Improved adherence to anti-retroviral therapy among traditionalists: reflections from rural South Africa

Background: Medical pluralism is common place in sub-Saharan Africa. The South African pluralistic health care environment is varied and includes traditionalist beliefs relating to the efficacy of African traditional medicine. Prior research indicates that traditionalism is associated with delays in testing for HIV and treatment interruption. Despite numerous reports about this in South Africa, there is a paucity of documented strategies to counter this trend.Objectives: To develop a strategy to reduce the impact of non-adherence to antiretroviral therapy among traditionalists in Wa- terberg district, Limpopo Province, South Africa. Methods:  Qualitative information was elicited from five face-to-face, dual moderated, semi-structured homogenous group dis- cussions. The groups comprised of 50 purposively selected, rurally based, mixed gender traditionalists living with HIV. Ground- ed theory was applied to analyse qualitative findings that emerged from the group discussions.Findings:  Self-reported increases in adherence to anti-retroviral therapy and a reduction in internalised stigma by the respon- dents. Both are attributed by the respondents to disease causation differentiation from a traditional explanation to an allopathic explanation.Conclusion: A nascent strategy has been developed which is contributing to improved adherence and a reduction in internalised stigma among traditionalists living with HIV in Waterberg district, South Africa.Keywords: HIV and AIDS; internalised stigma; makgoma; medical pluralism; ‘origins of HIV’

The Taming Wicked Problems Framework: A plausible biosocial contribution to ‘ending AIDS by 2030’

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) published the Gap Report, which states that a new biosocial response to the HIV and AIDS epidemic is required to reinforce the biomedical strategy – Vision 90:90:90 – which is designed to end AIDS by 2030. This article provides a descriptive account of how a community–university partnership developed and piloted an innovative, transdisciplinary approach to HIV and AIDS management that could represent a nascent biosocial candidate to reinforce the biomedical strategy. The biosocial strategy has been labelled as the Taming Wicked Problems Framework that is influenced by ontological perspectives associated with complexity theory. The article focuses on how the Taming Wicked Problems Framework was developed by co-opting and repurposing management techniques associated with complexity into an action-oriented HIV and AIDS combination intervention. Three years after the pilot began, the Taming Wicked Problems Framework continues to provision the partnership with opportunities to ‘tame’ non-linear, biosocial aspects of the HIV and AIDS epidemic in rural South Africa. However, with the benefit of hindsight, there are some improvements and caveats that are highlighted so that future applications will be more robust. It is suggested that the Taming Wicked Problems Framework could represent one localised biosocial response that could contribute to ending AIDS by 2030

Improved adherence to anti-retroviral therapy among traditionalists: reflections from rural South Africa

Background: Medical pluralism is common place in sub-Saharan Africa. The South African pluralistic health care environment is varied and includes traditionalist beliefs relating to the efficacy of African traditional medicine. Prior research indicates that traditionalism is associated with delays in testing for HIV and treatment interruption. Despite numerous reports about this in South Africa, there is a paucity of documented strategies to counter this trend. Objectives: To develop a strategy to reduce the impact of non-adherence to antiretroviral therapy among traditionalists in Waterberg district, Limpopo Province, South Africa. Methods: Qualitative information was elicited from five face-to-face, dual moderated, semi-structured homogenous group discussions. The groups comprised of 50 purposively selected, rurally based, mixed gender traditionalists living with HIV. Grounded theory was applied to analyse qualitative findings that emerged from the group discussions. Findings: Self-reported increases in adherence to anti-retroviral therapy and a reduction in internalised stigma by the respondents. Both are attributed by the respondents to disease causation differentiation from a traditional explanation to an allopathic explanation. Conclusion: A nascent strategy has been developed which is contributing to improved adherence and a reduction in internalised stigma among traditionalists living with HIV in Waterberg district, South Africa. DOI: https://dx.doi.org/10.4314/ahs.v19i1.15 Cite as: Burman C, M A. Improved adherence to anti-retroviral therapy among traditionalists: reflections from rural South Africa. Afri Health Sci.2019;19(1). 1422-1432. https://dx.doi. org/10.4314/ahs.v19i1.1

Chemokine receptors in the rheumatoid synovium: upregulation of CXCR5

In patients with rheumatoid arthritis (RA), chemokine and chemokine receptor interactions play a central role in the recruitment of leukocytes into inflamed joints. This study was undertaken to characterize the expression of chemokine receptors in the synovial tissue of RA and non-RA patients. RA synovia (n = 8) were obtained from knee joint replacement operations and control non-RA synovia (n = 9) were obtained from arthroscopic knee biopsies sampled from patients with recent meniscal or articular cartilage damage or degeneration. The mRNA expression of chemokine receptors and their ligands was determined using gene microarrays and PCR. The protein expression of these genes was demonstrated by single-label and double-label immunohistochemistry. Microarray analysis showed the mRNA for CXCR5 to be more abundant in RA than non-RA synovial tissue, and of the chemokine receptors studied CXCR5 showed the greatest upregulation. PCR experiments confirmed the differential expression of CXCR5. By immunohistochemistry we were able to detect CXCR5 in all RA and non-RA samples. In the RA samples the presence of CXCR5 was observed on B cells and T cells in the infiltrates but also on macrophages and endothelial cells. In the non-RA samples the presence of CXCR5 was limited to macrophages and endothelial cells. CXCR5 expression in synovial fluid macrophages and peripheral blood monocytes from RA patients was confirmed by PCR. The present study shows that CXCR5 is upregulated in RA synovial tissue and is expressed in a variety of cell types. This receptor may be involved in the recruitment and positioning of B cells, T cells and monocytes/macrophages in the RA synovium. More importantly, the increased level of CXCR5, a homeostatic chemokine receptor, in the RA synovium suggests that non-inflammatory receptor–ligand pairs might play an important role in the pathogenesis of RA

Expanding the prevention armamentarium portfolio: A framework for promoting HIV-conversant communities within a complex, adaptive epidemiological landscape

The article describes a design journey that culminated in an HIV-Conversant Community Framework that is now being piloted in the Limpopo Province of South Africa. The objective of the initiative is to reduce the aggregate community viral load by building capacity at multiple scales that strengthens peoples’ HIV-related navigational skill sets—while simultaneously opening a ‘chronic situation’ schema. The framework design is based upon a transdisciplinary methodological combination that synthesises ideas and constructs from complexity science and the management sciences as a vehicle through which to re-conceptualise HIV prevention. This resulted in a prototype that included the following constructs: managing HIV-prevention in a complex, adaptive epidemiological landscape; problematising and increasing the scope of the HIV knowledge armamentarium through education that focuses on the viral load and Langerhans cells; disruptive innovation and safe-fail probes followed by the facilitation of path creations and pattern management implementation techniques. These constructs are underpinned by a ‘middle-ground’ prevention approach which is designed to bridge the prevention ‘fault line’, enabling a multi-ontology conceptualisation of the challenge to be developed

Why does chronic inflammation persist: An unexpected role for fibroblasts

One of the most important but as yet unanswered questions in inflammation research is not why inflammation occurs (we all get episodes of self limiting inflammation during the course of our lives) but why it does not resolve. Current models of inflammation stress the role of antigen-specific lymphocyte responses and attempt to address the causative agent. However, recent studies have begun to challenge the primacy of the leukocyte and have instead focused on an extended immune system in which stromal cells, such as fibroblasts play a role in the persistence of the inflammatory lesion. In this review I will illustrate how fibroblasts help regulate the switch from acute resolving to chronic persistent inflammation and provide positional memory during inflammatory responses. In chronic inflammation the normal physiological process of the removal of unwanted inflammatory effector cells becomes disordered, leading to the accumulation of leucocytes within lymphoid aggregates that resemble those seen in lymphoid tissue. I will describe how fibroblasts provide survival and retention signals for leukocytes leading to their inappropriate and persistent accumulation within inflamed tissue

Relative preservation of triceps over biceps strength in upper limb-onset ALS: the 'split elbow'

OBJECTIVE Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease of the motor system. The split hand sign in ALS refers to observed preferential weakness of the lateral hand muscles, which is unexplained. One possibility is larger cortical representation of the lateral hand compared with the medial. Biceps strength is usually preserved relative to triceps in neurological conditions, but biceps has a larger cortical representation and might be expected to show preferential weakness in ALS. METHODS Using the South-East England Register for Amyotrophic Lateral Sclerosis, we performed a retrospective longitudinal cohort study and extracted the modified Medical Research Council (MRC) muscle strength score for biceps and triceps in patients with a diagnosis of upper limb-onset ALS in the 19-year period 1996-2015. A Wilcoxon signed-rank test was used to assess the relative strength of the muscles within the total sum of the upper limbs involved in the study. RESULTS There were 659 people with upper limb onset of weakness. In 215 there were insufficient data to perform the analysis, and a further 33 were excluded for other reasons, leaving 411 for analysis. Biceps was stronger than triceps in 87 limbs, and triceps was stronger than biceps in 258 limbs, with no difference seen in the remaining 477. Triceps strength scores (mean rank=186.1) were higher than ipsilateral biceps strength scores (mean rank=134.2), Z=-10.1, p<0.001 (two-tailed). CONCLUSION Triceps strength is relatively preserved compared with biceps in ALS. This is consistent with a broadly corticofugal hypothesis of selective vulnerability, in which susceptibility might be associated with larger cortical representation

The EAGLE instrument for the E-ELT: developments since delivery of Phase A

The EAGLE instrument is a Multi-Object Adaptive Optics (MOAO) fed, multiple Integral Field Spectrograph (IFS), working in the Near Infra-Red (NIR), on the European Extremely Large Telescope (E-ELT). A Phase A design study was delivered to the European Southern Observatory (ESO) leading to a successful review in October 2009. Since that time there have been a number of developments, which we summarize here. Some of these developments are also described in more detail in other submissions at this meeting. The science case for the instrument, while broad, highlighted in particular: understanding the stellar populations of galaxies in the nearby universe, the observation of the evolution of galaxies during the period of rapid stellar build-up between redshifts of 2-5, and the search for 'first light' in the universe at redshifts beyond 7. In the last 2 years substantial progress has been made in these areas, and we have updated our science case to show that EAGLE is still an essential facility for the E-ELT. This in turn allowed us to revisit the science requirements for the instrument, confirming most of the original decisions, but with one modification. The original location considered for the instrument (a gravity invariant focal station) is no longer in the E-ELT Construction Proposal, and so we have performed some preliminary analyses to show that the instrument can be simply adapted to work at the E-ELT Nasmyth platform. Since the delivery of the Phase A documentation, MOAO has been demonstrated on-sky by the CANARY experiment at the William Herschel Telescope.Comment: 10 pages, SPIE Conference proceedings, Amsterdam, July 201

The benefit of evolving multidisciplinary care in ALS: a diagnostic cohort survival comparison

BACKGROUND Care for people with amyotrophic lateral sclerosis (ALS) has altered at King's College Hospital over the last 20 years. The clinic has been a multidisciplinary, specialist, tertiary referral centre since 1995 with a large team with integrated palliative and respiratory care since 2006. We hypothesised that these changes would improve survival. METHODS In this retrospective observational study, patients diagnosed with El Escorial definite, probable and possible ALS between 1995-1998 and 2008-2011 were followed up. The primary outcome measure was a chi-square test for the proportion of each cohort surviving. Kaplan-Meier survival analysis and Cox multivariate regression were secondary analyses. RESULTS There was low reporting of some interventions. Five hundred and forty-seven people were included. Survival between the cohorts was significantly different (p = 0.022) with a higher proportion surviving during 2008-2011. Survival time was 21.6 (95% CI 19.2-24.0) months in the 2008-2011 cohort compared to 19.2 years (15.6-21.6) in the 1995-1998 cohort (log rank p = 0.018). Four hundred and ninety-three cases were included in the Cox regression. Diagnostic cohort was a significant predictor variable (HR 0.79 (0.64-0.97) p = 0.023). CONCLUSIONS These results support the hypothesis that integrated specialist clinics with multidisciplinary input improve survival in ALS

Association of T-Zone Reticular Networks and Conduits with Ectopic Lymphoid Tissues in Mice and Humans

Ectopic or tertiary lymphoid tissues (TLTs) are often induced at sites of chronic inflammation. They typically contain various hematopoietic cell types, high endothelial venules, and follicular dendritic cells; and are organized in lymph node–like structures. Although fibroblastic stromal cells may play a role in TLT induction and persistence, they have remained poorly defined. Herein, we report that TLTs arising during inflammation in mice and humans in a variety of tissues (eg, pancreas, kidney, liver, and salivary gland) contain stromal cell networks consisting of podoplanin+ T-zone fibroblastic reticular cells (TRCs), distinct from follicular dendritic cells. Similar to lymph nodes, TRCs were present throughout T-cell–rich areas and had dendritic cells associated with them. They expressed lymphotoxin (LT) β receptor (LTβR), produced CCL21, and formed a functional conduit system. In rat insulin promoter–CXCL13–transgenic pancreas, the maintenance of TRC networks and conduits was partially dependent on LTβR and on lymphoid tissue inducer cells expressing LTβR ligands. In conclusion, TRCs and conduits are hallmarks of secondary lymphoid organs and of well-developed TLTs, in both mice and humans, and are likely to act as important scaffold and organizer cells of the T-cell–rich zone