than to means-end reasoning. This it does by drawing together a biological understanding of semiconscious cognition with various practical geometric arts so as to re-stage the world as a series of susceptible situations which can be ridden rather than rigidly controlled. The paper examines the advent of technologies which attend to the variable geometry of so-called animal spirits in the realm of business and then, using Tarde's work as a springboard, considers some alternative means of understanding imitative rays which have less instrumental undertones. The paper is an illustration of the way in which biology and culture have increasingly become intertwined

Towards a Holistic Approach to Designing Theory-based Mobile Health Interventions

Increasing evidence has shown that theory-based health behavior change interventions are more effective than non-theory-based ones. However, only a few segments of relevant studies were theory-based, especially the studies conducted by non-psychology researchers. On the other hand, many mobile health interventions, even those based on the behavioral theories, may still fail in the absence of a user-centered design process. The gap between behavioral theories and user-centered design increases the difficulty of designing and implementing mobile health interventions. To bridge this gap, we propose a holistic approach to designing theory-based mobile health interventions built on the existing theories and frameworks of three categories: (1) behavioral theories (e.g., the Social Cognitive Theory, the Theory of Planned Behavior, and the Health Action Process Approach), (2) the technological models and frameworks (e.g., the Behavior Change Techniques, the Persuasive System Design and Behavior Change Support System, and the Just-in-Time Adaptive Interventions), and (3) the user-centered systematic approaches (e.g., the CeHRes Roadmap, the Wendel's Approach, and the IDEAS Model). This holistic approach provides researchers a lens to see the whole picture for developing mobile health interventions

Jordan’s Accession to the WTO: Retrospective and Prospective

Jordan acceded to the WTO in 1999. In its accession Jordan agreed, for example, to reduce tariffs on imported products and open its services market; it also modified its intellectual property regime. Jordan enjoyed special and differential treatment in few areas and was not able to designate olive oil as a good eligible for special safeguards. The WTO agreements required fundamental changes in the domestic laws and regulations of Jordan. The article concludes by arguing that Jordan’s accession to the WTO was a lengthy and costly process. Jordan agreed to an arduous package of legal and economic reforms. Given that Jordan agreed to greater commitments compared to the obligations of the original WTO members, the multilateral trading system witnessed an accession saga

Conceptualising technology enhanced destination experiences

The notion of creating rich and memorable experiences for consumers constitutes a prevalent concept in the tourism industry. With the proliferation of destination choices and increasing competition, it has become critical for destinations to find innovative ways to differentiate their products and create experiences that provide distinct value for the tourist. However, currently two major paradigm shifts are drastically changing the nature of experiences, the understanding of which is crucial for destinations to create successful experiences in the future. Experiences are transforming as (a) consumers now play an active part in co-creating their own experiences and (b) technology is increasingly mediating experiences. Despite the amount of literature recognising the impact of technology on experiences, a holistic conceptualisation of this change is missing. This paper thus raises the need to conflate the two-fold paradigm shift and calls for new reflections on the creation of experiences. The aim is to explore technology as a source of innovation to co-create enhanced destination experiences. The paper contributes on three levels: by introducing and conceptualising a new experience creation paradigm entitled Technology Enhanced Destination Experiences, by proposing an extended destination experience co-creation space in the pre/during/post phases of travel and by discussing managerial implications of this development for the future creation and management of experiences in a destination context. © 2012 Elsevier Ltd