Adolescent sexual networking and HIV transmission in rural Uganda

Information on 861 adolescents shows that in 1991 36 per cent reported having been sexually active in the previous 12 months, but only 6.2 per cent had ever used a condom (11% males, 2.4% females). The HIV infection rate was 5.9 per cent overall, 0.8 per cent in males and 9.9 per cent in females. The proportion sexually active and the rate of HIV infection rise with age. The annual incidence of HIV infection was 2.0 per 100 person-years of follow-up among all adolescents, 0.8 in males and 3.0 in females. The annual mortality rate among HIV-negative adolescents was 0.37 per cent versus 3.92 per cent among the HIV-positive adolescents, a rate ratio of 10.6. Sexual network data were collected on 389 adolescents aged 15-19 years of whom 55 per cent were sexually active. The median age of first sexual intercourse was 15 years in either sex. The 214 adolescents reported 339 sexual relationships of which 38.5 per cent were with spouses, 36 per cent with boy or girl friends and 21 per cent with ‘friends’. There were 52 concurrent sexual relationships reported by 35 adolescents. Males report higher rates of concurrent sexual relationships than females. The sexual partners of boys were mainly younger students and housemaids while the girls’ partners were mainly older traders and salaried workers. Adolescents in this community report high rates of sexual activity and have complex sexual networks. They probably are important in the dynamics of HIV infection

HIV infection in rural households, Rakai district, Uganda

The Rakai Project conducted a population-based cohort study in rural Rakai District, Uganda, a region with high rates of HIV prevalence. The cohort population described here was followed between 1990 and 1992 and consisted of all residents aged 15 years or more living in 1945 households in 31 community clusters. A detailed census was conducted at baseline in every study household. Census data were updated annually, and all inter-survey deaths, births, and migrations were recorded. Immediately following each annual census, all consenting adults were administered a socio-demographic, behavioural and health survey, and provided a blood sample for HIV testing. HIV prevalence in the study population was high, with 19.1 per cent of adults aged 15 or more years being HIV-positive. By household, the burden of infection was even more pronounced: 31.3 per cent of households had at least one HIV-infected resident adult. Twenty seven per cent of heads of households were also HIV-positive. Overall, 3.6 per cent of study households experienced the death of an HIV-positive adult per year, and another two per cent lost an HIV-negative adult. HIV-related adult mortality had substantially more effect on subsequent household dependency ratio and on material possessions than the death of an HIV-uninfected adult, in part because the former deaths were concentrated in adults aged 15-49, the most economically active age group in this rural population. Just under 15 per cent of children aged 14 years or less had lost one or both parents, and approximately half of these parental losses are estimated to be associated with HIV infection. Nineteen per cent of study households reported at least one resident child who had lost one or both parents. Although there is evidence that loss of a parent is associated with lower school attendance, orphans overall continue to be absorbed by community households which are headed by adults. HIV infection is very prevalent among adults in Rakai and the associated mortality imposes a substantial social and economic burden on households in the district

Evaluating the Process and Extent of Institutionalization: A Case Study of a Rapid Response Unit for Health Policy in Burkina Faso

Abstract Background: Good decision-making requires gathering and using sufficient information. Several knowledge translation platforms have been introduced in Burkina Faso to support evidence-informed decision-making. One of these is the rapid response service for health. This platform aims to provide quick access for policy-makers in Burkina Faso to highquality research evidence about health systems. The purpose of this study is to describe the process and extent of the institutionalization of the rapid response service. Methods: A qualitative case study design was used, drawing on interviews with policy-makers, together with documentary analysis. Previously used institutionalization frameworks were combined to guide the analysis. Results: Burkina Faso’s rapid response service has largely reached the consolidation phase of the institutionalization process but not yet the final phase of maturity. The impetus for the project came from designated project leaders, who convinced policy-makers of the importance of the rapid response service, and obtained resources to run a pilot. During the expansion stage, additional policy-makers at national and sub-national levels began to use the service. Unit staff also tried to improve the way it was delivered, based on lessons learned during the pilot stage. The service has, however, stagnated at the consolidation stage, and not moved into the final phase of maturity. Conclusion: The institutionalization process for the rapid response service in Burkina Faso has been fluid rather than linear, with some areas developing faster than others. The service has reached the consolidation stage, but now requires additional efforts to reach maturit

Lessons learned from descriptions and evaluations of knowledge translation platforms supporting evidence-informed policy-making in low- and middle-income countries : a systematic review

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A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem.

BACKGROUND: Although in developing countries the burden of morbidity and mortality due to infectious diseases has often overshadowed that due to chronic non-communicable diseases (NCDs), there is evidence now of a shift of attention to NCDs. DISCUSSION: Decreasing the chronic NCD burden requires a two-pronged approach: implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs, and effective and affordable delivery of primary care interventions for patients with chronic NCDs. The primary care response to common NCDs is often unstructured and inadequate. We therefore propose a programmatic, standardized approach to the delivery of primary care interventions for patients with NCDs, with a focus on hypertension, diabetes mellitus, chronic airflow obstruction, and obesity. The benefits of this approach will extend to patients with related conditions, e.g. those with chronic kidney disease caused by hypertension or diabetes. This framework for a "public health approach" is informed by experience of scaling up interventions for chronic infectious diseases (tuberculosis and HIV). The lessons learned from progress in rolling out these interventions include the importance of gaining political commitment, developing a robust strategy, delivering standardised interventions, and ensuring rigorous monitoring and evaluation of progress towards defined targets. The goal of the framework is to reduce the burden of morbidity, disability and premature mortality related to NCDs through a primary care strategy which has three elements: 1) identify and address modifiable risk factors, 2) screen for common NCDs and 3) and diagnose, treat and follow-up patients with common NCDs using standard protocols. The proposed framework for NCDs borrows the same elements as those developed for tuberculosis control, comprising a goal, strategy and targets for NCD control, a package of interventions for quality care, key operations for national implementation of these interventions (political commitment, case-finding among people attending primary care services, standardised diagnostic and treatment protocols, regular drug supply, and systematic monitoring and evaluation), and indicators to measure progress towards increasing the impact of primary care interventions on chronic NCDs. The framework needs evaluation, then adaptation in different settings. SUMMARY: A framework for a programmatic "public health approach" has the potential to improve on the current unstructured approach to primary care of people with chronic NCDs. Research to establish the cost, value and feasibility of implementing the framework will pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs

Equitable Access to Health Professional Training in Uganda: A Cross Sectional Study

Objective: We set out to assess inequalities to access health professional education, and the impact of an education improvement program supported by MEPI (Medical Education Partnership Initiative). Inequalities in the higher education system in sub-Saharan Africa remain despite some transformative policies and affirmative action. Methods: We reviewed enrollment data from four universities for the period 2001–2014 for various health professional training programs, and conducted group discussions through an iterative process with selected stakeholders, and including a group of education experts. Two time periods, 2001–2010 and 2011–2014, were considered. In 2010–11, the MEPI education program began. Gender ratios, regional representation, secondary schools, and the number of admissions by university and year were analysed. We used SPSS version 17 software to analyse these data with level of significance p < 0.05. We collated qualitative data along predetermined and emerging themes. Results: The overall male-to-female ratio among the student population was 2.3:1. In total, there were 7,023 admissions, 4,403 between 2001–2010 (440 per annum) and 2,620 between 2011–2014 (655 per annum) with p = 0.018. There were no significant increases in admissions in the central and western regions over the two time periods, 1,708 to 849 and 1,113 to 867 respectively, both p = 0.713 and p = 0.253. We propose improving the university admission criteria and increasing enrollment to health professions training schools. Conclusion: There were significant inequalities for higher education training in Uganda by gender, regional representation and school attended. Modifying the admission criteria and increasing enrollment may reduce these inequalities

Integrating care for diabetes and hypertension with HIV care in sub-Saharan Africa: A scoping review.

Introduction: Although HIV continues to have a high prevalence among adults in sub-Saharan Africa (SSA), the burden of noncommunicable diseases (NCD) such as diabetes and hypertension is increasing rapidly. There is an urgent need to expand the capacity of healthcare systems in SSA to provide NCD services and scale up existing chronic care management pathways. A scoping review mapped extant policy and evidence based literature on the feasibility of integrating NCD care with HIV in the region. Methods: A scoping review methodology was utilised to conduct a systematic search of peer-reviewed and grey literature published in English language and with no date limitation. A systematic search was conducted on PubMed, Embase, CINAHL, and the Cochrane library. The initial search identified 231 records considered for inclusion in this review. Twelve duplicate records were removed. The remaining 219 records were screened by title and abstract of which 165 records were excluded and 54 records were selected for full-text review. A further 16 records were excluded due to a lack of relevance or the unavailability of the full text article. Finally, 38 were charted and analysed thematically. Results: Thirty-eight studies were included. These comprised a range of different models to integrate NCD and HIV care in the region, reflecting differences in health system environments, and disease epidemiology. The studies provide a variety of evidence that integration of HIV and NCD care can be feasible and can improve clinical effectiveness and identify barriers and facilitators to integration and task shifting. The review confirms that integrated HIV and NCD care services is by-and-large feasible, being both clinically effective and cost-effective. Conclusion: The review may inform the understanding of how best to develop an integrated model of care service by reducing barriers to uptake, linkage and retention in HIV, diabetes and hypertension treatment in SSA countries

Perception and valuations of community-based education and service by alumni at Makerere University College of Health Sciences

<p>Abstract</p> <p>Background</p> <p>Training of health professionals can be deliberately structured to enhance rural recruitment by exposing the trainees to the realities of rural life and practice through Community-Based Education and Service (COBE) programs. Few studies have surveyed the alumni of these programs to establish their post-university views and whether the positive impact of COBE programs endures into the post-university life. This study surveyed the alumni of COBE at Makerere to obtain their perceptions of the management and administration of COBE and whether COBE had helped develop their confidence as health workers, competence in primary health care and willingness and ability to work in rural communities.</p> <p>Objectives</p> <p>• To assess the efficiency of the management and administration of COBES.</p> <p>• To obtain the views of the impact of COBES on its alumni.</p> <p>Methods</p> <p>A mixed qualitative and quantitative study was conducted using focus group discussions (FGD) and a telephone administered questionnaire. From a total of 300 COBES alumni 150 were contacted. Twenty four Alumni (13 females and 11 males) were purposefully selected by discipline, gender and place of work, and invited for the focus group discussion. The discussions were transcribed and analyzed using a manifest content analysis table. The thematic issues from the FGDs were used to develop a structured questionnaire which was administered by telephone by the authors. The data were entered into Microsoft excel template and exported to Stata for analysis. The findings of the telephone survey were used to cross-match the views expressed during the focus group discussions.</p> <p>Results</p> <p>The alumni almost unanimously agree that the initial three years of COBES were very successful in terms of administration and coordination. COBES was credited for contributing to development of confidence as health workers, team work, communication skills, competence in primary health care and willingness to work in rural areas. The COBES alumni also identified various challenges associated with administration and coordination of COBES at Makerere.</p> <p>Conclusions</p> <p>This study has established that the positive impact of COBES endures with the alumni of the program. Health planners should take advantage of the impact of COBES and provide it with more support.</p

Inhibition of Vaginal Lactobacilli by a Bacteriocin-Like Inhibitor Produced by Enterococcus faecium 62-6: Potential Significance for Bacterial Vaginosis

Objective: Bacterial vaginosis (BV) is characterized by a shift in vaginal tract ecology, which includes a decrease in the concentration and/or prevalence of facultative lactobacilli. Currently, mechanisms which could account for the disappearance of lactobacilli are not well understood. The objective of this study was to determine whether vaginal streptococci/enterococci can produce bacteriocin-like inhibitors antagonistic to vaginal lactobacilli. Methods: Seventy strains of vaginal streptococci or enterococci were tested for antagonistic activities against vaginal lactobacilli using the deferred antagonism technique. Results: One strain, Enterococcus faecium 62-6, which strongly inhibited growth of lactobacilli was selected for further characterization. The spectrum of inhibitory activity of strain 62-6 included Gram-positive organisms from the vaginal environment, although native lactobacilli from the same host were resistant to inhibitor action. Following growth inMRSbroth the strain 62-6 inhibitor was shown to be heat- (100℃, 30 minutes), cold- (4℃, less than 114 days) and pH- (4–7) stable. The sensitivity of inhibitor-containing supernatants to pepsin and α-chymotrypsin suggested an essential proteinaceous component. The inhibitor was sensitive to lipase but resistant to lysozyme. Dialysis of inhibitor-containing culture supernatants suggested a molecular mass greater than 12 000 Da. All physicochemical properties were consistent with its classification as a bacteriocin-like inhibitor. Kinetic assays demonstrated a sharp onset of inhibitor production coinciding with a concentration of 62-6 of 10(7) cfu/ml, suggesting that production may be regulated by quorum sensing. Conclusions: These results may have clinical significance as a novel mechanism to account for the decline of vaginal Lactobacillus populations and contribute to both the establishment and recurrence of BV