Effective coverage for antiretroviral therapy in a Ugandan district with a decentralized model of care

This article was published in the PLoS ONE [© 2013 PLoS ONE] and The Journal's website is at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0069433Introduction:While increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce. We examined and report effective coverage data from a public ART program in rural Uganda.Methods:We conducted a retrospective cohort study at all ART-providing governmental health facilities in Iganga District, Eastern Uganda. Based on all HIV patients registered between April 2004 and September 2009 (n = 4775), we assessed indicators of program performance and determined rates of retention and Cox proportional hazards for attrition. Effective ART coverage was calculated using projections (SPECTRUM software) adapted to the district demographic structure and number of people receiving ART.Results:By September 2009, district public sector effective ART coverage was 10.3% for adults and 1.9% for children. After a median follow-up of 26.9 months, overall ART retention was 54.7%. The probability of retention was 0.72 (95% confidence interval (CI) 0.69-0.75) at 12 and 0.58 (CI 0.54-0.62) at 36 months after ART initiation. Individual health facilities differed considerably regarding performance indicators and retention. Overall, 198 (16.9%) individual files of 1171 registered ART patients were lost. Young adult age (15-24 years) had a higher risk of attrition (HR 2.1, CI 1.4-3.2) as well as WHO stage I (HR 4.8, CI 1.9-11.8) and WHO stage IV (HR 2.5, CI 1.3-4.7). An interval ≥6 weeks between HIV testing and ART initiation was associated with a reduced risk (HR 0.6, CI 0.47-0.78).Conclusion:Compared to reported national data effective ART coverage in Iganga District was low. Intensified efforts to improve access, retention in care, and quality of documentation are urgently needed. Children and young adults require special attention in the program.Publishe

Vascular plant species richness in forest vegetation records differs depending on surveyor

Flächenbezogene Artenzahlen sind besonders im Kontext von Monitoringprojekten grundlegend für die Beurteilung von Veränderungen der Biodiversität. Diese Studie vergleicht die von neun Bearbeitern (5 Einzelbearbeiter, 2 Zweierteams) erfasste Zahl an Gefäßpflanzenarten bei Vegetationserhebungen auf markierten Flächen von 4, 100 und 400 m2 Größe in einem artenreichen Kalkbuchenwald im Göttinger Stadtwald. Dabei wurden Bearbeiter- und Zeiteffekte untersucht, sowie artspezifische Übersehensraten, Fehlbestimmungsraten und Ungenauigkeiten bei der Zuordnung von Pflanzenindividuen zur jeweiligen Aufnahmefläche (Fehlzuordnungsraten) abgeschätzt. Protokollierte Fragen ließen keine systematischen Unterschiede bei der Vertrautheit der Bearbeiter mit der Vegetation vor Ort erkennen, so dass Ausbildung und Erfahrung für gefundene Unterschiede ausschlaggebend sein dürften. Bei den 4 m2 großen Erhebungseinheiten ergaben sich bei der Artenzahl relative Abweichungen der Bearbeiter vom Erwartungswert von 8 bis 26 % (1 bis 4 Arten absolut). Diese waren bei den 100 m2 großen Erhebungseinheiten mit 9 bis 27 % (2 bis 6 Arten absolut) höher. Mit zunehmender Flächengröße nahm der Flächenidentitätseffekt tendenziell ab und der Bearbeitereffekt signifikant zu. Bei den 100 m2 großen Flächen hatte eine längere Bearbeitungszeit einen positiven Effekt auf die Artenzahl. Mit Hilfe artbezogener Auswertungen wurden Übersehens-, Fehlbestimmungs- und Fehlzuordnungsraten ermittelt. Nicht eine Art wurde von allen Bearbeitern auf allen Flächen gefunden, auf denen sie jeweils auftrat. Schwer differenzierbare Arten sowie Arten in ungünstigen Entwicklungsstadien wiesen höhere Übersehens-, aber auch höhere Fehlbestimmungsraten auf. Bei morphologisch gut charakterisierten Arten wurde bei Einzelfunden von einer Fehlzuordnung zur Erhebungseinheit ausgegangen. Die erzielten Ergebnisse sind auch für andere Projekte zur Erfassung der Biodiversität relevant und Bemühungen zur Reduzierung entsprechender Bearbeitereffekte sollten unternommen werden. Eine organisatorische Einbindung entsprechender Bemühungen wird vorgeschlagen.Local species richness is a crucial biodiversity measure also in monitoring projects. This study was carried out in a speciesrich beech forest on limestone within the communal forest of the city of Göttingen. It compares species richness estimates from nine surveyors (five individuals and two teams of two) on plots of 4, 100, and 400 m2 size. The influence of surveyor and elapsed time on the outcome was investigated. Additionally, species-specific overlooking and misinterpretation rates were estimated. As a further source of error, wrong assignment of plant specimen to plots was considered. Analysis of recorded questions of the probates did not reveal a differentiated familiarity with the on-site vegetation on the base of their professional embedding in regional terms. Outcomes have therefore to be seen as the result of individual training and experience. On the spatial level of the 4 m2 plots relative deviances between expected values of species richness and estimates of individual surveyors varied between 8 and 26% (1 to 4 species absolutely). At the 100 m2 plots differences between surveyors were with 9 to 27% (2 to 6 species absolutely) even more pronounced. With increasing plot area effects from plot identity tend to decrease, while observer effects distinctly increase. For the 100 m2 plot level an effect of processing time was detectable. None of the species were found by all surveyors at all subplots on which they occurred. Closely related or otherwise similar species, and those which were in an unfavourable developmental stage, had a higher chance of being overlooked or misinterpreted. Species with peculiar morphological features were considered to be misallocated. For all three types of error respective rates were calculated. The relationships found have generally to be considered in monitoring projects focusing on vegetation changes; however, in large-scale cross-sectional surveys respective error rates should be considered. An organized controlling system is outlined

Patients included for hazard ratio analysis.

<p>Patients included for hazard ratio analysis.</p

Adjusted hazard ratios for attrition to the ART program (n = 931).

<p>HR: Hazard Ratio; CI: Confidence Interval; Each factor is adjusted for all other factors in the column.</p

ART patient characteristics.

<p>IQR: Inter Quartile Range;</p>*<p>Pearson-Chi² Test or Mann Whitney Test comparing Hospital to Health Centre results.</p

Probability of retention in care for ART patients in Iganga District, Uganda.

<p>Probability of retention in care for ART patients in Iganga District, Uganda.</p