Antiretroviral therapy in a community clinic - early lessons from a pilot project

Objectives. To report on operational and clinical problems encountered during the first 6 months of a community-based antiretroviral therapy (ART) programme. Methods. ART was implemented in a primary care setting utilising an easily replicable service-delivery model based on a medical officer and nurse. Therapeutic counsellors, themselves HIV-infected, provided counselling and adherence support. Drug and monitoring costs were charitably funded and provincial health authorities supplied the medical infrastructure. The HIV Research Unit, University of Cape Town, supplied training and additional clinical support. Local HIV primary care clinics provided patient referrals. Standardised ART regimens were used with strict entry criteria (AIDS or CD4 count < 200 cells/µl). Results. Demand for the service was high. Referred patients had advanced disease (AIDS 57%, median CD4 count 96/µl) and high pre-treatment mortality (83/100 person-years). Mycobacterial disease was a major contributor to this mortality (40%). Scheduled clinic visit hours were six times higher during recruitment than maintenance. Attributable costs were: drugs 61%, staff 27%, viral load and CD4 cell counts 10% and safety monitoring 2%. Viral load after 16 weeks of therapy was < 400 copies/ml in the first 16 patients. Conclusions. ART can be successfully implemented within a primary care setting. Drug purchases and staff salaries drive programme costing. The service model is capable of managing 250 - 300 patients on chronic ART, but staffing needs to be increased during recruitment. Attention must be given to the diagnosis of tuberculosis during screening and early ART. Incorporating therapeutic counsellors into the programme increased community involvement and utilised a valuable and previously untapped resource

Recent applications and potential of near-term (interannual to decadal) climate predictions

Following efforts from leading centres for climate forecasting, sustained routine operational near-term climate predictions (NTCP) are now produced that bridge the gap between seasonal forecasts and climate change projections offering the prospect of seamless climate services. Though NTCP is a new area of climate science and active research is taking place to increase understanding of the processes and mechanisms required to produce skillful predictions, this significant technical achievement combines advances in initialisation with ensemble prediction of future climate up to a decade ahead. With a growing NTCP database, the predictability of the evolving externally-forced and internally-generated components of the climate system can now be quantified. Decision-makers in key sectors of the economy can now begin to assess the utility of these products for informing climate risk and for planning adaptation and resilience strategies up to a decade into the future. Here, case studies are presented from finance and economics, water management, agriculture and fisheries management demonstrating the emerging utility and potential of operational NTCP to inform strategic planning across a broad range of applications in key sectors of the global economy

Within-subject associations between inflammation and features of depression: Using the flu vaccine as a mild inflammatory stimulus

BackgroundInflammation plays a role in mood and behavior that may be relevant to identifying risk factors and treatment for depression and other stress-related illnesses. The purpose of this study was to examine whether fluctuations in inflammation following a mild immune stimulus were associated with changes in daily reported features of depression for up to a week in a healthy sample of young adults.MethodsForty-one undergraduate students completed daily diaries of mood, feelings of social disconnection, sleep, and physical symptoms for one week before and after receiving the seasonal influenza vaccine. Circulating plasma interleukin-6 (IL-6) was measured via blood samples taken immediately before and one day after vaccination.ResultsThere was a significant increase in circulating IL-6 from pre- to post-intervention (p = .008), and there was significant variability in the magnitude of IL-6 change. Greater increases in IL-6 were associated with greater mood disturbance on post-vaccine days, specifically depressed mood and cognitive symptoms.ConclusionsMinor increases in inflammation were associated with corresponding increases in features of depression, and these associations occurred in the absence of any physical symptoms. The influenza vaccine could be used to probe causal relationships with a high degree of ecological validity, even in high-risk and vulnerable populations, to better understand the role of inflammation in the pathogenesis of depression