Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya

<p>Abstract</p> <p>Background</p> <p>Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya.</p> <p>Methods</p> <p>We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation.</p> <p>Results</p> <p>Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness.</p> <p>Conclusion</p> <p>During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.</p

'Duck to water' or 'fish out of water'? Diversity in the experience of negotiating the transition to university

Winstone and Hulme present a critical discussion of the notion of transition to university. They argue that the common emphasis on the challenging nature of the transition fails to acknowledge the diversity in students’ experiences; for some students, the liminality and discomfort experienced during this critical period in their educational journey can be a transformational and empowering rite of passage. Rather than homogenising students’ experiences, Winstone and Hulme argue that it is beneficial to explore the transition experience through the lens of students’ expectations and subsequent experiences and to view the transition to university as part of a trajectory of transition experience within a student’s educational journey. The chapter also presents practical suggestions for engaging multiple student voices in understanding and facilitating positive transition experiences

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Increased detection of proliferating, polyfunctional, HIV-1-specific T cells in DNA-modified vaccinia virus Ankara-vaccinated human volunteers by cultured IFN-gamma ELISPOT assay.

Induction of a long-term immunological memory, which can expand and defend the host upon pathogen encounter, is the "holy grail" of vaccinology. Here, using a sensitive cultured IFN-gamma ELISPOT assay, we show that 50% (15 out of 30) of healthy, HIV-1/2-uninfected volunteers who received pTHr.HIVA DNA prime-modified vaccinia virus Ankara. HIVA boost vaccine regimen 1 to 3 1/2 years ago had detectable HIV-1-specific T-cell responses. These T cells, predominantly of the CD4(+) subtype, could proliferate and produce multiple cytokines in response to in vitro peptide stimulation. Peptide mapping studies showed that the vaccine-induced CD4(+) T cells were mostly directed toward epitopes targeted in HIV-1-infected individuals. In addition, we used the same assay to re-evaluate 51 volunteers from past vaccine trial IAVI-006 and corrected the previously reported 10% of vaccine responders to 50%. Thus, we confirmed that cultured assays are a valuable tool for studying T-cell memory. These results are discussed in the context of the current state-of-affairs of the HIV-1 vaccine field

Vulcan petawatt: Design, operation and interactions at 5 × 10 20Wcm-2

The Vulcan Nd:glass laser at the Central Laser Facility (CLF) is a petawatt (1015 Watts) interaction facility, designed to deliver irradiance on target of 1021W.cm-2 for the UK and international user community. The facility came online to users in 2002 and considerable experience has been gained operating Vulcan in this mode. The facility delivers a wide-ranging experimental program in fundamental physics and advanced applications. This includes the interaction of ultrahigh intensity light with matter, fast ignition fusion research, photon induced nuclear reactions, electron and ion acceleration by light waves, and the exploration of the exotic world of plasma physics dominated by relativity. We report on the first year's operation of the facility and the highlights of the experimental campaigns. Copyright © 2005 Cambridae University Press

Vulcan petawatt - An ultra-high-intensity interaction facility

The Vulcan Nd: glass laser at the Central Laser Facility is a Petawatt (10 15 W) interaction facility available to the UK and international user community. The facility came online to users in 2002 and considerable experience has been gained operating the Vulcan facility in this mode. The facility is designed to deliver irradiance on target of 10 21 W cm -2 for a wide-ranging experimental programme in fundamental physics and advanced applications. This includes the interaction of super-high-intensity light with matter, fast ignition fusion research, photon induced nuclear reactions, electron and ion acceleration by light waves and the exploration of the exotic world of plasma physics dominated by relativity