Avascular necrosis of the femoral head in HIV positive patients-an assessment of risk factors and early response to surgical treatment

26 consecutive patients (37 hips) with avascular necrosis (AVN) of the femoral head treated surgically at our institution from 1999 to 2008 were reviewed . The aims of the study were to evaluate the risk factors associated with AVN in HIV positive and HIV negative individuals, and assess early response to total hip replacement (THR) surgery in HIV positive and negative patients. There were 15 male and 11 female  patients in total. The mean age for all patients was 47.1± 8.0 years  (range, 33 to 66 years). 12 patients were HIV positive, 11 patients were HIV negative and 3 patients had unknown HIV status. Excessive alcohol intake was the most common risk factor for developing AVN .15 patients (58%) had more than one risk factor for AVN and only 2/12 (17%) HIV positive patients had no other risk factor apart from HIV infection. There were no early postoperative complications in 34 arthroplasties in both HIV positive and negative patients. The aetiology of AVN seems often to be multifactorial, even in the presence of HIV infection. Early response to arthroplasty surgery in AVN of the femoral head is equally good irrespective of the HIV serostatus of the patients

Opportunities for Energy-Water Nexus Management in the Middle East & North Africa

Electric power is required to produce, treat, distribute, and recycle water while water is required to generate and consume electricity. Naturally, this energy-water nexus is most evident in multi-utilities that provide electricity and water but still exists when the nexus has distinct organizations as owners and operators. Therefore, the sustainability question that arises from energy-water trade-offs and synergies is very much tied to the potential for economies of scope. Furthermore, in the Middle East and North Africa (MENA) region, multi-utilities are not only common, but also the nexus is particularly exacerbated by the high energy intensity of the water supply due to limited fresh water resources. The goal of this paper is to identify and motivate several opportunities for enhanced integrated operations management and planning in the energy-water nexus in multi-utilities in the MENA. It proceeds in four parts. First, an exposition of the energy-water nexus especially as it applies to the MENA is given. This discussion focuses on the electric power system, the potable water distribution system, and thirdly, the wastewater distribution system. Second, the paper shifts to opportunities in integrated operations management highlighted by an energy-water nexus supply- side economic dispatch illustration. Thirdly, the discussion shifts to planning opportunities for the energy-water nexus for the sustainable development of water and energy resources. A concluding section summarizes the policy implications of the identified opportunities

Characterisation of the Trypanosoma brucei rhodesiense isolates from Tanzania using serum resistance associated gene as molecular marker

Serum resistance associated (SRA) gene has been found to confer resistance to the innate trypanolytic factor (TLF) found in normal human serum; thus allowing Trypanosoma brucei brucei to survive exposure to normal human serum. This study was carried out to examine the presence of SRA gene and identify the origin of T. b. rhodesiense isolates from three districts in Tanzania, namely Kibondo, Kasulu and Urambo. Twenty-six T. b. rhodesiense isolates and two references T. b. rhodesiense isolates from Kenya were examined for SRA gene using simple Polymerase Chain Reaction technique. The gene was found to be present in all 26 T. b. rhodesiense isolates including the two references isolates from Kenya. The SRA gene was confirmed to be specific to T. b. rhodesiense since it could not be amplified from all other Trypanozoon including T. b. gambiense; and gave an amplified fragment of the expected size (3.9kb), confirming that all these isolates were T. b. rhodesiense of the northern variant. Although the geographic distributions of T. b. gambiense and T. b. rhodesiense are clearly localized to west/central Africa and eastern Africa, respectively, natural movement of people and recent influx of large number of refugees into Tanzania from the Democratic Republic of Congo, could have brought T. b. gambiense in western Tanzania. The overlap in distribution of both of these pathogenic sub-species could result in erroneous diagnoses since both trypanosome sub-species are morphologically identical, and currently serologic methods have low specificity. Both the susceptible and resistant T.b. rhodesiense isolates possessed the SRA gene suggesting that there is no correlation between drug resistance and presence of SRA gene. The use of SRA gene helps to confirm the identity and diversity of some of the isolates resistant to various drugs. Keywords: Trypanosoma brucei rhodesiense, resistance, SRA gene, PCR, TanzaniaTanzania Health Research Bulletin Vol. 9 (1) 2007: pp.25-3

Conducting a Large Public Health Data Collection Project in Uganda: Methods, Tools, and Lessons Learned

We report on the implementation experience of carrying out data collection and other activities for a public health evaluation study on whether U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) investment improved utilization of health services and health system strengthening in Uganda. The retrospective study period focused on the PEPFAR scale-up, from mid-2005 through mid-2011, a period of expansion of PEPFAR programing and health services. We visited 315 health care facilities in Uganda in 2011 and 2012 to collect routine health management information system data forms, as well as to conduct interviews with health system leaders. An earlier phase of this research project collected data from all 112 health district headquarters, reported elsewhere. This article describes the lessons learned from collecting data from health care facilities, project management, useful technologies, and mistakes. We used several new technologies to facilitate data collection, including portable document scanners, smartphones, and web-based data collection, along with older but reliable technologies such as car batteries for power, folding tables to create space, and letters of introduction from appropriate authorities to create entrée. Research in limited-resource settings requires an approach that values the skills and talents of local people, institutions and government agencies, and a tolerance for the unexpected. The development of personal relationships was key to the success of the project. We observed that capacity building activities were repaid many fold, especially in data management and technology

Taenia solium cysticercosis in Eastern and Southern Africa: an emerging problem in agriculture and public health

Pig production has increased tremendously in Eastern and Southern Africa (ESA), particularly in smallholder rural communities. The increase in pig production has mainly been due to land scarcity, increase in pork consumption in many areas including urban centers, and the recognition by many communities of the fast and greater return of the pig industry, compared with other domesticated livestock industries. Concurrent with the increase in smallholder pig keeping and pork consumption, there have been increasing reports of Taenia solium cysticercosis in pigs and humans in the ESA region, although the problems are under-recognized by all levels in many ESA countries. Having recognizing this, scientists researching T. solium in ESA formed a regional cysticercosis working group (CWGESA) to increase awareness of the problem and enable effective and sustainable control of T. solium. This article summarizes the status of T. solium infections in humans and pigs in the ESA countries and highlights the formation and progress of the CWGESA

A Single-Blind randomized controlled trial to evaluate the effect of extended counseling on uptake of pre-antiretroviral care in eastern uganda

<p>Abstract</p> <p>Background</p> <p>Many newly screened people living with HIV (PLHIV) in Sub-Saharan Africa do not understand the importance of regular pre-antiretroviral (ARV) care because most of them have been counseled by staff who lack basic counseling skills. This results in low uptake of pre-ARV care and late treatment initiation in resource-poor settings. The effect of providing post-test counseling by staff equipped with basic counseling skills, combined with home visits by community support agents on uptake of pre-ARV care for newly diagnosed PLHIV was evaluated through a randomized intervention trial in Uganda.</p> <p>Methods</p> <p>An intervention trial was performed consisting of post-test counseling by trained counselors, combined with monthly home visits by community support agents for continued counseling to newly screened PLHIV in Iganga district, Uganda between July 2009 and June 2010, Participants (N = 400) from three public recruitment centres were randomized to receive either the intervention, or the standard care (the existing post-test counseling by ARV clinic staff who lack basic training in counseling skills), the control arm. The outcome measure was the proportion of newly screened and counseled PLHIV in either arm who had been to their nearest health center for clinical check-up in the subsequent three months +2 months. Treatment was randomly assigned using computer-generated random numbers. The statistical significance of differences between the two study arms was assessed using chi-square and t-tests for categorical and quantitative data respectively. Risk ratios and 95% confidence intervals were used to assess the effect of the intervention.</p> <p>Results</p> <p>Participants in the intervention arm were 80% more likely to accept (take up) pre-ARV care compared to those in the control arm (RR 1.8, 95% CI 1.4-2.1). No adverse events were reported.</p> <p>Conclusions</p> <p>Provision of post-test counseling by staff trained in basic counseling skills, combined with home visits by community support agents had a significant effect on uptake of pre-ARV care and appears to be a cost-effective way to increase the prerequisites for timely ARV initiation.</p> <p>Trial registration</p> <p>The trial was registered by Current Controlled Trials Ltd C/OBioMed Central Ltd as <a href="http://www.controlled-trials.com/ISRCTN94133652">ISRCTN94133652</a> and received financial support from Sida and logistical support from the European Commission.</p

Factors associated with pre-ART loss-to-follow up in adults in rural KwaZulu-Natal, South Africa:a prospective cohort study

Background: Timely initiation of antiretroviral treatment (ART) requires sustained engagement in HIV care before treatment eligibility. We assessed loss to follow-up (LTFU) correlates in HIV-positive adults accessing HIV treatment and care, not yet ART-eligible (CD4 &gt;500 cells/mm3).Methods: This was a sub-study of a prospective cohort study (focusing on sexual behaviour) in an area of high HIV prevalence and widespread ART availability in rural KwaZulu-Natal, South Africa. Psychosocial, clinical and demographic data were collected at recruitment from individuals with CD4 &gt;500 cells/mm3. LTFU was defined as not attending clinic within 13 months of last visit or before death. Individuals starting ART were censored at ART initiation. Data were collected between January 2009 and January 2013. Analysis used Competing Risks regression.Results: Two hundred forty-seven individuals (212 females) were recruited (median follow-up 2.13 years, total follow-up 520.15 person-years). 86 remained in pre-ART care (34.8 %), 94 were LTFU (38.1 %), 58 initiated ART (23.5 %), 7 died (2.8 %), 2 transferred out (0.8 %). The LTFU rate was 18.07 per 100 person-years (95 % CI 14.76–21.12). LTFU before a competing event was 13.5 % at one and 34.4 % at three years. Lower LTFU rates were significantly associated with age (&gt;37 versus ?37 years: adjusted sub-Hazard ratio (aSHR) 0.51, 95 % CI 0.30–0.87), openness with family/friends (a little versus not at all, aSHR 0.81, 95 % CI 0.45–1.43; a lot versus not at all, aSHR 1.57, 95 % CI 0.94–2.62), children (0 versus 4+, aSHR 0.68, 95 % CI 0.24–1.87; 1 versus 4+, aSHR 2.05 95 % CI 1.14–3.69, 2 versus 4+; aSHR 1.71, 95 % CI 0.94–3.09; 3 versus 4a, aSHR 1.14, 95 % CI 0.57–2.30), previous CD4 counts (1 versus 0, aSHR 0.81, 95 % CI 0.45–1.43; 2+ versus 0, aSHR 0.43, 95 % CI 0.25–0.73), and most recent partner HIV status (not known versus HIV-positive, aSHR 0.77, 95 % CI 0.50–1.19; HIV-negative versus HIV-positive, aSHR 2.40, 95 % CI 1.18–4.88). The interaction between openness with family/friends and HIV partner disclosure was close to significance (p?=?0.06). Those who had neither disclosed to partners nor were open with family/friends had lowest LTFU rates.Conclusions: Strategies to retain younger people in pre-ART care are required. How openness with others, partner HIV status and disclosure, and children relate to LTFU needs further exploration.<br/

Phase II Evaluation of Sensitivity and Specificity of PCR and NASBA Followed by Oligochromatography for Diagnosis of Human African Trypanosomiasis in Clinical Samples from D.R. Congo and Uganda

Diagnosis plays a central role in the control of human African trypanosomiasis (HAT) whose mainstay in disease control is chemotherapy. However, accurate diagnosis is hampered by the absence of sensitive techniques for parasite detection. Without concentrating the blood, detection thresholds can be as high as 10,000 trypanosomes per milliliter of blood. The polymerase chain reaction (PCR) and nucleic acid sequence-based amplification (NASBA) are promising molecular diagnostics that generally yield high sensitivity and could improve case detection. Recently, these two tests were coupled to oligochromatography (OC) for simplified and standardized detection of amplified products, eliminating the need for electrophoresis. In this study, we evaluated the diagnostic accuracy of these two novel tests on blood specimens from HAT patients and healthy endemic controls from D.R. Congo and Uganda. Both tests exhibited good sensitivity and specificity compared to the current diagnostic tests and may be valuable tools for sensitive and specific parasite detection in clinical specimens. These standardized molecular test formats open avenues for improved case detection, particularly in epidemiological studies and in disease diagnosis at reference centres

Integrating innovations:a qualitative analysis of referral non-completion among rapid diagnostic test-positive patients in Uganda's human African trypanosomiasis elimination programme

BACKGROUND: The recent development of rapid diagnostic tests (RDTs) for human African trypanosomiasis (HAT) enables elimination programmes to decentralise serological screening services to frontline health facilities. However, patients must still undertake multiple onwards referral steps to either be confirmed or discounted as cases. Accurate surveillance thus relies not only on the performance of diagnostic technologies but also on referral support structures and patient decisions. This study explored why some RDT-positive suspects failed to complete the diagnostic referral process in West Nile, Uganda. METHODS: Between August 2013 and June 2015, 85% (295/346) people who screened RDT-positive were examined by microscopy at least once; 10 cases were detected. We interviewed 20 RDT-positive suspects who had not completed referral (16 who had not presented for their first microscopy examination, and 4 who had not returned for a second to dismiss them as cases after receiving discordant [RDT-positive, but microscopy-negative results]). Interviews were analysed thematically to examine experiences of each step of the referral process. RESULTS: Poor provider communication about HAT RDT results helped explain non-completion of referrals in our sample. Most patients were unaware they were tested for HAT until receiving results, and some did not know they had screened positive. While HAT testing and treatment is free, anticipated costs for transportation and ancillary health services fees deterred many. Most expected a positive RDT result would lead to HAT treatment. RDT results that failed to provide a definitive diagnosis without further testing led some to question the expertise of health workers. For the four individuals who missed their second examination, complying with repeat referral requests was less attractive when no alternative diagnostic advice or treatment was given. CONCLUSIONS: An RDT-based surveillance strategy that relies on referral through all levels of the health system is inevitably subject to its limitations. In Uganda, a key structural weakness was poor provider communication about the possibility of discordant HAT test results, which is the most common outcome for serological RDT suspects in a HAT elimination programme. Patient misunderstanding of referral rationale risks harming trust in the whole system and should be addressed in elimination programmes