DRAFT Report:Community Systems Strengthening Toward a Research Agenda

Communities have a long history of acting to preserve and promote the health of their members. Public health researchers, programmers, and funders are increasingly recognizing that community involvement is essential to improving health, especially among populations that are disproportionately affected by HIV. The Global Fund to fight AIDS, Tuberculosis and Malaria, together with civil society organizations and other development partners, created the Community Systems Strengthening (CSS) Framework to help Global Fund applicants frame, define, and quantify efforts to strengthen community contributions engagement (Global Fund 2011). Although the use of a CSS approach in health programming implementation shows promise, it lacks a theoretical framework to guide collaborations with communities. Additionally, it suffers from a paucity of program designs and evaluation practices, an incomplete evidence-based rationale for investing in CSS, and imprecise definitions (e.g., what is meant by “community” and “CSS”).The purpose of this paper is to highlight promising areas for future research related to CSS. Toward this objective, we propose to lay a foundation for a CSS research agenda by using theories and approaches relevant to CSS, reinforced with evidence from projects that employ similar approaches

Community and service provider views to inform the 2013 WHO consolidated antiretroviral guidelines:key findings and lessons learnt

Objective:The objective was to evaluate community and healthcare worker (HCW) values and preferences on key topics to inform the development of the 2013 WHO consolidated guidelines for antiretroviral therapy in low and middle income countries. Design:Cross-sectional e-survey and e-forum discussion; focus group discussions (FGDs) Methods:Data were collected on community perspectives regarding a range of potential clinical and operational recommendations in the 2013 guidelines between November 2012 and January 2013 through an e-survey (n = 1088) and e-forum (n = 955). Additional FGDs were held with people living with HIV (PLHIV) in Malawi and Uganda (n = 88) on antiretroviral therapy (ART) use among pregnant women. Two surveys were also undertaken on similar topics covered in the e-survey for health care workers caring for adults (n = 98) and children (n = 348). Results:There were 1088 e-survey respondents from 117 countries: of whom 37.7% (298/791) were females, 49.9% (431/864) PLHIV, and 20.9% (174/831) from low-income countries. The proportion of e-survey respondents who supported raising the CD4 T-cell threshold for ART initiation in adults from 350 to 500 cells/μl was 51.0% (355/696), and regardless of CD4 T-cell count for all pregnant females 89.8% (607/676), HIV serodiscordant partners 71.9% (486/676), and all children on diagnosis of infection 47.4% (212/447). E-survey respondents strongly supported discontinuing use of stavudine (72.7%, 416/572), task-shifting/sharing from doctors to nurses (75.2%, 275/365) and from nurses to community health workers (71.1%, 261/367) as strategies to expand access to HIV testing, care, and treatment. Focus group discussion respondents identified service capacity, and social and legal concerns as key considerations influencing the decisions of women living with HIV to continue ART after the risk of vertical transmission has passed. Key lessons learnt in these consultations included the need for piloting and validation of questions; sufficient time to adequately disseminate the survey; and consideration of using FGDs and mobile phone technology to improve participation of people with limited internet access. Conclusion:Community participation in guideline development processes is important to ensure that their perspectives are considered in the resulting recommendations. Communities should be actively involved in the adaptation, implementation, and accountability processes related to the guidelines

Intermediate- and High-Velocity Ionized Gas toward zeta Orionis

We combine UV spectra obtained with the HST/GHRS echelle, IMAPS, and Copernicus to study the abundances and physical conditions in the predominantly ionized gas seen at high (-105 to -65 km/s) and intermediate velocities (-60 to -10 km/s) toward zeta Ori. We have high resolution (FWHM ~ 3.3-4.5 km/s) and/or high S/N spectra for at least two significant ions of C, N, Al, Si, S, and Fe -- enabling accurate estimates for both the total N(H II) and the elemental depletions. C, N, and S have essentially solar relative abundances; Al, Si, and Fe appear to be depleted by about 0.8, 0.3-0.4, and 0.95 dex, respectively. While various ion ratios would be consistent with collisional ionization equilibrium (CIE) for T ~ 25,000-80,000 K, the widths of individual high-velocity absorption components indicate that T ~ 9000 K -- so the gas is not in CIE. Analysis of the C II fine-structure excitation equilibrium yields estimated densities (n_e ~ n_H ~ 0.1-0.2 cm^{-3}), thermal pressures (2 n_H T ~ 2000-4000 cm^{-3}K), and thicknesses (0.5-2.7 pc) for the individual clouds. We compare the abundances and physical properties derived for these clouds with those found for gas at similar velocities toward 23 Ori and tau CMa, and also with several models for shocked gas. While the shock models can reproduce some features of the observed line profiles and some of the observed ion ratios, there are also significant differences. The measured depletions suggest that \~10% of the Al, Si, and Fe originally locked in dust in the pre-shock medium may have been returned to the gas phase, consistent with predictions for the destruction of silicate dust in a 100 km/s shock. The near-solar gas phase abundance of carbon, however, seems inconsistent with the predicted longer time scales for the destruction of graphite grains.Comment: 50 pages, 9 figures; aastex; accepted by Ap

Millimeter dust continuum emission unveiling the true mass of giant molecular clouds in the Small Magellanic Cloud

CO observations have been so far the best way to trace molecular gas in external galaxies, but at low metallicity the gas mass deduced could be largely underestimated. At present, the kinematic information of CO data cubes are used to estimate virial masses and trace the total mass of the molecular clouds. Millimeter dust emission can also be used as a dense gas tracer and could unveil H2 envelopes lacking CO. These different tracers must be compared in different environments. This study compares virial masses to masses deduced from millimeter emission, in two GMC samples: the local molecular clouds in our Galaxy and their equivalents in the Small Magellanic Cloud (SMC), one of the nearest low metallicity dwarf galaxy. In our Galaxy, mass estimates deduced from millimeter emission are consistent with masses deduced from gamma ray analysis and trace the total mass of the clouds. Virial masses are systematically larger (twice on average) than mass estimates from millimeter dust emission. This difference decreases toward high masses and has already been reported in previous studies. In the SMC however, molecular cloud masses deduced from SIMBA millimeter observations are systematically higher (twice on average for conservative values of the dust to gas ratio and dust emissivity) than the virial masses from SEST CO observations. The observed excess can not be accounted for by any plausible change of dust properties. Taking a general form for the virial theorem, we show that a magnetic field strength of ~15 micro Gauss in SMC clouds could provide additional support to the clouds and explain the difference observed. Masses of SMC molecular clouds have therefore been underestimated so far. Magnetic pressure may contribute significantly to their support.Comment: 10 pages, 2 figures, Astronomy & Astrophysics accepte

Tiny-Scale Molecular Structures in the Magellanic Clouds (Part 1)

We report on the {\small FUSE} detections of the HD and CO molecules {\bf on the lines of sight towards three Large Magellanic stars}: Sk $-$67D05, Sk $-$68D135, and Sk $-$69D246. HD is also detected for the first time {\bf on the lines of sight towards two Small Magellanic Cloud stars}: AV 95 and Sk 159. While the HD and CO abundances are expected to be lower in the Large Magellanic Cloud where molecular fractions are a third of the Galactic value and where the photodissociation flux is up to thousands times larger, we report an average HD/H$_2$ ratio of 1.4$\pm$0.5 ppm and CO/H$_2$ ratio ranging from 0.8 to 2.7 ppm similar to the Galactic ones. We tentatively identify a deuterium reservoir (hereafter D--reservoir) towards the Small Magellanic Cloud, along the light path to AV 95. We derive a D/H ratio ranging from 1. 10$^{-6}$ to 1.1 10$^{-5}$.Comment: 34 pages, 10 tables, 12 figures, accepted for publication in A&

The Magellanic Bridge as a DLA System: Physical Properties of Cold Gas toward PKS0312-770

We measure the physical properties of a local multi-component absorption-line system at V_sol ~ 200 km/s toward the quasar PKS0312-770 behind the Magellanic Bridge (MB) using Hubble Space Telescope STIS spectroscopy in conjunction with photoionization modeling. At an impact parameter of ~ 10 kpc from the Small Magellanic Cloud (SMC), this sightline provides a unique opportunity to probe the chemical properties and ionization structure in a nearby absorption line system with a column density of logN(HI) ~ 20.2, at the transition between Damped Lyman Alpha (DLA) and sub-DLA systems. We find that metallicity of -1.0 < logZ < -0.5 and ionization parameter of -6 < logU < -5 for three low-ionization components and logU ~ -2.6 for one high-ionization component. One component at V_sol = 207 km/s shows an alpha-element abundance log(Si/H) ~ -5.0, making it ~ 0.2 dex more metal rich than both SMC H II regions and stars within the MB and the SMC. The N/Si ratio in this component is log(N/Si) = -0.3+/-0.1, making it comparable to other N-poor dwarf galaxies and ~ 0.2 dex lower than H II regions in the SMC. Another component at V_sol = 236 km/s shows a similar Si/H ratio but has log(N/Si) = -1.0+/-0.2, indicating a nitrogen deficiency comparable to that seen in the most N-poor DLA systems. These differences imply different chemical enrichment histories between components along the same sightline. Our results suggest that, if these absorbers are representative some fraction of DLA systems, then 1) DLA systems along single sight-lines do not necessarily represent the global properties of the absorbing cloud, and b) the chemical composition within a given DLA cloud may be inhomogeneous.Comment: 28 pages, including 16 figures; accepted for publication in the Astrophysical Journa

Interstellar H I and H_2 in the Magellanic Clouds: An Expanded Sample Based on UV Absorption-Line Data

We have determined column densities of H I and/or H_2 for sight lines in the Magellanic Clouds from archival HST and FUSE spectra of H I Lyman-alpha and H_2 Lyman-band absorption. Together with some similar data from the literature, we now have absorption-based N(H I) and/or N(H_2) for 285 LMC and SMC sight lines (114 with a detection or limit for both species) -- enabling more extensive, direct, and accurate determinations of molecular fractions, gas-to-dust ratios, and elemental depletions in these two nearby, low-metallicity galaxies. For sight lines where the N(H I) estimated from 21 cm emission is significantly higher than the value derived from Lyman-alpha absorption (presumably due to emission from gas beyond the target stars), integration of the 21 cm profile only over the velocity range seen in Na I or H_2 absorption generally yields much better agreement. Conversely, N(21 cm) can be lower than N(Ly-alpha) by factors of 2--3 in some LMC sight lines -- suggestive of small-scale structure within the 21 cm beam(s) and/or some saturation in the emission. The mean gas-to-dust ratios obtained from N(H_tot)/E(B-V) are larger than in our Galaxy, by factors of 2.8--2.9 in the LMC and 4.1--5.2 in the SMC -- i.e., factors similar to the differences in metallicity. The N(H_2)/E(B-V) ratios are more similar in the three galaxies, but with considerable scatter within each galaxy. These data may be used to test models of the atomic-to-molecular transition at low metallicities and predictions of N(H_2) based on comparisons of 21 cm emission and the IR emission from dust.Comment: 67 pages; 18 figures; aastex; accepted to ApJ; higher quality figures (1, 2, 9, 18) are available at http://astro.uchicago.edu/~dwelty/MCH

A Unified Representation of Gas-Phase Element Depletions in the Interstellar Medium

A study of gas-phase element abundances reported in the literature for 17 different elements sampled over 243 sight lines in the local part of our Galaxy reveals that the depletions into solid form (dust grains) are extremely well characterized by trends that employ only three kinds of parameters. One is an index that describes the overall level of depletion applicable to the gas in any particular sight line, and the other two represent linear coefficients that describe how to derive each element's depletion from this sight-line parameter. The information from this study reveals the relative proportions of different elements that are incorporated into dust at different stages of grain growth. An extremely simple scheme is proposed for deriving the dust contents and metallicities of absorption-line systems that are seen in the spectra of distant quasars or the optical afterglows of gamma-ray bursts. Contrary to presently accepted thinking, the elements sulfur and krypton appear to show measurable changes in their depletions as the general levels of depletions of other elements increase, although more data are needed to ascertain whether or not these findings truly compelling. Nitrogen appears to show no such increase. The incorporation of oxygen into solid form in the densest gas regions far exceeds the amounts that can take the form of silicates or metallic oxides; this conclusion is based on differential measurements of depletion and thus is unaffected by uncertainties in the solar abundance reference scale.Comment: 166 pages, 21 figures, pages 116-166 contain detailed tabulations that may not be of interest to most readers. Accepted for publication in the Astrophysical Journa