Nutrition and inflammation serum biomarkers are associated with 12-week mortality among malnourished adults initiating antiretroviral therapy in Zambia

<p>Abstract</p> <p>Background</p> <p>A low body mass index (BMI) at antiretroviral therapy (ART) initiation is a strong predictor of mortality among HIV-infected adults in resource-constrained settings. The relationship between nutrition and inflammation-related serum biomarkers and early treatment outcomes (e.g., less than 90 days) in this population is not well described.</p> <p>Methods</p> <p>An observational cohort of 142 HIV-infected adults in Lusaka, Zambia, with BMI under 16 kg/m²or CD4⁺lymphocyte counts of less than 50 cells/mm³, or both, was followed prospectively during the first 12 weeks of ART. Baseline and serial post-treatment phosphate, albumin, ferritin and highly sensitive C-reactive protein (hsCRP) serum levels were measured. The primary outcome was mortality.</p> <p>Results</p> <p>Lower baseline phosphate and albumin serum levels, and higher ferritin and hsCRP, were significantly associated with mortality prior to 12 weeks (p < 0.05 for all comparisons), independent of known risk factors for early ART-associated mortality in sub-Saharan Africa. The time-dependent interval change in albumin was associated with mortality after adjusting for the baseline value (AHR 0.62 [0.43, 0.89] per 5 g/L increase), but changes in the other biomarkers were not.</p> <p>Conclusions</p> <p>The predictive value of serum biomarkers for early mortality in a cohort of adults with malnutrition and advanced HIV in a resource-constrained setting was primarily driven by pre-treatment values, rather than post-ART changes. Interventions to promote earlier HIV diagnosis and treatment, address nutritional deficiencies, and identify the etiologies of increased systemic inflammation may improve ART outcomes in this vulnerable population.</p

An Empirical Approach to Defining Loss to Follow-up Among Patients Enrolled in Antiretroviral Treatment Programs

In many programs providing antiretroviral therapy (ART), clinicians report substantial patient attrition; however, there are no consensus criteria for defining patient loss to follow-up (LTFU). Data on a multisite human immunodeficiency virus (HIV) treatment cohort in Lusaka, Zambia, were used to determine an empirical “days-late” definition of LTFU among patients on ART. Cohort members were classified as either “in care” or LTFU as of December 31, 2007, according to a range of days-late intervals. The authors then looked forward in the database to determine which patients actually returned to care at any point over the following year. The interval that best minimized LTFU misclassification was described as “best-performing.” Overall, 33,704 HIV-infected adults on ART were included. Nearly one-third (n = 10,196) were at least 1 day late for an appointment. The best-performing LTFU definition was 56 days after a missed visit, which had a sensitivity of 84.1% (95% confidence interval (CI): 83.2, 85.0), specificity of 97.5% (95% CI: 97.3, 97.7), and misclassification of 5.1% (95% CI: 4.8, 5.3). The 60-day threshold performed similarly well, with only a marginal difference (<0.1%) in misclassification. This analysis suggests that ≥60 days since the last appointment is a reasonable definition of LTFU. Standardization to empirically derived definitions of LTFU will permit more reliable comparisons within and across programs

Adherence to first-line antiretroviral therapy affects non-virologic outcomes among patients on treatment for more than 12 months in Lusaka, Zambia

Background High-level adherence to antiretroviral therapy (ART) is associated with favourable patient outcomes. In resource-constrained settings, however, there are few validated measures. We examined the correlation between clinical outcomes and the medication possession ratio (MPR), a pharmacy-based measure of adherence

Estimating Loss to Follow-Up in HIV-Infected Patients on Antiretroviral Therapy: The Effect of the Competing Risk of Death in Zambia and Switzerland

BACKGROUND: Loss to follow-up (LTFU) is common in antiretroviral therapy (ART) programmes. Mortality is a competing risk (CR) for LTFU; however, it is often overlooked in cohort analyses. We examined how the CR of death affected LTFU estimates in Zambia and Switzerland. METHODS AND FINDINGS: HIV-infected patients aged ≥18 years who started ART 2004-2008 in observational cohorts in Zambia and Switzerland were included. We compared standard Kaplan-Meier curves with CR cumulative incidence. We calculated hazard ratios for LTFU across CD4 cell count strata using cause-specific Cox models, or Fine and Gray subdistribution models, adjusting for age, gender, body mass index and clinical stage. 89,339 patients from Zambia and 1,860 patients from Switzerland were included. 12,237 patients (13.7%) in Zambia and 129 patients (6.9%) in Switzerland were LTFU and 8,498 (9.5%) and 29 patients (1.6%), respectively, died. In Zambia, the probability of LTFU was overestimated in Kaplan-Meier curves: estimates at 3.5 years were 29.3% for patients starting ART with CD4 cells <100 cells/µl and 15.4% among patients starting with ≥350 cells/µL. The estimates from CR cumulative incidence were 22.9% and 13.6%, respectively. Little difference was found between naïve and CR analyses in Switzerland since only few patients died. The results from Cox and Fine and Gray models were similar: in Zambia the risk of loss to follow-up and death increased with decreasing CD4 counts at the start of ART, whereas in Switzerland there was a trend in the opposite direction, with patients with higher CD4 cell counts more likely to be lost to follow-up. CONCLUSIONS: In ART programmes in low-income settings the competing risk of death can substantially bias standard analyses of LTFU. The CD4 cell count and other prognostic factors may be differentially associated with LTFU in low-income and high-income settings

An evolving agricultural extension model for lasting impact: How willing are Tanzanian farmers to pay for extension services?

Community-based extension services (CES) are vital for improving farmers’ livelihoods, but most of them face a challenge of sustainability after phasing out of the externally funded initiatives that they are part of. This study estimated farmer’s willingness to pay (WTP) for four types of agricultural extension services (AES) in the cereals’ value chains provided as a part of two United States Agency for International Development (USAID)-funded Feed the Future initiatives in Tanzania. Data were collected from 595 smallholder cereal farmers using a primary survey in four districts of the Southern Highlands. We implemented a double-bounded dichotomous choice contingent valuation method. Average WTP figures ranged from 20,000 to 24,000 TZS (8–10 USD) depending on the type of AES. Several socioeconomic and agriculture-related variables influenced smallholders’ WTP for the extension services. This research explored the feasibility of a farmer-led model as a pathway to delink extension services from public and donor funding to achieve sustainable rural development. Farmers place a monetary value on extension services indicating that policymakers and practitioners should make further efforts to enhance a community’s ability to achieve self-reliance through investments in CES

The impact of demonstration plots on improved agricultural input purchase in Tanzania: Implications for policy and practice.

In this paper, the authors use survey data from over 800 households to examine the impact of demonstration plots and associated activities (distribution of small packs of agricultural inputs) on smallholder farmers' decisions to buy agricultural inputs in Tanzania. Using propensity score matching and inverse probability-weighted adjustment models, the authors estimated the effect of access to demonstration plots alone and demonstration plots combined with small packs of agricultural inputs on a household's decision to purchase improved inputs. The results indicate that access to demonstration plots and demonstration plots with small packs increased the probability of purchasing improved inputs by 13-17 percentage points. This paper suggests that demonstration plots and demonstration plots with small packs are an effective model for enhancing improved technology adoption and are further increased when those inputs are available within a 5km radius. The results point to the importance of strengthening farmers' organizations and last-mile agricultural input suppliers in order to enhance and facilitate access to information, appropriate production techniques, and improved inputs. The results also indicate the importance of investing in infrastructure to reduce transportation costs that limit market efficiency for appropriate technologies

Soil loss due to crop harvesting in Usambara Mountains, Tanzania: the case of carrot, onion and potato

International Journal of Plant and Soil Science 2015; 4 (1): 18-28Among the various soil erosion processes threatening sustainable agriculture, soil losses due to root, tuber and bulb harvesting are poorly documented, particularly in tropical environments. A study was thus conducted in two villages with contrasting agro-ecological conditions on Acrisols and Fluvisols in Western Usambara Mountains, Tanzania. The aim was to investigate the mass of soil and nutrients lost and the factors influencing variation of soil loss due to crop harvesting (SLCH) for Carrot (Daucus carrota), Onion (Allium cepa L.) and Potato (Solanum tuberosum L.) under low input agriculture. A total of 108 farm plots were sampled from the two villages. The mean SLCH values were significantly higher for carrot (7.1 Mg/ha/harvest) than for onion (3.8 Mg/ha/harvest) than for potatoes (0.7 Mg/ha/harvest). Soil nutrient losses in kg/ha/harvest were higher for carrot than for onion and potatoes (e.g. 30 N, 0.1 P, 1.5 K for carrot vs 6.3 N, 0.04 P, 0.2 K for onion) in Majulai village. SLCH was greater in Migambo (humid cold) than in Majulai (dry warm) for all the studied crops. Soil water content at harvest time played a significant (P = .05) role in inducing SLCH for onion while bulk density for carrot, whereas for potato they were not significantly influenced by soil water content and bulk density. Soil texture played only a minor role to SLCH of the studied crops. The observed soil and nutrient losses in the current study are substantial and pose a challenge that calls for immediate attention to the harvesting practices in the study area. However, combating water erosion is far more urgent.COSTECH; SUA; VLIR - UO