An Evaluation of the Performance and Acceptability of Three LED Fluorescent Microscopes in Zambia: Lessons Learnt for Scale-Up

The World Health Organization recommends the roll-out of light-emitting diode (LED) fluorescent microscopes (FM) as an alternative to light microscopes in resource-limited settings. We evaluated the acceptability and performance of three LED FMs after a short orientation among laboratory technicians from government health centers in Zambia. Sixteen technicians with varied light microscopy experience were oriented to FMs and divided into groups; each group read a different set of 40 slides on each LED FM (Primo Star iLED™, Lumin™, FluoLED™) and on a reference mercury-vapor FM (Olympus BX41TF). Slide reading times were recorded. An experienced FM technician examined each slide on the Olympus BX41TF. Sensitivity and specificity compared to TB culture were calculated. Misclassification compared to the experienced technician and inter-rater reliability between trainees was assessed. Trainees rated microscopes on technical aspects. Primo Star iLED™, FluoLED™ and Olympus BX41TF had comparable sensitivities (67%, 65% and 65% respectively), with the Lumin™ significantly worse (56%; p<0.05). Specificity was low for trainees on all microscopes (75.9%) compared to the experienced technician on Olympus BX41TF (100%). Primo Star iLED™ had significantly less misclassification (21.1% p<0.05) than FluoLED™ (26.5%) and Lumin™ (26.8%) and significantly higher inter-rater reliability (0.611; p<0.05), compared to FluoLED™ (0.523) and Lumin™ (0.492). Slide reading times for LED FMs were slower than the reference, but not significantly different from each other. Primo Star iLED™ rated highest in acceptability measures, followed by FluoLED™ then Lumin™. Primo Star iLED™ was consistently better than FluoLED™ and Lumin™, and performed comparably to the Olympus BX41TF in all analyses, except reading times. The Lumin™ compared least favorably and was thought unacceptable for use. Specificity and inter-rater reliability were low for all microscopes suggesting that a brief orientation was insufficient in this setting. These results provide important data for resource-limited settings to consider as they scale-up LED FMs

Screening for tuberculosis and testing for human immunodeficiency virus in Zambian prisons

Objective: To improve the Zambia Prisons Service's implementation of tuberculosis screening and human immunodeficiency virus (HIV) testing. Methods: For both tuberculosis and HIV, we implemented mass screening of inmates and community-based screening of those residing in encampments adjacent to prisons. We also established routine systems – with inmates as peer educators – for the screening of newly entered or symptomatic inmates. We improved infection control measures, increased diagnostic capacity and promoted awareness of tuberculosis in Zambia's prisons. Findings: In a period of 9 months, we screened 7638 individuals and diagnosed 409 new patients with tuberculosis. We tested 4879 individuals for HIV and diagnosed 564 cases of infection. An additional 625 individuals had previously been found to be HIV-positive. Including those already on tuberculosis treatment at the time of screening, the prevalence of tuberculosis recorded in the prisons and adjacent encampments – 6.4% (6428/100 000) – is 18 times the national prevalence estimate of 0.35%. Overall, 22.9% of the inmates and 13.8% of the encampment residents were HIV-positive. Conclusion: Both tuberculosis and HIV infection are common within Zambian prisons. We enhanced tuberculosis screening and improved the detection of tuberculosis and HIV in this setting. Our observations should be useful in the development of prison-based programmes for tuberculosis and HIV elsewhere

Response of six common beans cultivars to phosphate and potassium fertilization in Lichinga, Niassa, Mozambique.

A field experiment was conducted to check out the response of the common bean BRS 293 Pontal to basic fertilization with Phosphorus (P) and Potassium, in the environmental conditions of Lichinga, Niassa, Mozambique. A complete factorial 5x4 was used, with five rates of P2O5 (0, 35, 70, 140, and 280 kg/ha, as Triple Superphosphate) and four rates of K2O (0, 50, 100 and 200 kg/ha, as Potassium Chloride). The experimental area was also fertilized with 90 kg/ha of Nitrogen (N), as Urea, spliced in 23 kg N/ha at planting and 67 kg N/ha 20 days after plants emergency. Each treatment was replicated four time in the field, in randomized blocks (18 m2 each, with five liner of six lineal meters each, spaced 0,45 cm, with nine seeds seeded per meter). At harvest (area of 3 m within the central lines), it was evaluated the plant final stand, degree of lodging, number of pods per plant, number of grains per pod, weight of 100 grains, and productivity. Based in the analysis of the data, it is concluded that maximum productivity, equivalent to 3,616 kg of grains/ha, would be obtained with a combination of 406 kg/ha of P2O5 and 43 kg/ha of K2O. Such rate is above what would be expected, which indicates that new studies would be necessary for better recommendation of P2O5 fertilization in this area

Response of six common beans cultivars to phosphate and potassium fertilization in Lichinga, Niassa, Mozambique.

A field experiment was conducted to check out the response of the common bean BRS 293 Pontal to basic fertilization with Phosphorus (P) and Potassium, in the environmental conditions of Lichinga, Niassa, Mozambique. A complete factorial 5x4 was used, with five rates of P2O5 (0, 35, 70, 140, and 280 kg/ha, as Triple Superphosphate) and four rates of K2O (0, 50, 100 and 200 kg/ha, as Potassium Chloride). The experimental area was also fertilized with 90 kg/ha of Nitrogen (N), as Urea, spliced in 23 kg N/ha at planting and 67 kg N/ha 20 days after plants emergency. Each treatment was replicated four time in the field, in randomized blocks (18 m2 each, with five liner of six lineal meters each, spaced 0,45 cm, with nine seeds seeded per meter). At harvest (area of 3 m within the central lines), it was evaluated the plant final stand, degree of lodging, number of pods per plant, number of grains per pod, weight of 100 grains, and productivity. Based in the analysis of the data, it is concluded that maximum productivity, equivalent to 3,616 kg of grains/ha, would be obtained with a combination of 406 kg/ha of P2O5 and 43 kg/ha of K2O. Such rate is above what would be expected, which indicates that new studies would be necessary for better recommendation of P2O5 fertilization in this area

Genetic diversity and population structure of the African catfish, <i>Clarias gariepinus</i> (Burchell, 1822) in Kenya: implication for conservation and aquaculture

African catfish, Clarias gariepinus, is an important species in aquaculture and fisheries in Kenya. Mitochondrial D-loop control region was used to determine genetic variation and population structure in samples of C. gariepinus from 10 sites including five natural populations (Lakes Victoria (LVG), Kanyaboli (LKG), Turkana (LTA), Baringo (LBA) and Jipe (LJP), and five farms (Sangoro Aquaculture Center (SAN), Sagana Aquaculture Centre (SAG), University of Eldoret Fish Farm (UoE), Kibos Fish Farm (KIB), and Wakhungu Fish Farm (WKU)) in Kenya. Similarly, samples from eight localities (four natural populations: LVG/LKG, LTA, LBA, and four farmed: SAN, SAG, KIB, UoE) were genotyped using six microsatellite DNA loci. For the D-loop control region, samples from natural sites exhibited higher numbers of haplotypes and haplotype diversities compared to farmed samples, and 88.2% of haplotypes were private. All except LJP and LTA shared haplotypes, and the highest number of shared haplotypes (8) was detected in KIB. The 68 haplotypes we found in 268 individuals grouped into five phylogenetic clades: LVG/LKG, LTA, LBA, LJP and SAG. Haplotypes of farmed C. gariepinus mostly have haplotypes typical of LVG/LKG, and some shared haplotypes of the LBA population. Microsatellite analysis showed farmed samples have higher numbers of alleles than natural samples, but higher observed and expected heterozygosity levels were found in samples of natural populations. Fifteen pair-wise comparisons had significantly different FST values. All samples were in Hardy-Weinberg equilibrium. Samples from the eight localities grouped into four genetic clusters (LVG/LKG, LTA, LBA and SAG), indicating genetically distinct populations, which should be considered for aquaculture and conservation

Ecosystem services from Southern African woodlands and their future under global change

Miombo and mopane woodlands are the dominant land cover in southern Africa. Ecosystem services from these woodlands support the livelihoods of 100 M rural people and 50 M urban dwellers, and others beyond the region. Provisioning services contribute $9 ± 2 billion yr(−1) to rural livelihoods; 76$780 M. Woodlands support much of the region's agriculture through transfers of nutrients to fields and shifting cultivation. Woodlands store 18–24 PgC carbon, and harbour a unique and diverse flora and fauna that provides spiritual succour and attracts tourists. Longstanding processes that will impact service provision are the expansion of croplands (0.1 M km(2); 2000–2014), harvesting of woodfuels (93 M tonnes yr(−1)) and changing access arrangements. Novel, exogenous changes include large-scale land acquisitions (0.07 M km(2); 2000–2015), climate change and rising CO(2). The net ecological response to these changes is poorly constrained, as they act in different directions, and differentially on trees and grasses, leading to uncertainty in future service provision. Land-use change and socio-political dynamics are likely to be dominant forces of change in the short term, but important land-use dynamics remain unquantified. This article is part of the themed issue ‘Tropical grassy biomes: linking ecology, human use and conservation’

Testing a global standard for quantifying species recovery and assessing conservation impact

Recognizing the imperative to evaluate species recovery and conservation impact, in 2012 the International Union for Conservation of Nature (IUCN) called for development of a “Green List of Species” (now the IUCN Green Status of Species). A draft Green Status framework for assessing species’ progress toward recovery, published in 2018, proposed 2 separate but interlinked components: a standardized method (i.e., measurement against benchmarks of species’ viability, functionality, and preimpact distribution) to determine current species recovery status (herein species recovery score) and application of that method to estimate past and potential future impacts of conservation based on 4 metrics (conservation legacy, conservation dependence, conservation gain, and recovery potential). We tested the framework with 181 species representing diverse taxa, life histories, biomes, and IUCN Red List categories (extinction risk). Based on the observed distribution of species’ recovery scores, we propose the following species recovery categories: fully recovered, slightly depleted, moderately depleted, largely depleted, critically depleted, extinct in the wild, and indeterminate. Fifty-nine percent of tested species were considered largely or critically depleted. Although there was a negative relationship between extinction risk and species recovery score, variation was considerable. Some species in lower risk categories were assessed as farther from recovery than those at higher risk. This emphasizes that species recovery is conceptually different from extinction risk and reinforces the utility of the IUCN Green Status of Species to more fully understand species conservation status. Although extinction risk did not predict conservation legacy, conservation dependence, or conservation gain, it was positively correlated with recovery potential. Only 1.7% of tested species were categorized as zero across all 4 of these conservation impact metrics, indicating that conservation has, or will, play a role in improving or maintaining species status for the vast majority of these species. Based on our results, we devised an updated assessment framework that introduces the option of using a dynamic baseline to assess future impacts of conservation over the short term to avoid misleading results which were generated in a small number of cases, and redefines short term as 10 years to better align with conservation planning. These changes are reflected in the IUCN Green Status of Species Standard

Pentecostalism, gerontocratic rule and democratization in Malawi: the changing position of the young in political culture

This chapter explores the relationship between the father-metaphor, gerontocratic power, democratization and religion in the context of changing political culture in Malawi. It argues that democratization in Malawi signalled a change in the nature of the dominant gerontocratic power relations associated with Chewa political traditions, and gave the young an opportunity to escape from their tightly circumscribed sociopolitical space in what for thirty years had been a highly supervised society. It further argues that religion, in particular 'born-again' (often Pentecostal) Christianity, played a significant role in changing the meaning of the crucial root paradigm of gerontocracy in Malawian political culture. The chapter shows that the position adopted by religious youth groups in the 1990s was the outcome of a 'struggle for youth' that Malawian society had faced since colonial times and in which religion played a significant role. In so doing, it deconstructs the so-called 'conservative nature' of Christian fundamentalism-cum- Pentecostalism.ASC – Publicaties niet-programma gebonde

The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa

Introduction Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. Methods The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Results Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced‐prophylaxis components. Enhanced‐prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced‐prophylaxis still conveyed health gains in CrAg‐negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost‐effective unless the price of CrAg testing fell below US$2.30. Conclusions The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices

Late Presentation With HIV in Africa: Phenotypes, Risk, and Risk Stratification in the REALITY Trial.

This article has been accepted for publication in Clinical Infectious Diseases Published by Oxford University PressBackground: Severely immunocompromised human immunodeficiency virus (HIV)-infected individuals have high mortality shortly after starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods: The Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children ≥5 years of age with CD4 counts .1). Results: Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P < .04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P = .02). Of five late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/µL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/µL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/µL), but low symptom burden and maintained fat mass. The remaining groups had 4%-6% mortality. Conclusions: Clinical and laboratory features identified groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up. Clinical Trials Registration: ISRCTN43622374.REALITY was funded by the Joint Global Health Trials Scheme (JGHTS) of the UK Department for International Development, the Wellcome Trust, and Medical Research Council (MRC) (grant number G1100693). Additional funding support was provided by the PENTA Foundation and core support to the MRC Clinical Trials Unit at University College London (grant numbers MC_UU_12023/23 and MC_UU_12023/26). Cipla Ltd, Gilead Sciences, ViiV Healthcare/GlaxoSmithKline, and Merck Sharp & Dohme donated drugs for REALITY, and ready-to-use supplementary food was purchased from Valid International. A. J. P. is funded by the Wellcome Trust (grant number 108065/Z/15/Z). J. A. B. is funded by the JGHTS (grant number MR/M007367/1). The Malawi-Liverpool–Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine (grant number 101113/Z/13/Z) and the Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi (grant number 203077/Z/16/Z) are supported by strategic awards from the Wellcome Trust, United Kingdom. Permission to publish was granted by the Director of KEMRI. This supplement was supported by funds from the Bill & Melinda Gates Foundation