The United Nations, the African Union and the rule of law in Southern Sudan

The argument of this thesis is that measures taken by international bodies to establish the rule of law in postconflict situations are undertaken in the mistaken belief that they will automatically enhance conditions for the rule of law to flourish. In fact, examination of the situation in Southern Sudan demonstrates that there is a wide disconnection between the measures pursued and the outcome of the process. This study will therefore inquire into the different meanings attributed to the concept of the rule of law in order to establish what the concept signifies in the context of statebuilding, with a focus on Southern Sudan. How does the theoretical understanding of the rule of law correlate with the legal and institutional measures taken by international organizations such as the United Nations and the African Union to build the effectiveness of the state in Southern Sudan? The study will further address issues such as what kind of state institutions are envisaged by rule of law reforms, together with the historical and theoretical imperatives which orient and drive the rule of law building process in post-conflict situations. The research is envisaged as a contribution to the debate on how to make ‘rule of law work on the ground’. It is hoped that if practitioners and policy makers take into account the findings of this study, their contribution to rule of law reforms in countries like Southern Sudan that have experienced protracted conflicts will not only achieve their objectives of reforms but also significantly improve the social and economic wellbeing and human rights protection of the people in whose name these reforms are pursued

Sero-Prevalence and Factors Associated with Toxoplasma gondii Infection among Pregnant Women Attending Antenatal Care in Mwanza, Tanzania.

Serological screening of pregnant women for Toxoplasma gondii-specific antibodies is not practiced as an antenatal care in Tanzania; and there is a limited data about sero-prevalence of T. gondii infection in developing countries. We therefore conducted this study to determine the sero-prevalence and factors associated with T. gondii infection among pregnant women attending antenatal care clinics in Mwanza, Tanzania. Between 1st November 2012 and 31st May 2013 a total of 350 pregnant women attending antenatal care clinics in Mwanza were enrolled and screened for IgG and IgM antibodies against T. gondii using the ELISA technique. Of 350 pregnant women, 108 (30.9%) were sero-positive for T. gondii-specific antibodies. The risk of contracting T. gondii infection increases by 7% with each yearly increase in a woman's age (OR=1.07, 95% CI: 1.02 - 1.11, p=0.002). The sero-positivity rate of T. gondii-specific antibodies was higher among pregnant women from the urban than those from rural communities (41.5% versus 22.0%); [OR=2.2, 95% CI; 1.4 - 3.7, p=0.001]. Likewise employed/business women were more likely to get T. gondii infection than peasants (40.0% versus 25.9%) [OR=1.9, 95% CI: 1.2 - 3.0, p=0.006]. Sero-prevalence of T. gondii-specific antibodies is high among pregnant women in Mwanza with a significant proportion of women at risk of contracting primary T. gondii infections. Screening of T. gondii infections during antenatal care should be considered in Tanzania as the main strategy to minimize congenital toxoplasmosis

Maternal Death Reviews at Bugando Hospital North-western Tanzania: A 2008-2012 Retrospective Analysis.

Unacceptably high levels of maternal deaths still occur in many sub-Saharan countries and the health systems may not favour effective use of lessons from maternal death reviews to improve maternal survival. We report results from the analysis of data from maternal death reviews at Bugando Medical Centre north-western Tanzania in the period 2008-2012 and highlight the process, challenges and how the analysis provided a better understanding of maternal deaths. Retrospective analysis using maternal death review data and extraction of missing information from patients' files. Analysis was done in STATA statistical package into frequencies and means ± SD and median with 95 % CI for categorical and numerical data respectively. There were 80 deaths; mean age of the deceased 27.1 ± 6.2 years and a median hospital stay of 11.0 days [95 % CI 11.0-15.3]. Most deaths were from direct obstetric causes (90); 60 % from eclampsia, severe pre-eclampsia, sepsis, abortion and anaesthetic complications. Information on ANC attendance was recorded in 36.2 % of the forms and gestation age of the pregnancy resulting into the death in 23.8 %. Sixty one deaths (76.3 %) occurred after delivery. The mode of delivery, place of delivery and delivery assistant were recorded in 44 (72.1), 38 (62.3) and 23 (37.7 %) respectively. Routine maternal death reviews in this setting do not involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses. Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care

HIV Drug Resistance (HIVDR) in Antiretroviral Therapy-Naïve Patients in Tanzania Not Eligible for WHO Threshold HIVDR Survey Is Dramatically High

The World Health Organization (WHO) has recommended guidelines for a HIV drug resistance (HIVDR) survey for resource-limited countries. Eligibility criteria for patients include age below 25 years in order to focus on the prevalence of transmitted HIVDR (tHIVDR) in newly-infected individuals. Most of the participating sites across Africa have so far reported tHIVDR prevalences of below 5%. In this study we investigated whether the rate of HIVDR in patients <25 years is representative for HIVDR in the rest of the therapy-naïve population. HIVDR was determined in 88 sequentially enrolled ART-naïve patients from Mwanza, Tanzania (mean age 35.4 years). Twenty patients were aged <25 years and 68 patients were aged 25-63 years. The frequency of HIVDR in the study population was 14.8% (95%; CI 0.072-0.223) and independent of NVP-resistance induced by prevention of mother-to-child transmission programs. Patients >25 years had a significantly higher HIVDR frequency than younger patients (19.1%; 95% CI 0.095-0.28) versus 0%, P = 0.0344). In 2 out of the 16 patients with HIVDR we found traces of antiretrovirals (ARVs) in plasma. ART-naïve patients aged over 25 years exhibited significantly higher HIVDR than younger patients. Detection of traces of ARVs in individuals with HIVDR suggests that besides transmission, undisclosed misuse of ARVs may constitute a significant factor in the generation of the observed high HIVDR rate. The current WHO tHIVDR survey that is solely focused on the transmission of HIVDR and that excludes patients over 25 years of age may therefore result in substantial underestimation of the prevalence of HIVDR in the therapy-naïve population. Similar studies should be performed also in other areas to test whether the so far reported optimistic picture of low HIVDR prevalence in young individuals is really representative for the rest of the ART-naïve HIV-infected population

Making Global Health Rotations a Two-Way Street

As US residency programs are increasingly offering global health electives for their trainees, there is a growing call for these opportunities to include bidirectional exchanges—where residents from both the US and international partner institutions rotate at the other’s site. Curricular, logistical, and funding challenges of hosting residents from an international site may be barriers to developing these programs. In this report, the authors describe an 8-year experience of a US institution hosting residents from a resource-limited international partner and provide a framework for others institutions to develop bidirectional exchanges. They also report the visiting international residents’ perceptions of the impact of the exchange on their clinical practice, teaching, career paths, and their home institution

Effects of Prednisolone on Disease Progression in Antiretroviral-Untreated HIV Infection: A 2-Year Randomized, Double-Blind Placebo-Controlled Clinical Trial

Background HIV-disease progression correlates with immune activation. Here we investigated whether corticosteroid treatment can attenuate HIV disease progression in antiretroviral-untreated patients. Methods Double-blind, placebo-controlled randomized clinical trial including 326 HIV-patients in a resource-limited setting in Tanzania (clinicaltrials.gov NCT01299948). Inclusion criteria were a CD4 count above 300 cells/μl, the absence of AIDS-defining symptoms and an ART-naïve therapy status. Study participants received 5 mg prednisolone per day or placebo for 2 years. Primary endpoint was time to progression to an AIDS-defining condition or to a CD4-count below 200 cells/μl. Results No significant change in progression towards the primary endpoint was observed in the intent-to-treat (ITT) analysis (19 cases with prednisolone versus 28 cases with placebo, p = 0.1407). In a per-protocol (PP)-analysis, 13 versus 24 study participants progressed to the primary study endpoint (p = 0.0741). Secondary endpoints: Prednisolone-treatment decreased immune activation (sCD14, suPAR, CD38/HLA-DR/CD8+) and increased CD4-counts (+77.42 ± 5.70 cells/μl compared to -37.42 ± 10.77 cells/μl under placebo, p < 0.0001). Treatment with prednisolone was associated with a 3.2-fold increase in HIV viral load (p < 0.0001). In a post-hoc analysis stratifying for sex, females treated with prednisolone progressed significantly slower to the primary study endpoint than females treated with placebo (ITT-analysis: 11 versus 21 cases, p = 0.0567; PP-analysis: 5 versus 18 cases, p = 0.0051): No changes in disease progression were observed in men. Conclusions This study could not detect any significant effects of prednisolone on disease progression in antiretroviral-untreated HIV infection within the intent-to-treat population. However, significant effects were observed on CD4 counts, immune activation and HIV viral load. This study contributes to a better understanding of the role of immune activation in the pathogenesis of HIV infection

Demographic patient characteristics of the study population.

<p>The study population consisted of 120 ART-naive HIV-1 infected adults. PBMC- or plasma samples from 88 patients yielded amplicons for the bulk sequencing reaction. Data are expressed as means ± S.D. and range in parentheses. Patients with CD4 counts <200/ml at sample date initiated ART if CD4 counts remained below 350/ml four weeks later.</p