Successes and Challenges in an Integrated Tuberculosis/HIV Clinic in a Rural, Resource-Limited Setting: Experiences from Kericho, Kenya

Objective. To describe TB/HIV clinic outcomes in a rural, Ministry of Health hospital. Design. Retrospective, secondary analyses. Descriptive statistics and logistic regression analyses evaluated baseline characteristics and outcomes. Results. Of 1,911 patients, 89.8% were adults aged 32.0 (±12.6) years with baseline CD4 = 243.3 (±271.0), 18.2% < 50 cells/mm3. Pulmonary (84.8%, (32.2% smear positive)) exceeded extrapulmonary TB (15.2%). Over 5 years, treatment success rose from 40.0% to 74.6%, lost to follow-up dropped from 36.0% to 12.5%, and deaths fell from 20.0% to 5.4%. For patients starting ART after TB treatment, those with CD4 ≥ 50 cells/mm3 were twice as likely to achieve treatment success (OR = 2.0, 95% CI = 1.3–3.1) compared to those with CD4 < 50 cells/mm3. Patients initiating ART at/after 2 months were twice as likely to achieve treatment success (OR = 2.0, 95% CI = 1.3–3.3). Yearly, odds of treatment success improved by 20% (OR = 1.2, 95% CI = 1.0–1.5). Conclusions. An integrated TB/HIV clinic with acceptable outcomes is a feasible goal in resource-limited settings

Computational Opioid Prescribing: A Novel Application of Clinical Pharmacokinetics

We implemented a pharmacokinetics-based mathematical modeling technique using algebra to assist pre-scribers with point-of-care opioid dosing. We call this technique computational opioid prescribing (COP). Because population pharmacokinetic parameter values are needed to estimate drug dosing regimen designs for individual patients using COP, and those values are not readily available to prescribers because they exist scattered in the vast pharmacology literature, we estimated the population pharmacokinetic parameter values for 12 commonly prescribed opioids from various sources using the bootstrap resampling technique. Our results show that opioid dosing regimen design, evaluation, and modification is feasible using COP. We conclude that COP is a new technique for the quantitative assessment of opioid dosing regimen design evaluation and adjustment, which may help prescribers to manage acute and chronic pain at the point-of-care. Potential benefits include opioid dose optimization and minimization of adverse opioid drug events, leading to potential improvement in patient treatment outcomes and safety

Reference Ranges for the Clinical Laboratory Derived from a Rural Population in Kericho, Kenya

The conduct of Phase I/II HIV vaccine trials internationally necessitates the development of region-specific clinical reference ranges for trial enrolment and participant monitoring. A population based cohort of adults in Kericho, Kenya, a potential vaccine trial site, allowed development of clinical laboratory reference ranges. Lymphocyte immunophenotyping was performed on 1293 HIV seronegative study participants. Hematology and clinical chemistry were performed on up to 1541 cohort enrollees. The ratio of males to females was 1.9∶1. Means, medians and 95% reference ranges were calculated and compared with those from other nations. The median CD4+ T cell count for the group was 810 cells/µl. There were significant gender differences for both red and white blood cell parameters. Kenyan subjects had lower median hemoglobin concentrations (9.5 g/dL; range 6.7–11.1) and neutrophil counts (1850 cells/µl; range 914–4715) compared to North Americans. Kenyan clinical chemistry reference ranges were comparable to those from the USA, with the exception of the upper limits for bilirubin and blood urea nitrogen, which were 2.3-fold higher and 1.5-fold lower, respectively. This study is the first to assess clinical reference ranges for a highland community in Kenya and highlights the need to define clinical laboratory ranges from the national community not only for clinical research but also care and treatment

eCooking Delivery Models: Approach to Designing Delivery Models for Electric Pressure Cookers with Case Study for Tanzania

This paper defines eCooking Delivery Models (eCDMs) as the activities, resources and actors needed to deliver modern electric cooking (eCooking) appliances to end-users in need of innovative clean cooking solutions in the Global South. We define the eCooking Market System (socio-economic and cultural context, the enabling environment, market chains, support services) which conceptualizes the real-world market factors and surrounding context related to enabling the uptake and sustained use of eCooking appliances by end-users. We also describe an approach to design eCDMs and identify the support services required to start and sustain the market delivery infrastructure. The eCDM concept and approach are demonstrated through designing eCDMs and support services for electric pressure cookers (EPCs) for two end-user segments in Tanzania: rural and peri-urban/urban customer segments. Research methods included: focus groups and workshops (12), household surveys (51), cooking demonstrations (11), offering end-users the chance to purchase EPCs through various financing mechanisms, and interviews (eight with market actors, 18 with enabling environment stakeholders). This led to stakeholder mapping, understanding end-users, market chains, and enabling environment, and identification of eCDMs and support services to reach the focus customer segments. The case study outcome was a plan to implement support services, which is being carried out by a Tanzanian NGO, and we reflect on progress thus far in supporting the eCooking market in Tanzania. The concept and approach can support similar action research in other contexts to accelerate the transition to modern energy cooking services

Of monopolies and mini grids: case studies from Kenya, Tanzania, Nigeria and Senegal

Recent advances in decentralised renewable electricity systems have undermined long-held assumptions that electricity access and rural electrification can only be achieved via the extension of the national grid. Renewable energy and solar hybrid mini grids are being promoted as one low-cost option to meet Sustainable Energy for All’s commitment to universal energy access by 2030, because of their potential to connect low-income, rural and/or dispersed communities for whom the cost of extending the main grid is considered too expensive. As this paper discusses in relation to four countries in sub-Saharan Africa: Kenya, Tanzania, Nigeria and Senegal, in recent years new private sector actors in renewable energy mini grids have started to emerge, marking a shift away from large-scale diesel or hydro mini grids run by government utilities, and small-scale mini grid development previously led by bi-lateral donors and community organisations on a project-by-project basis. However, there have been considerable governance and regulatory challenges to the development and deployment of renewable energy mini grids at scale, which has often taken place in the absence of national regulation rather than because of it. Moreover, some state-owned electricity utilities and associated institutions have been resistant at once to new private sector actors and decentralised systems. Meanwhile, the term ‘mini grid’ lacks a common definition and is simultaneously associated with energy access as well as productive use, despite the often competing objectives of these end uses. This paper unpacks some of these dynamics through an extensive desk-based study of grey and academic literature and a regulatory comparison of the four case study countries. Building on scholarship from development and energy geography, we argue that a more granular analysis is needed in order to account for the complex and evolving processes of electricity decentralisation in low- and middle-income countries