Agreement between physicians and non-physician clinicians in starting antiretroviral therapy in rural Uganda

<p>Abstract</p> <p>Background</p> <p>The scarcity of physicians in sub-Saharan Africa – particularly in rural clinics staffed only by non-physician health workers – is constraining access to HIV treatment, as only they are legally allowed to start antiretroviral therapy in the HIV-positive patient. Here we present a pilot study from Uganda assessing agreement between non-physician clinicians (nurses and clinical officers) and physicians in their decisions as to whether to start therapy.</p> <p>Methods</p> <p>We conducted the study at 12 government antiretroviral therapy sites in three regions of Uganda, all of which had staff trained in delivery of antiretroviral therapy using the WHO Integrated Management of Adult and Adolescent Illness guidelines for chronic HIV care. We collected seven key variables to measure patient assessment and the decision as to whether to start antiretroviral therapy, the primary variable of interest being the Final Antiretroviral Therapy Recommendation. Patients saw either a clinical officer or nurse first, and then were screened identically by a blinded physician during the same clinic visit. We measured inter-rater agreement between the decisions of the non-physician health workers and physicians in the antiretroviral therapy assessment variables using simple and weighted Kappa analysis.</p> <p>Results</p> <p>Two hundred fifty-four patients were seen by a nurse and physician, while 267 were seen by a clinical officer and physician. The majority (> 50%) in each arm of the study were in World Health Organization Clinical Stages I and II and therefore not currently eligible for antiretroviral therapy according to national antiretroviral therapy guidelines. Nurses and clinical officers both showed moderate to almost perfect agreement with physicians in their Final Antiretroviral Therapy Recommendation (unweighted κ = 0.59 and κ = 0.91, respectively). Agreement was also substantial for nurses versus physicians for assigning World Health Organization Clinical Stage (weighted κ = 0.65), but moderate for clinical officers versus physicians (κ = 0.44).</p> <p>Conclusion</p> <p>Both nurses and clinical officers demonstrated strong agreement with physicians in deciding whether to initiate antiretroviral therapy in the HIV patient. This could lead to immediate benefits with respect to antiretroviral therapy scale-up and decentralization to rural areas in Uganda, as non-physician clinicians – particularly clinical officers – demonstrated the capacity to make correct clinical decisions to start antiretroviral therapy. These preliminary data warrant more detailed and multicountry investigation into decision-making of non-physician clinicians in the management of HIV disease with antiretroviral therapy, and should lead policy-makers to more carefully explore task-shifting as a shorter-term response to addressing the human resource crisis in HIV care and treatment.</p

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Commercial Motorcycle (Boda Boda) Riders and the Production of Space in Kampala City, Uganda

Using a hybrid theoretical framework combining Lefebvre’s theory of production of space, and de Certeau’s everyday theory specifically the concepts, “strategies” and “tactics”; and several conceptual ideas developed by Southern urbanists like AbdouMaliq Simone; and Asef Bayat, this study investigated the following research questions: how do boda boda riders perceive, experience, and use (appropriate) space; how is their use of space influenced by the way their industry and city are organized; how is their use of space influenced by relationships among them, and, between them, the state, and other consumers of space; and what are the outcomes of these processes? Eighteen semistructured interviews and fourteen ride-alongs were conducted with riders. Fifteen key informants including 5 traffic police officers, 9 leaders of riders’ associations and 1 official of Kampala City Council Authority were interviewed. These methods were augumented by documentary reviews, observations and informal consultations. Results show that production of space by riders involves the production of liminal identities and spaces. Technology, modalities of ownership and contractual arrangements, riders’ biography, design and quality of the city’s abstract space, and riders’ calculative mentality, among other factors, influenced the way riders used space. Riders perceived space, specifically the city’s space as a space of livelihood formation, possibilities and xvi spectacle. The city was also parsed a contested space and laboratory of learning; these perceptions reflected riders’ experiences of space as an arena of order and disorder, social marginalization, and theatre of learning. A compendium of practices and tactics pertaining to creating, accessing, and maintaining space; movement; and entrepreneurship was documented. Relationships between riders were mediated mainly by reciprocity of action. While riders conflicted, the level of animosity among them was less compared to that between them, pedestrians and motorists. “Politics of Noise” and “Silence” characterized relationships between riders and the state, and were emblematic of the urban politics of Kampala. Furthermore, the state insinuated itself in space via “carrot” and “stick” policing strategies. These strategies in turn invoked tactics and practices like protests, petitioning and violence or the “politics of noise,” hence they were dialectical. All facets of this research were wrought with contradictions as explicated in Lefebvre’s theory. Results also supported Michel de Certeau’s concepts and those of Southern urbanists. Ideas from the Global South contextualized the findings, making them more relevant. Overall, production of space by riders underscores the imbrication of formality with informality, and co-mingledness of micro, meso and macro processes and structures

Safety, health and environmental impacts of commercial motorcycles in Sub-Saharan African cities

ABSTRACTIn Sub-Saharan Africa, vulnerable road users make up approximately 50% of all traffic fatalities. Despite the dangers of using motorcycles for transportation, the usage of motorcycles—and more recently, motor tricycles—for both personal and commercial purposes has increased exponentially in most Sub-Saharan African cities. The study sought to study the safety, health and environmental impact of commercial motorcycles in Sub-Saharan African cities. Two cities—the national capital and a secondary city—were selected in each of our five study countries: Ghana, Liberia, Kenya, Tanzania and Uganda. Using a mixed-methods approach, motorcycle taxi operators were surveyed and key transport stakeholders were interviewed in these ten cities. In Ghana, where both motorcycle and motor-tricycle taxis are officially banned but continue to operate, we also surveyed motor-tricycle taxi operators. The results indicated variability in accident occurrence across countries for both minor and major road traffic collisions (RTCs) among motorcycle/tricycle taxi riders. Apart from Liberia, motorcycle/tricycle taxi unions in our study countries contribute to improving the safety of their riders. Interest in electric bikes is low amongst riders in all five countries, with education and infrastructure provision required to cause a shift from conventional bikes to electric bikes