The future of financing for HIV services in Uganda and the wider sub-Saharan Africa region: should we ask patients to contribute to the cost of their care?

Whilst multi-lateral funding for HIV/AIDS dramatically increased from 2004 to 2008, it has largely plateaued in the last 8 years. Across sub-Saharan Africa, up to 20 % of total spending on health is used for HIV services, and of this over 85 % is estimated to come from international funding rather than in-country sources. In Uganda, the fiscal liability to maintain services for all those who are currently receiving it is estimated to be as much as 3 % of Gross Domestic Product (GDP). In order to meet the growing need of increased patient numbers and further ART coverage the projected costs of comprehensive HIV care and treatment services will increase substantially. Current access to HIV care includes free at point of delivery (provided by Ministry of Health clinics), as well as out-of-pocket financing and health insurance provided care at private for- and not for- profit facilities. The HIV response is funded through Ugandan Ministry of Health national budget allocations, as well as multilateral donations such as the President's Emergency Plan for AIDS in Africa (PEPFAR) and Global Fund (GF) and other international funders. We are concerned that current funding mechanism for HIV programs in Uganda may be difficult to sustain and as service providers we are keen to explore ways in which provide lifelong HIV care to as many people living with HIV (PLHIV) as possible. Until such time as the Ugandan economy can support universal, state-supported, comprehensive healthcare, bridging alternatives must be considered. We suggest that offering patients with the sufficient means to assume some of the financial burden for their care in return for more convenient services could be one component of increasing coverage and sustaining services for those living with HIV

The future of financing for HIV services in Uganda and the wider sub-Saharan Africa region: should we ask patients to contribute to the cost of their care?

Abstract Whilst multi-lateral funding for HIV/AIDS dramatically increased from 2004 to 2008, it has largely plateaued in the last 8 years. Across sub-Saharan Africa, up to 20 % of total spending on health is used for HIV services, and of this over 85 % is estimated to come from international funding rather than in-country sources. In Uganda, the fiscal liability to maintain services for all those who are currently receiving it is estimated to be as much as 3 % of Gross Domestic Product (GDP). In order to meet the growing need of increased patient numbers and further ART coverage the projected costs of comprehensive HIV care and treatment services will increase substantially. Current access to HIV care includes free at point of delivery (provided by Ministry of Health clinics), as well as out-of-pocket financing and health insurance provided care at private for- and not for- profit facilities. The HIV response is funded through Ugandan Ministry of Health national budget allocations, as well as multilateral donations such as the President’s Emergency Plan for AIDS in Africa (PEPFAR) and Global Fund (GF) and other international funders. We are concerned that current funding mechanism for HIV programs in Uganda may be difficult to sustain and as service providers we are keen to explore ways in which provide lifelong HIV care to as many people living with HIV (PLHIV) as possible. Until such time as the Ugandan economy can support universal, state-supported, comprehensive healthcare, bridging alternatives must be considered. We suggest that offering patients with the sufficient means to assume some of the financial burden for their care in return for more convenient services could be one component of increasing coverage and sustaining services for those living with HIV

Phylodynamic analysis of an emergent Mycobacterium bovis outbreak in an area with no previously known wildlife infections

1. Understanding how an emergent pathogen successfully establishes itself and persists in a previously unaffected population is a crucial problem in disease ecology, with important implications for disease management. In multi-host pathogen systems this problem is particularly difficult, as the importance of each host species to transmission is often poorly characterised, and the disease epidemiology is complex. Opportunities to observe and analyse such emergent scenarios are few. 2. Here, we exploit a unique dataset combining densely-collected data on the epidemiological and evolutionary characteristics of an outbreak of Mycobacterium bovis (the causative agent of bovine tuberculosis, bTB) in a population of cattle and badgers in an area considered low-risk for bTB, with no previous record of either persistent infection in cattle, or of any infection in wildlife. We analyse the outbreak dynamics using a combination of mathematical modelling, Bayesian evolutionary analyses, and machine learning. 3. Comparison to M. bovis whole-genome sequences from Northern Ireland confirmed this to be a single introduction of the pathogen from the latter region, with evolutionary analysis supporting an introduction directly into the local cattle population six years prior to its first discovery in badgers. 4. Once introduced, the evidence supports M. bovis epidemiological dynamics passing through two phases, the first dominated by cattle-to-cattle transmission before becoming established in the local badger population. 5. Synthesis and applications. The raw data object of this analysis were used to support decisions regarding the control of a M. bovis emergent outbreak, of considerable concern because of the geographical distance from previously known high-risk areas. Our further analyses, estimating the time of introduction (and therefore the likely magnitude of any hidden outbreak) and the rates of cross-species transmission, provided valuable confirmation that the extent and focus of the imposed controls were appropriate. Not only these findings strengthen the call for genomic surveillance, but they also pave the path for future outbreaks control, providing insights for more rapid and decisive evidence-based decision-making. As the methods we used and developed are agnostic to the disease itself, they are also valuable for other slowly transmitting pathogens

Erosion rates in a wet, temperate climate derived from rock luminescence techniques

Abstract. A new luminescence erosion-meter has huge potential for inferring erosion rates on sub-millennial scales for both steady and transient states of erosion, which is currently not possible with any existing techniques capable of measuring erosion. This study applies new rock luminescence techniques to a well-constrained scenario provided by the Beinn Alligin rock avalanche, NW Scotland. Boulders in this deposit are lithologically consistent, have known cosmogenic nuclide ages, and independently-derived Holocene erosion rates. We find that luminescence-derived exposure ages for the Beinn Alligin rock avalanche were an order of magnitude younger than existing cosmogenic nuclide exposure ages, suggestive of high erosion rates (as supported by field evidence of quartz grain protrusions on the rock surfaces). Erosion rates determined by luminescence were consistent with independently-derived rates measured from boulder-edge roundness. Inversion modelling indicates a transient state of erosion reflecting the stochastic nature of erosional processes over the last ~4 ka in the wet, temperate climate of NW Scotland. Erosion was likely modulated by known fluctuations in moisture availability, and to a lesser extent temperature, which controlled the extent of chemical weathering of these highly-lithified rocks prior to erosion. The use of a multi-elevated temperature, post-infra-red, infra-red stimulated luminescence (MET-pIRIR) protocol (50, 150 and 225 °C) was advantageous as it identified samples with complexities introduced by within-sample variability (e.g. surficial coatings). This study demonstrates that the luminescence erosion-meter can infer accurate erosion rates on sub-millennial scales and identify transient states of erosion (i.e. stochastic processes) in agreement with independently-derived erosion rates for the same deposit. </jats:p

Trypanosoma brucei BRCA2 acts in a life cycle-specific genome stability process and dictates BRC repeat number-dependent RAD51 subnuclear dynamics

Trypanosoma brucei survives in mammals through antigenic variation, which is driven by RAD51-directed homologous recombination of Variant Surface Glycoproteins (VSG) genes, most of which reside in a subtelomeric repository of &gt;1000 silent genes. A key regulator of RAD51 is BRCA2, which in T. brucei contains a dramatic expansion of a motif that mediates interaction with RAD51, termed the BRC repeats. BRCA2 mutants were made in both tsetse fly-derived and mammal-derived T. brucei, and we show that BRCA2 loss has less impact on the health of the former. In addition, we find that genome instability, a hallmark of BRCA2 loss in other organisms, is only seen in mammal-derived T. brucei. By generating cells expressing BRCA2 variants with altered BRC repeat numbers, we show that the BRC repeat expansion is crucial for RAD51 subnuclear dynamics after DNA damage. Finally, we document surprisingly limited co-localization of BRCA2 and RAD51 in the T. brucei nucleus, and we show that BRCA2 mutants display aberrant cell division, revealing a function distinct from BRC-mediated RAD51 interaction. We propose that BRCA2 acts to maintain the huge VSG repository of T. brucei, and this function has necessitated the evolution of extensive RAD51 interaction via the BRC repeats, allowing re-localization of the recombinase to general genome damage when needed

Developing independent investigators for clinical research relevant for Africa

Sustainable research capacity building requires training individuals at multiple levels within a supportive institutional infrastructure to develop a critical mass of independent researchers. At many African medical institutions, a PhD is important for academic promotion and is, therefore, an important focal area for capacity building programs. We examine the training at the Infectious Diseases Institute (IDI) as a model for in-country training based on systems capacity building and attention to the academic environment. PhD training in Africa should provide a strong research foundation for individuals to perform independent, original research and to mentor others. Training the next generation of researchers within excellent indigenous academic centers of excellence with strong institutional infrastructure will empower trainees to ask regionally relevant research questions that will benefit Africans

The SAMI Galaxy Survey: Environmental analysis of the orbital structures of passive galaxies

Most dynamical models of galaxies to date assume axisymmetry, which is not representative of a significant fraction of massive galaxies. We have built triaxial orbit-superposition Schwarzschild models of galaxies observed by the SAMI Galaxy Survey, in order to reconstruct their inner orbital structure and mass distribution. The sample consists of 153 passive galaxies with total stellar masses in the range $10^{9.5}$ to $10^{12} M_{\odot}$. We present an analysis of the internal structures and intrinsic properties of these galaxies as a function of their environment. We measure their environment using three proxies: central or satellite designation, halo mass and local $5^{th}$ nearest neighbour galaxy density. We find that although these intrinsic properties correlate most strongly with stellar mass, environment does play a secondary role: at fixed stellar mass, galaxies in the densest regions are more radially anisotropic. In addition, central galaxies, and galaxies in high local densities show lower values of edge-on spin parameter proxy \lam. We also find suggestions of a possible trend of the fractions of orbits with environment for lower-mass galaxies (between $10^{9.5}$ and $10^{11} M_{\odot}$) such that, at fixed stellar mass, galaxies in higher local densities and halo mass have higher fractions of hot orbits and lower fractions of warm orbits. Our results demonstrate that after stellar mass, environment does play a role in shaping present-day passive galaxies.Comment: 21 pages. Accepted for publication in MNRA

The accretion histories of brightest cluster galaxies from their stellar population gradients

We analyse the spatially-resolved stellar populations of 9 local ($z<0.1$) Brightest Cluster Galaxies (BCGs) observed with VIMOS in IFU mode. Our sample is composed of 7 slow-rotating and 2 fast-rotating BCGs. We do not find a connection between stellar kinematics and stellar populations in this small sample. The BCGs have shallow metallicity gradients (median $\Delta$[Fe/H] $= -0.11\pm0.1$), high central metallicities (median $[$Fe/H]$_{[\alpha/Fe]=0} = 0.13\pm0.07$), and a wide range of central ages (from 5 to 15 Gyr). We propose that the reason for this is diverse evolutionary paths in BCGs. 67 per cent of the sample (6/9) show $\sim 7$ Gyr old central ages, which reflects an active accretion history, and 33 per cent of the sample (3/9) have central ages older than 11 Gyr, which suggest no star formation since $z=2$. The BCGs show similar central stellar populations and stellar population gradients to early-type galaxies of similar mass (M$_{dyn}> 10^{11.3}$M$_{\odot}$) from the ATLAS$^{3D}$ survey (median [Z/H] $= 0.04\pm0.07$, $\Delta$[Z/H] $= -0.19\pm0.1$). However, massive early-type galaxies from ATLAS$^{3D}$ have consistently old ages (median Age $=12.0\pm3.8$Gyr). We also analyse the close massive companion galaxies of two of the BCGs. These galaxies have similar stellar populations to their respective BCGs.Comment: Accepted for publication, MNRAS, March 3, 201