Implementing antiretroviral therapy in rural communities: the Lusikisiki model of decentralized HIV/AIDS care.

Health worker shortages are a major bottleneck to scaling up antiretroviral therapy (ART), particularly in rural areas. In Lusikisiki, a rural area of South Africa with a population of 150,000 serviced by 1 hospital and 12 clinics, Médecins Sans Frontières has been supporting a program to deliver human immunodeficiency virus (HIV) services through decentralization to primary health care clinics, task shifting (including nurse-initiated as opposed to physician-initiated treatment), and community support. This approach has allowed for a rapid scale-up of treatment with satisfactory outcomes. Although the general approach in South Africa is to provide ART through hospitals-which seriously limits access for many people, if not the majority of people-1-year outcomes in Lusikisiki are comparable in the clinics and hospital. The greater proximity and acceptability of services at the clinic level has led to a faster enrollment of people into treatment and better retention of patients in treatment (2% vs. 19% lost to follow-up). In all, 2200 people were receiving ART in Lusikisiki in 2006, which represents 95% coverage. Maintaining quality and coverage will require increased resource input from the public sector and full acceptance of creative approaches to implementation, including task shifting and community involvement

FORCED AIR HEATING IN HEALTH FACILITIES AS A STRATEGY TO REDUCE NOSOCOMIAL TB TRANSMISSION IN RESOURCE-LIMITED SETTINGS.

Cape Town TB Conferenc

Dry supplementary feeding programmes: an effective short-term strategy in food crisis situations.

Malnutrition is frequently a predominant problem in disasters, and supplementary feeding programmes (SFPs) are often set up in food emergencies. This review analyses the effectiveness of such programmes in crisis situations in Liberia, Burundi and Goma (Congo), concluding that it is feasible to enrol large numbers of children in SFPs and achieve proportions of recovery above 75% if these programmes are implemented as a short-term measure in emergency situations. However, satisfactory SFP results do not necessarily indicate improved nutritional status of the whole population

Nevirapine-Induced Heratotoxicity: Incidence, Risk Factors and Associated Mortality in a Primary Care ART Programme in South Africa

CROI 200

The prevention of mother-to-child HIV transmission programme and infant feeding practices

Since the first cases of HIV transmission through breastfeeding were documented, a fierce debate has raged on appropriate guidelines for infant feeding in resource-poor settings. A major problem is determining when it is safe and feasible to formula-feed, as breast-milk protects against other diseases. A cross-sectional survey of 113 women attending the programme for the prevention of mother-to-child transmission in Khayelitsha, Cape Town, was conducted. Over 95% of women on the programme formula-fed their infants and did not breast- feed at all. Seventy per cent of women said that their infant had never had diarrhoea, and only 3% of children had had two episodes of diarrhoea. Focus groups identified the main reasons for not breast-feeding given by women to their families and those around them. Formula feeding is safe and feasible in an urban environment where sufficient potable water is available

Structural Optimisation: Biomechanics of the Femur

A preliminary iterative 3D meso-scale structural model of the femur was developed, in which bar and shell elements were used to represent trabecular and cortical bone respectively. The cross-sectional areas of the bar elements and the thickness values of the shell elements were adjusted over successive iterations of the model based on a target strain stimulus, resulting in an optimised construct. The predicted trabecular architecture, and cortical thickness distribution showed good agreement with clinical observations, based on the application of a single leg stance load case during gait. The benefit of using a meso-scale structural approach in comparison to micro or macro-scale continuum approaches to predictive bone modelling was achievement of the symbiotic goals of computational efficiency and structural description of the femur.Comment: Accepted by Engineering and Computational Mechanics (Proceedings of the ICE

Thresholds, breakpoints, and nonlinearity in freshwaters as related to management.

Nonlinear ecological responses to anthropogenic forcing are common, and in some cases, the ecosystem responds by assuming a new stable state. This article is an overview and serves as the introduction to several articles in this BRIDGES cluster that are directed toward managers interested in dealing with nonlinear responses in freshwaters, particularly streams. A threshold or breakpoint occurs where the system responds rapidly to a relatively small change in a driver. The existence of a threshold can signal a change in system configuration to an alternative stable state, although such a change does not occur with all thresholds. In general, a mechanistic understanding of ecological dynamics is required to predict thresholds, where they will occur, and if they are associated with the occurrence of alternative stable states. Thresholds are difficult to predict, although a variety of univariate methods has been used to indicate thresholds in ecological data. When we applied several methods to one type of response variable, the resulting threshold values varied 3-fold, indicating that more research on detection methods is necessary. Numerous case studies suggest that the threshold concept is important in all ecosystems. Managers should be aware that human actions might result in undesirable rapid changes and potentially an unwanted alternative stable state, and that recovery from that state might require far more resources and time than avoiding entering the state in the first place would have required. Given the difficulties in predicting thresholds and alternative states, the precautionary approach to ecosystem management is probably the most prudent

Evaluation of a diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV-infected adults

Objective: To evaluate the diagnostic accuracy of and reduction in diagnostic delay attributable to a clinical algorithm used for the diagnosis of smear-negative pulmonarytuberculosi& (SNPTB) in HfV-infected adults.Design. An algorithm was designed to facilitate clinicoradiological diagnosis of pulmonary TB (PTB) in HIV-infected smear-negative adult patients. A folder review was performed on the first 58 cases referred for empirical TB treatment using this algorithm.Setting. Nolungile HIV Clinic, Site Khayelitsha.Subjects. Subjects included 58 HIV-infected adult patients with suspected PTB consecutively referred to the local TB clinic for outpatient TB treatment using this algorithm between 12 February 2004 and 30 April 2005.Outcome measures. Outcome measures were response of C-reactive protein, haemoglobin, weight and symptoms to TB treatment, and TB culture result. Diagnostic delay On days) was calculated.Results. Thirty-two of the 58 patients (55%) had positive TB cultures (definite TB). Initiation of TB treatment occurred on average 19.5 days before the positive culture report. A further 21 patients (36%) demonstrated clinical improvement on empirical treatment (probable/possible TB). Two did not improve and subsequently died without a definitive diagnosis. Three patients defaulted treatment.Conclusions.SNPTB is more common in HIV-infected patients and leads to diagnostic delay. This algorithm allowed for earlier initiation of TB treatment in HIV-infected patients presenting with symptoms of PTB and negative smears or nonproductive cough in a high TB incidence setting