Cost and cost-effectiveness of switching from d4T or AZT to a TDF-based first-line regimen in a resource-limited setting in rural Lesotho

Article approval pendingLatest World Health Organization guidelines recommend shifting away from Stavudine (d4T)-based regimens due to severe side effects. However, widespread replacement of d4T by Tenofovir (TDF) or Zidovudine (AZT) is hampered by cost concerns

Free healthcare provision with an NGO or by the Malian government

The provision of free healthcare is increasingly advocated as a way to improve access to health services for vulnerable population groups. However, decision makers are still short of factual data about the effects of payment exemptions (free provision) where they have already been introduced, and on the impact of different forms of implementation in French-speaking countries of West Africa. In the South of Mali, two types of free healthcare for children under 5 have been introduced : i) initially, a partial exemption, covering only the rapid diagnosis and treatment of malaria, and ii) subsequently total exemption for all primary healthcare. The partial exemption was first implemented by an NGO in a single district, then scaled up by the Ministry of Health on a nationwide scale. Following the partial exemption, health center attendance increased from 0.3 annual consultations per child, to 0.5, and then to 1.8 when total exemption was introduced. The rises in attendance were immediate and lasting for all health centers, whether implemented by the NGO or by the government. Attendance during the rainy season was multiplied by 1.5 after the government-organized partial exemption. Statistical analysis shows that if the government alone (without NGO) were to bring in 100 % free healthcare for children, it could increase health center attendance by a factor in the order of 4.Pour améliorer l’accès des populations vulnérables aux services de santé, l’organisation de la gratuité des soins est de plus en plus préconisée. Pourtant, les responsables manquent encore d’informations factuelles sur les effets des exemptions (gratuité) déjà réalisées et sur l’influence des diverses formes de mise en œuvre dans les pays francophones de l’Afrique de l’Ouest. Au Sud du Mali, deux types de gratuité des soins pour les enfants de 0 à 4 ans ont été réalisées : i) d’abord partielle en ne couvrant que le diagnostic rapide et le traitement du paludisme, ii) puis totale pour tous les soins de santé de première ligne. La gratuité partielle a été mise en œuvre d’abord par une ONG dans un seul district, puis par le ministère de la Santé à l’échelle du pays. L’utilisation des centres de santé est passée de 0,3 consultation annuelle par enfant à 0,5, suite à l’exemption partielle ; et puis à 1,8 suite à la gratuité totale. Les hausses d’utilisation ont été immédiates et durables pour tous les centres de santé, tant pour la mise en œuvre par l’ONG que par l’État. La fréquentation en saison pluvieuse a été multipliée par 1,5 à la suite de la gratuité partielle organisée par l’État. L’analyse statistique montre que si l’État seul (sans ONG) mettait en place la gratuité totale des soins pour les enfants, il pourrait augmenter la fréquentation des centres de santé d’un facteur de l’ordre de 4.Para mejorar el acceso de las poblaciones vulnerables a los servicios de salud, se recomienda cada vez más la gratuidad de la atención. Sin embargo, los gestores de los servicios de salud carecen todavía de información fáctica sobre los efectos de los programas de exenciones (gratuidad) ya realizados y sobre el impacto de sus diversas formas de implementación en los países francófonos del África Occidental. En el sur de Mali se aplicaron dos tipos de gratuidad para la atención de los niños de 0 a 4 años : i) en una primera etapa, la gratuidad fue parcial y cubrió solo el diagnóstico rápido y el tratamiento del paludismo, ii) en una segunda etapa, la gratuidad fue total incluyendo toda la atención primaria. Estas intervenciones fueron puestas en marcha en un distrito por una ONG, y a nivel nacional por el Ministerio de Sanidad. El uso de centros de salud aumentó de 0,3 consultas anuales por niño, a 0,5 en el periodo de gratuidad parcial y a 1,8 en el periodo de gratuidad total. Los aumentos del uso fueron inmediatos y persistentes en todos los centros de salud, tanto en la intervención de la ONG como en la intervención estatal. La frecuentación durante la estación lluviosa se multiplicó por 1,5 tras la gratuidad parcial organizada por el estado. El análisis estadístico muestra que si el Estado implementara la gratuidad total del cuidado para los niños, sin intervención por parte de la ONG, podría aumentar la frecuentación de los centros de salud en un factor cercano al 4

Feasibility and effectiveness of two community based HIV testing models in rural Swaziland

To evaluate the feasibility (population reached, costs) and effectiveness (positivity rates, linkage to care) of two strategies of community-based HIV testing and counselling (HTC) in rural Swaziland

Early initiation of antiretroviral therapy and associated reduction in mortality, morbidity and defaulting in a nurse-managed, community cohort in Lesotho.

INTRODUCTION: The latest WHO guidelines recommend initiating antiretroviral therapy (ART) at CD4 cell counts less than 350 cells/μl. However, donors and national governments are reluctant to support implementation owing to uncertainty regarding feasibility and relative benefit. Lesotho has supported earlier initiation since 2008. We assessed outcomes comparing early (CD4 cell counts >200 cells/μl) and late (CD4 cell counts ≤200 cells/μl) initiation. METHODS: We describe survival probability among patients initiating ART at CD4 cell counts 200 or less and more than 200 cells/μl and assess associations between baseline CD4 cell counts and mortality, morbidity, loss to follow-up and hospitalization using Cox regression adjusting for confounders identified a priori. RESULTS: Our analysis included 1177 patients; median age was 38 years and the majority (67%) were women. Median time on ART for the overall cohort was 506 days (interquartile range 396-608). Five hundred and thirty eight patients initiated ART at a CD4 cell count 200 cells/μl or less (interquartile range 54-160) and 639 patients initiated at CD4 cell count more than 200 cells/μl (interquartile range 238-321). In multivariate analysis, we found that patients initiating at CD4 cell count more than 200 cells/μl were 68% less likely to die (adjusted hazard ratio 0.32, 95% confidence interval 0.20-0.50), and 39% less likely to be lost to follow-up (adjusted hazard ratio 0.61, 95% confidence interval 0.43-0.87). Initiating ART at CD4 cell count more than 200 cells/μl was also associated with a 27% reduction in the rate of incident morbidity (adjusted hazard ratio 0.73, 95% confidence interval 0.65-0.82) and a 63% decreased rate of hospitalization (adjusted hazard ratio 0.37, 95% confidence interval 0.19-0.73). CONCLUSION: Earlier initiation is feasible in a low resource, high HIV prevalence setting, and provides important benefits in terms of reduced mortality, morbidity, retention and hospitalization. Donors should fully support the implementation of the latest WHO recommendations

Trends in Loss to Follow-Up among Migrant Workers on Antiretroviral Therapy in a Community Cohort in Lesotho

BACKGROUND: The provision of antiretroviral therapy (ART) to migrant populations raises particular challenges with respect to ensuring adequate treatment support, adherence, and retention in care. We assessed rates of loss to follow-up for migrant workers compared with non-migrant workers in a routine treatment programme in Morjia, Lesotho. DESIGN: All adult patients (≥18 years) initiating ART between January 1, 2008, and December 31, 2008, and followed up until the end of 2009, were included in the study. We described rates of loss to follow-up according to migrant status by Kaplan-Meier estimates, and used Poisson regression to model associations between migrant status and loss to follow-up controlling for potential confounders identified a priori. RESULTS: Our cohort comprised 1185 people, among whom 12% (148) were migrant workers. Among the migrant workers, median age was 36.1 (29.6-45.9) and the majority (55%) were male. We found no statistically significant differences between baseline characteristics and migrant status. Rates of lost to follow up were similar between migrants and non-migrants in the first 3 months but differences increased thereafter. Between 3 and 6 months after initiating antiretroviral therapy, migrants had a 2.78-fold increased rate of defaulting (95%CI 1.15-6.73); between 6 and 12 months the rate was 2.36 times greater (95%CI 1.18-4.73), whereas after 1 year the rate was 6.69 times greater (95%CI 3.18-14.09). CONCLUSIONS: Our study highlights the need for programme implementers to take into account the specific challenges that may influence continuity of antiretroviral treatment and care for migrant populations

Exploring the control of earthworm faeces micro- and macro-scale features on soil organic matter dynamics across species and ecological categories

International audienc

Exploring the control of earthworm cast macro- and micro-scale features on soil organic carbon mineralization across species and ecological categories

International audienceThe role of earthworms on biogeochemical carbon cycling is a major knowledge gap resulting from the difficulty of isolating and exploring the effects provided by the diversity of organisms. In this study, we investigated the effect of six earthworm species belonging to three ecological categories on soil organic carbon (SOC) mineralization. To this end, we produced casts in microcosms with the six species in the same soil and with the same litter material. The casts were subjected to laboratory ageing for 140 days. During this process, we monitored physicochemical parameters, CO2 emissions and determined the micro-scale organization of the casts’ particulate organic matter and pores using X-ray microtomography.Our results showed contrasting properties of fresh casts of the three ecological categories, in accordance with the earthworm species’ morphological or behavioral strategies, indicating that those were maintained in artificial environments. However, species-specific changes in cast properties throughout ageing increased intragroup variability among ecological categories. As a result we observed earthworm species-specific evolution of CO2 mineralization rates during casts ageing. We found that at least half of the variability in CO2 emissions was explained by cast microstructural changes, related to the spatial arrangement between particulate organic matter, porosity, and mineral particles. We conclude that earthworm species-specific traits may play a role in organic carbon protection through their impact on microstructural cast properties

Algorithms for baseline screening of creatinine.

<p>Algorithms for baseline screening of creatinine.</p