Reduction in mortality from HIV-related CNS infections in routine care in Africa (DREAMM): a before-and-after, implementation study

BACKGROUND: Four decades into the HIV epidemic, CNS infection remains a leading cause of preventable HIV-related deaths in routine care. The Driving Reduced AIDS-associated Meningo-encephalitis Mortality (DREAMM) project aimed to develop, implement, and evaluate pragmatic implementation interventions and strategies to reduce mortality from HIV-related CNS infection. METHODS: DREAMM took place in five public hospitals in Cameroon, Malawi, and Tanzania. The main intervention was a stepwise algorithm for HIV-related CNS infections including bedside rapid diagnostic testing and implementation of WHO cryptococcal meningitis guidelines. A health system strengthening approach for hospitals was adopted to deliver quality care through a co-designed education programme, optimised clinical and laboratory pathways, and communities of practice. DREAMM was led and driven by local leadership and divided into three phases: observation (including situational analyses of routine care), training, and implementation. Consecutive adults (aged ≥18 years) living with HIV presenting with a first episode of suspected CNS infection were eligible for recruitment. The primary endpoint was the comparison of 2-week all-cause mortality between observation and implementation phases. This study completed follow-up in September, 2021. The project was registered on ClinicalTrials.gov, NCT03226379. FINDINGS: From November, 2016 to April, 2019, 139 eligible participants were enrolled in the observation phase. From Jan 9, 2018, to March 25, 2021, 362 participants were enrolled into the implementation phase. 216 (76%) of 286 participants had advanced HIV disease (209 participants had missing CD4 cell count), and 340 (69%) of 494 participants had exposure to antiretroviral therapy (ART; one participant had missing ART data). In the implementation phase 269 (76%) of 356 participants had a probable CNS infection, 203 (76%) of whom received a confirmed microbiological or radiological diagnosis of CNS infection using existing diagnostic tests and medicines. 63 (49%) of 129 participants died at 2 weeks in the observation phase compared with 63 (24%) of 266 in the implementation phase; and all-cause mortality was lower in the implementation phase when adjusted for site, sex, age, ART exposure (adjusted risk difference –23%, 95% CI –33 to –13; p<0·001). At 10 weeks, 71 (55%) died in the observation phase compared with 103 (39%) in the implementation phase (–13%, –24 to –3; p=0·01). INTERPRETATION: DREAMM substantially reduced mortality from HIV-associated CNS infection in resource-limited settings in Africa. DREAMM scale-up is urgently required to reduce deaths in public hospitals and help meet Sustainable Development Goals. FUNDING: European and Developing Countries Clinical Trials Partnership, French Agency for Research on AIDS and Viral Hepatitis. TRANSLATIONS: For the French and Portuguese translations of the abstract see Supplementary Materials section

Descriptive epidemiology of salivary gland neoplasms in Nigeria: An AOPRC multicenter tertiary hospital study

Objectives: Accurate diagnosis of salivary gland neoplasms (SGN) in many centers in Africa is limited by poor diagnostic resources and ancillary services. Hence, we have carried out a multicenter epidemiological study to understand the true burden of SGN in Nigeria. Method: In this descriptive cross‐sectional study, we have deployed resources available to members of the African Oral Pathology Consortium (AOPRC) to examine the burden of salivary gland lesions in Nigeria, using a multicenter approach. Data from seven major tertiary health institutions in northern, western, and southern Nigeria were generated using a standardized data extraction format and analyzed using the Epi‐info software (Version 7.0, Atlanta, USA). Result: Of the 497 cases examined across the seven centers, we observed that SGN occurred more in females than males. Overall, pleomorphic salivary adenoma (PA) was found to be the most common. PA was found to be the commonest benign SGN while adenocystic carcinoma (ADCC) was the commonest malignant SGN. Regional variations were observed for age group, diagnosis, and gender distribution. Significant statistical differences were found between males and females for malignant SGNs (p‐value=0.037). Conclusion: We found regional variation in the pattern of distribution of SGN in Nigeria. This is the largest multicenter study of SGN in Nigeria, and our findings are robust and representative of the epidemiology of this neoplasm in Nigeria

Les défis techniques et politiques du secteur forestier industriel au Cameroun

Cameroon’s forest sector has for many decades been characterized by industrial, large-scale, concession-based and export-oriented timber production. Over the past two decades, many innovative regulations have been adopted that largely responded to the external requests of the country’s technical and financial partners. By using data and information collected over more than a decade, complemented by semi-structured interviews, we assess how some of the most relevant regulations have been implemented. Findings indicate that over the years, a clear disconnect appears between what is promised and adopted in the rules and regulations governing the industrial sector, and what is actually implemented on the ground. We discuss how such disconnect may have originated and how it may negatively impact the sustainable development of the industrial forest sector. We propose some technical and policy options that may improve the sector’s management, positively impact Cameroon’s international image and possibly strengthen the country’s engagement in international regimes such as FLEGT and/or REDD+.El sector forestal de Camerun durante muchas décadas se ha caracterizado por la producción industrial a gran escala, basada en la concesión y en madera orientada a la exportación. Durante las ultimas dos décadas, muchas regulaciones innovadoras que se han adoptado en gran medida respondieron a las solicitudes externas de socios técnicos y financieros del país. Mediante el uso de datos e información recogidos durante más de una década, complementados con entrevistas semi-estructuradas, evaluamos cómo se aplicaron algunas de las regulaciones más relevantes. Los resultados indican que a lo largo de los años aparece una desconexión clara entre lo que se promete y se adopta en normas y reglamentos que regulan el sector industrial, y lo que realmente se implementa. Se discute cual puede ser el origen de tal desconexión y cómo esta puede influir negativamente en el desarrollo sostenible del sector forestal industrial. Proponemos algunas opciones técnicas y políticas que podrían impactar positivamente en la imagen internacional de Camerœn y posiblemente fortalecer la participación del país en los regímenes internacionales como FLEGT y/o REDD+.Pendant plusieurs décennies, le secteur forestier camerounais a été caractérisé par une exploitation industrielle du bois d’œuvre dans les concessions forestières à grandes surfaces, l’essentiel de la production visant principalement à satisfaire la demande extérieure du bois. Durant les deux dernières décennies, un grand nombre de décrets, d’arrêtés et de règlements innovants ont été adoptés, en grande partie sous l’impulsion des partenaires techniques et financiers internationaux du pays. A partir des données d’exploitation recueillies pendant plus d’une décennie, complétées par une série d’interviews semi-structurées des parties prenantes à l’exploitation forestières, cet article fait une évaluation de la mise en œuvre des dispositions règlementaires les plus importantes du secteur. Les résultats indiquent une nette différence entre les dispositions des textes règlementaires du secteur forestier industriel et les pratiques observées au fil des années. Nous discutons les déterminants d’une telle différence ainsi que ses impacts potentiels sur le développement durable du secteur forestier industriel. Nous proposons quelques options politiques et techniques qui pourraient améliorer la gestion du secteur forestier industriel, renforcer les engagements pris par le Cameroun dans des régimes internationaux tels que le FLEGT et/ou la REDD+ et avoir un impact positif sur l’image du Cameroun sur la scène internationale