A strategy to improve skills in pharmaceutical supply management in East Africa: the regional technical resource collaboration for pharmaceutical management

<p>Abstract</p> <p>Background</p> <p>International initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative have significantly increased availability and access to medicines in some parts of the developing world. Despite this, however, skills remain limited on quantifying needs for medications and ordering, receiving and storing medications appropriately; recording medications inventories accurately; distributing medications for use appropriately; and advising patients on how to use medications appropriately. The Regional Technical Resource Collaboration for Pharmaceutical Management (RTRC) has been established to help address the problem of skills shortage in pharmaceutical management in East Africa.</p> <p>Methods</p> <p>The initiative brings together academic institutions from four East African countries to participate in skills-building activities in pharmaceutical supply management. The initiative targeted the institutions' ability to conduct assessments of pharmaceutical supply management systems and to develop and implement effective skills-building programmes for pharmaceutical supply chain management.</p> <p>Results</p> <p>Over a two-year period, the RTRC succeeded in conducting assessments of pharmaceutical supply management systems and practices in Kenya, Rwanda, Tanzania and Uganda. In 2006, the RTRC participated in a materials-development workshop in Kampala, Uganda, and contributed to the development of comprehensive HIV/AIDS pharmaceutical management training materials; these materials are now widely available in all four countries. In Tanzania and Uganda the RTRC has been involved with the training of health care workers in HIV/AIDS pharmaceutical management. In Kenya, Tanzania and Uganda the RTRC has been conducting operations research to find solutions to their countries' skills-shortage problems. Some of the interventions tested include applying and evaluating the effectiveness of a novel skills-building approach for pharmaceutical supply management.</p> <p>Conclusion</p> <p>Nurturing collaboration between regional institutions in resource-limited countries to build in-country skills in pharmaceutical supply management appears to be an effective intervention. Support from local programmes and technical assistance from organizations and institutions with the necessary expertise is critical for success, particularly at inception. The skills acquired by local institutions can be incorporated into both pre-service and in-service teaching curricula. This ensures long-term availability of skills in-country. The ability of trained institutions to mobilize their own resources for skills-building activities is crucial for the success and sustainability of these programmes.</p

Conditional Cash Transfers Improve Retention in PMTCT Services by Mitigating the Negative Effect of Not Having Money to Come to the Clinic

To elucidate the mechanisms by which a cash incentive intervention increases retention in prevention of mother-to-child transmission (PMTCT) services

Conditional Cash Transfers to Increase Retention in PMTCT Care, Antiretroviral Adherence, and Postpartum Virological Suppression: A Randomized Controlled Trial

Novel strategies are needed to increase retention in prevention of mother-to-child HIV transmission (PMTCT) services. We have recently shown that small, incremental cash transfers conditional on attending clinic resulted in increased retention along the PMTCT cascade. However, whether women who receive incentives to attend clinic visits are as adherent to antiretrovirals (ARV) as those who do not was unknown

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial

Abstract Background Despite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. Methods The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. Discussion If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. Trial registration The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669

Conditional cash transfers and uptake of and retention in prevention of mother-to-child HIV transmission care: a randomised controlled trial

Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa

Co-limitation towards lower latitudes shapes global forest diversity gradients

The latitudinal diversity gradient (LDG) is one of the most recognized global patterns of species richness exhibited across a wide range of taxa. Numerous hypotheses have been proposed in the past two centuries to explain LDG, but rigorous tests of the drivers of LDGs have been limited by a lack of high-quality global species richness data. Here we produce a high-resolution (0.025° × 0.025°) map of local tree species richness using a global forest inventory database with individual tree information and local biophysical characteristics from ~1.3 million sample plots. We then quantify drivers of local tree species richness patterns across latitudes. Generally, annual mean temperature was a dominant predictor of tree species richness, which is most consistent with the metabolic theory of biodiversity (MTB). However, MTB underestimated LDG in the tropics, where high species richness was also moderated by topographic, soil and anthropogenic factors operating at local scales. Given that local landscape variables operate synergistically with bioclimatic factors in shaping the global LDG pattern, we suggest that MTB be extended to account for co-limitation by subordinate drivers

Optimization of HIV therapy in patients co-infected with tuberculosis: a pharmacogenetic and pharmacokinetic study of efavirenz in Rwandan adult patients undergoing HIV and tuberculosis co-treatment

Tuberculosis (TB) is the most common opportunistic infection among people infected with human immunodeficiency virus (HIV). The co-management of HIV/TB co-infection is prone to multiple drug-drug interactions. In addition, the recommended HIV drug efavirenz (EFV) has a narrow therapeutic window which compromises its clinical safety and exhibits a highly variable pharmacokinetics (PK) between subjects due to genetic factors. A lack of genomic data on many African populations limits attempts aiming at optimizing therapies in general, HIV therapy in particular. This thesis specifically aimed to obtain genomic data in an African population and to investigate the pharmacokinetic and pharmacogenetic aspects of EFV exposure in the presence of TB therapy. A clinical study was conducted in Rwandan HIV patients co-infected with TB. EFV plasma concentrations, CD4 cell counts and HIV-RNA copies were monitored. Genotyping for 13 single nucleotide polymorphisms (SNPs) with respect to five cytochrome P450 enzymes was conducted. A rapid and selective high performance liquid chromatography analytical method was developed for the quantification of EFV in plasma containing HIV and TB drugs. Genetic variation was observed in 11 out of the 13 analyzed SNPs with minor allele frequencies for 12 SNPs. There was a significant difference between CYP1A2 -739T/G and T/T genotypes only in the presence of rifampicin-based TB treatment (RBT). In the presence and in the absence of RBT, CYP2B6 516T/T genotype was found to be associated with higher EFV plasma levels. CYP2A6 1093G>A, CYP2B6 516G>T and CYP2B6 983T>C SNPs were found to be independent predictors of EFV plasma levels accounting for 27%, 43%, and 29%, respectively, of the total variance in EFV plasma levels. There was a high positive predictive value for CYP2B6 516T/T and 983T/T genotypes in predicting supra-therapeutic EFV plasma levels. RBT was shown to significantly lower EFV plasma levels but did not affect HIV-treatment response. There were higher clearance (CL/F) values in patients with previous exposure to HIV therapy than in patients who were administered RBT prior to HIV therapy. Expectedly, carriers of CYP2B6 516G/G and T/T genotypes exhibited higher and lower CL/F, respectively, regardless of the previous treatment received by the patients. In conclusion, CYP enzymes of the accessory metabolic pathways of EFV (CYP1A2 and CYP2A6) could explain variability in EFV exposure, in addition to CYP2B6 which proved to be the main pharmacogenetic determinant of EFV exposure in the patient population studied. As proven by the observed high positive predictive value, predictive genotyping in CYP2B6 SNPs may be useful in optimizing EFV-based HIV therapy. Not only should the patient genotype status with respect to CYP2B6 be taken into account, but also each individual patient treatment history, with caution to previous exposure to HAART. Even though it is clear from this thesis that specific CYP genotypes and co-medications do have a definite effect on EFV plasma levels causing its variation, this however does not seem to influence the efficacy of the EFV-based regimens in general

Prices of antihypertensive medicines in sub-Saharan Africa and alignment to WHO's model list of essential medicines

OBJECTIVE To investigate compliance of National Essential Medicines Lists (NEMLs) with the WHO Essential Medicines List (WHO/EML) in 2007 and to compare prices of antihypertensive drugs in and between 13 sub-Saharan African countries. METHODOLOGY Data on NEMLs and drug prices were collected from 65 public and 65 private pharmacies ( five of each per country). Prices were compared with the International Drug Price Indicator Guide (IDPIG). The cost of drug treatment within a country was calculated using defined daily doses (DDD) and between countries using DDD prices adjusted for purchasing power parity-based gross domestic product per capita. RESULTS All surveyed countries had a NEML. However, none of these lists were in complete alignment with the 2007 WHO/EML, and 38% had not been updated in the last 5 years. Surveyed medicines were cheaper when on the NEMLs; they were also cheaper in public than in private pharmacies. Prices varied greatly per medicine. A large majority of the public prices were higher than those indicated by the IDPIG. Overall, hydrochlorothiazide is the cheapest drug. CONCLUSION There are substantial differences in NEML composition between the 13 countries. The proportion of NEMLs not regularly updated was double the global United Nations estimates. Prices of WHO/EML-advised drugs differ greatly between drugs and for each drug within and between countries. In general, the use of drugs on the NEML improves financial accessibility, and these drugs should be prescribed preferentially

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial

Abstract Background Despite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. Methods The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. Discussion If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. Trial registration The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669

Efficacy of Single-Dose Praziquantel for the Treatment of <i>Schistosoma mansoni</i> Infections among School Children in Rwanda

Preventive chemotherapy with single-dose praziquantel is the WHO-recommended intervention strategy to eliminate schistosomiasis as a public health problem in endemic countries. Surveillance of drugs used in mass drug administration (MDA) programs is recommended to evaluate its effectiveness in reducing transmissions. After a decade-long implementation of a school-based MDA program in Rwanda, we conducted efficacy surveillance of single-dose praziquantel MDA against S. mansoni infection. Two weeks before MDA, stool examinations were performed to screen MDA-eligible school children (n = 4998) for S. mansoni infection using the Kato–Katz technique, and 265 (6.5%) children tested positive for the infection. All children received praziquantel and albendazole as preventive chemotherapy through the MDA campaign. Infected children were enrolled and followed for efficacy monitoring, and stool examination was repeated after three weeks post-MDA (n = 188). Before treatment, 173 (92%) had a light infection, and 15 (8%) had a moderate infection intensity. The primary and secondary outcomes were parasitological cure and egg reduction rates at three weeks post-treatment. The overall cure and egg reduction rates for S. mansoni infection were 97.9% (95% CI = 94.6–99.4) and 97.02%, respectively. Among the 173 children with light infection intensity, 170 (98.3%, 95% CI = 95.0–99.6) were cured, and among the 15 children who had moderate infection intensity, 14 (93.3%) were cured. No significant association between cure rate and pre-treatment infection intensity was observed. We conclude that single-dose praziquantel is efficacious against light-to-moderate S. mansoni infection. Preventive chemotherapy with praziquantel effectively reduces schistosome reservoirs and transmission among school-age children