CD4 trajectory adjusting for dropout among HIV-positive patients receiving combination antiretroviral therapy in an East African HIV care centre

Objective: Estimates of CD4 response to antiretroviral therapy (ART) obtained by averaging data from patients in care, overestimate population CD4 response and treatment program effectiveness because they do not consider data from patients who are deceased or not in care. We use mathematical methods to assess and adjust for this bias based on patient characteristics. Design: We examined data from 25,261 HIV-positive patients from the East Africa IeDEA Consortium. Methods: We used inverse probability of censoring weighting (IPCW) to represent patients not in care by patients in care with similar characteristics. We address two questions: What would the median CD4 be “had everyone starting ART remained on observation?” and “were everyone starting ART maintained on treatment?” Results: Routine CD4 count estimates were higher than adjusted estimates even under the best-case scenario of maintaining all patients on treatment. Two years after starting ART, differences between estimates diverged from 30 cells/µL, assuming similar mortality and treatment access among dropouts as patients in care, to over 100 cells/µL assuming 20% lower survival and 50% lower treatment access among dropouts. When considering only patients in care, the proportion of patients with CD4 above 350 cells/µL was 50% adjusted to below 30% when accounting for patients not in care. One-year mortality diverged 6–14% from the naïve estimates depending on assumptions about access to care among lost patients. Conclusions: Ignoring mortality and loss to care results in over-estimation of ART response for patients starting treatment and exaggerates the efficacy of treatment programs administering it

Evaluation of the stock structure of cobia (Rachycentron canadum) in the southeastern United States by using dart-tag and genetics data

Available tag-recapture and population genetics data for cobia (Rachycentron canadum) in the south-eastern United States were evaluated to provide information on population structure and determine the geographic boundary between stocks in the Gulf of Mexico and the Atlantic Ocean. The movements of 1750 cobia were evaluated on the basis of assigned tagging and recapture zones. Genetic samples from an additional 2796 cobia collected during the presumed spawning season were genotyped at 10 microsatellite loci, and standard population genetic statistical analyses were applied to the resulting sample data set. Tag- recapture results indicate that cobia tagged south of Cape Canaveral, Florida, primarily move between that area and the Gulf of Mexico and that cobia tagged north of Georgia have little interaction with the area south of Cape Canaveral. Cobia tagged at Cape Canaveral distributed widely throughout the entire southeastern coast of the United States. Genetic analysis results agree, indicating separate stocks that occur from Texas through Hobe Sound on the east coast of Florida and from Savannah, Georgia, to the Chesapeake Bay in Virgina, with distinct genetic groupings within the Atlantic Ocean stock. The results indicate a transition area that occurs from Cape Canaveral through northern Georgia, and additional data from this region are necessary to further refine the stock boundary

Sharks, rays and marine protected areas: a critical evaluation of current perspectives

Marine protected areas (MPAs) are increasingly advocated for the conservation and management of sharks and rays. However, substantial uncertainty remains regarding which species can benefit from MPAs. Meanwhile, area-focused protection targets have spurred recent and rapid gains in the creation of large MPAs, many of which carry vague objectives set by a diverse group of stakeholders with potentially different notions of "success." Here, we capture and critically evaluate current views on the use of MPAs for shark and ray conservation. Through interviews with scientists, MPA managers, fisheries experts, conservation practitioners, advocates and policy experts (n = 53), we demonstrate a variety of perspectives regarding: (a) the effectiveness of MPAs as a tool for shark and ray conservation; (b) which factors influence the success of MPAs for sharks and rays; and (c) the desired outcomes of these MPAs. While MPAs created specifically for sharks and rays were viewed to be slightly more effective than regular MPAs as a tool for shark and ray conservation, both were generally considered insufficient in isolation. Despite greater emphasis on social success factors (e.g., local support) over biophysical success factors (e.g., size), biological outcomes (e.g., increased abundance) were prioritized over social outcomes (e.g., livelihood benefits). We argue that a stronger focus on achieving social outcomes can enhance the potential for MPAs to benefit sharks and rays. In revealing current thinking regarding the drivers and indicators of MPA success for sharks and rays, the results of this study can inform efforts to conserve and manage these species

Evaluating the Impact of a HIV Low-Risk Express Care Task-Shifting Program: A Case Study of the Targeted Learning Roadmap

In conducting studies on an exposure of interest, a systematic roadmap should be applied for translating causal questions into statistical analyses and interpreting the results. In this paper we describe an application of one such roadmap applied to estimating the joint effect of both time to availability of a nurse-based triage system (low risk express care (LREC)) and individual enrollment in the program among HIV patients in East Africa. Our study population is comprised of 16;513 subjects found eligible for this task-shifting program within 15 clinics in Kenya between 2006 and 2009, with each clinic starting the LREC program between 2007 and 2008. After discretizing followup into 90-day time intervals, we targeted the population mean counterfactual outcome (i.e. counterfactual probability of either dying or being lost to follow up) at up to 450 days after initial LREC eligibility under three fixed treatment interventions. These were (i) under no program availability during the entire follow-up, (ii) under immediate program availability at initial eligibility, but non-enrollment during the entire follow-up, and (iii) under immediate program availability and enrollment at initial eligibility. We further estimated the controlled direct effect of immediate program availability compared to no program availability, under a hypothetical intervention to prevent individualenrollment in the program. Targeted minimum loss-based estimation was used to estimate the mean outcome, while Super Learning was implemented to estimate the required nuisance parameters. Analyses were conducted with the ltmle R package; analysis code is available at an online repository as an R package. Results showed that at 450 days, the probability of in-care survival for subjects with immediate availability and enrollment was 0:93 (95% CI: 0.91, 0.95) and 0:87 (95% CI: 0.86, 0.87) for subjects with immediate availability never enrolling. For subjects without LREC availability, it was 0:91 (95% CI: 0.90, 0.92). Immediate program availability without individualenrollment, compared to no program availability, was estimated to slightly albeit significantly decrease survival by 4% (95% CI 0.03,0.06, p\u3c 0:01). Immediately availability and enrollment resulted in a 7% higher in-care survival compared to immediate availability with non-enrollment after 450 days (95% CI -0.08,-0.05, p\u3c 0:01). The results are consistent with a fairly small impact of both availability and enrollment in the LREC program on in-care survival

Compensatory Growth of the Sandbar Shark in the Western North Atlantic Including the Gulf of Mexico

The number of Sandbar Sharks Carcharhinus plumbeus in the western North Atlantic Ocean has experienced a drastic decline since the early 1980s, reaching a minimum during the early 1990s. Catch rates in the early 1990s were a mere 25% of those during the 1980s. According to several fishery-independent surveys, the low point in Sandbar Shark abundance followed a period of high exploitation. Growth models fit to age-length data collected from 1980 to 1983 and from 2001 to 2004 were compared to investigate potential changes in parameter estimates that might reveal compensatory responses in the Sandbar Shark population. Statistical differences were found between the model parameters for the two time periods, but the differences in growth rates were minimal. The parameters from the three-parameter von Bertalanffy growth model for female sharks during the 1980-1983 and 2000-2004 time periods were as follows: L = 188.4 and 178.3cm FL; k = 0.084 and 0.106; and t(0) = -4.097 and -3.41. For males the growth parameters were as follows: L = 164.63 and 173.66cm; k = 0.11 and 0.11; and t(0) = -3.62 and -3.33. The estimated age at 50% maturity for female Sandbar Sharks changed from 15years to 12.49years between the two time periods

Trends in the clinical characteristics of HIV-infected patients initiating antiretroviral therapy in Kenya, Uganda and Tanzania between 2002 and 2009

East Africa has experienced a rapid expansion in access to antiretroviral therapy (ART) for HIV-infected patients. Regionally representative socio-demographic, laboratory and clinical characteristics of patients accessing ART over time and across sites have not been well described. We conducted a cross-sectional analysis of characteristics of HIV-infected adults initiating ART between 2002 and 2009 in Kenya, Uganda and Tanzania and in the International Epidemiologic Databases to Evaluate AIDS Consortium. Characteristics associated with advanced disease (defined as either a CD4 cell count level of less than 50 cells/mm3 or a WHO Stage 4 condition) at the time of ART initiation and use of stavudine (D4T) or nevirapine (NVP) were identified using a log-link Poisson model with robust standard errors. Among 48,658 patients (69% from Kenya, 22% from Uganda and 9% from Tanzania) accessing ART at 30 clinic sites, the median age at the time of ART initiation was 37 years (IQR: 31-43) and 65% were women. Pre-therapy CD4 counts rose from 87 cells/mm3 (IQR: 26-161) in 2002-03 to 154 cells/mm3 (IQR: 71-233) in 2008-09 (p<0.001). Accessing ART at advanced disease peaked at 35% in 2005-06 and fell to 27% in 2008-09. D4T use in the initial regimen fell from a peak of 88% in 2004-05 to 59% in 2008-09, and a greater extent of decline was observed in Uganda than in Kenya and Tanzania. Self-pay for ART peaked at 18% in 2003, but fell to less than 1% by 2005. In multivariable analyses, accessing ART at advanced immunosuppression was associated with male sex, women without a history of treatment for prevention of mother to child transmission (both as compared with women with such a history) and younger age after adjusting for year of ART initiation and country of residence. Receipt of D4T in the initial regimen was associated with female sex, earlier year of ART initiation, higher WHO stage, and lower CD4 levels at ART initiation and the absence of co-prevalent tuberculosis. Public health ART services in east Africa have improved over time, but the fraction of patients accessing ART with advanced immunosuppression is still high, men consistently access ART with more advanced disease, and D4T continues to be common in most settings. Strategies to facilitate access to ART, overcome barriers among men and reduce D4T use are needed

BMC Res Notes

Objective Pediatric antiretroviral therapy (ART) for children with HIV (CHIV) must be dosed appropriately for children’s changing weights as they grow. To inform accurate estimates of ART formulations and doses needed, we described weight-for-age distributions among CHIV on ART in the IeDEA global pediatric collaboration between 2004 and 2016, using data from six regions (East, West, Central, and Southern Africa, Asia–Pacific, and Central/South America and the Caribbean). Results Overall, 59,862 children contributed to the analysis. Age and weight data were available from 530,080 clinical encounters for girls and 537,894 for boys. For each one-year age stratum from 0 to 15 years, we calculated the proportion of children in each of the weight bands designated by the World Health Organization as relevant to pediatric ART formulations: 0 to  < 3 kg, 3 to  < 6 kg, 6 to  < 10 kg, 10 to  < 14 kg, 14 to  < 20 kg, 20 to  < 25 kg, 25 to  < 30 kg, 30 to  < 35 kg, 35 to  < 40 kg, 40 to  < 45 kg, 45 to  < 50 kg, 50 to  < 55 kg, 55 to  < 60 kg, and ≥ 60 kg. Data are reported for the entire cohort, as well as stratified by sex and IeDEA region, calendar year of ART use, and duration on ART at time of assessment (< 12 or ≥ 12 months), provided in data tables. These data are critical to improve the accuracy of forecasting and procurement of pediatric ART formulations as the pediatric HIV epidemic and pediatric HIV treatment strategies evolve

A Longitudinal Analysis of Volunteerism Activities for Individuals Educated in Public and Private Schools

Previous studies offer evidence that U.S. public and private high schools differentially influence volunteerism in adolescence. However, these studies are typically cross-sectional and only consider whether the individual volunteered or not. We address patterns of volunteering from adolescence into adulthood and the kind of volunteering activity in which individuals engage. We also theorize that distinctive civic values within public and private schools together with their respective organizational ties to other civic organizations channel students into particular volunteering activities. Relying on a longitudinal, nationally-representative sample of U.S. adolescents, we track volunteering from adolescence into young adulthood and identify the types of volunteering activities in which respondents engage. Results demonstrate that the likelihood of volunteering changes through the life course, and students from different schooling backgrounds systematically sort into specific volunteering activities as our theories predict