Task Sharing and Shifting to Provide Pathology Diagnostic Services: The Kenya Fine-Needle Aspiration Biopsy Cytology and Bone Marrow Aspiration and Trephine Biopsy Training Program

Purpose: Fine-needle aspiration biopsy (FNAB) cytology is a simple, inexpensive, and accurate diagnostic test for benign, infectious, and malignant lesions of the breast, thyroid, lymph nodes, and other organs. Similarly, bone marrow aspiration and trephine (BMAT) biopsy procedures are relatively simple and inexpensive techniques that are important for diagnosing and monitoring many hematologic diseases including leukemias and lymphomas. However, the scarcity of pathologists in Kenya limits patient access to these simple diagnostic tests. We describe a task sharing and shifting program that sought to improve the provision of FNABs and BMAT biopsies in tertiary public hospitals in Kenya. Methods: Between January 2016 and February 2017, we trained pathologists, pathology residents, and technologists from the University of Nairobi and Aga Khan University Hospital, Nairobi, in FNAB and BMAT biopsies, who in turn trained pathologists, medical officers (MO), clinical officers (CO), and technologists at five tertiary public hospitals. The program involved curriculum development, training workshops, the establishment of new and strengthening existing FNAB and BMAT biopsy clinics, interim site visits, audits, and stakeholder workshops. Results: Fifty-one medical personnel at the tertiary hospitals were trained. The FNAB numbers increased by 41% to 1,681, with 139 malignant diagnoses (7.1%). BMAT biopsy numbers increased by 268% to 140, with 34 malignant cases. Between 60% and 100% of the FNAB and BMAT biopsy procedures were performed by MO and CO over the project period. One new FNAB and two new BMAT biopsy clinics were established. Conclusion: This project demonstrates a successful model of task sharing and shifting from specialist pathologists to MO and CO that improved access to important FNAB and BMAT biopsy services in a low-resource setting

Prioritizing climate-smart livestock technologies in rural Tanzania : A minimum data approach

Crop-livestock production systems play an important role in the livelihoods of many rural communities in sub-Saharan Africa (SSA) but are vulnerable to the adverse impacts of climate change. Understanding which farming options will give the highest return on investment in light of climate change is critical information for decision-making. While there is continued investment in testing adaptation options using on-farm experiments, simulation models remain important tools for ‘ex-ante’ assessments of the impacts of proposed climate-smart agricultural technologies (CSA). This study used the Ruminant model and the Trade-offs Analysis model for Multi-Dimensional Impact Assessment (TOA-MD) to assess how improved livestock management options affect the three pillars of CSA: increased productivity, improved food security, and reduced greenhouse gas (GHG) emissions. Our sample was stratified into: 1) households with local cow breeds (n = 28); 2) households with improved dairy cow breeds (n = 70); and 3) households without dairy cows (n = 66). Results showed that the predicted adoption rates for improved livestock feeding among households with improved dairy cows (stratum 2) were likely to be higher compared to households with only local cows (stratum 1). Both households with local cows and those with improved cows had increased income and food security. However, overall poverty reduction was only modest for households with local cows. Expected methane emissions intensity declined with adoption of improved livestock feeding strategies both in stratum 1 and stratum 2, and greater impacts were observed when households in stratum 2 received an additional improved cow breed. Providing a cow to households that were not keeping cows showed substantial economic gains. Additional research is, however, needed to understand why those farms currently do not have cows, which may determine if the predicted adoption rates are feasible.</p

Baseline Characteristics of the CLinic-based ART Diagnostic Evaluation (CLADE) Trial Participants.

<p>Notes:</p><p>1. Data presented as mean (SD) or n (%)</p><p>2. Two participants who were randomized but did not continue ART are excluded.</p><p>3. Categorical grades based upon the DAIDS Toxicity tables: Grade 1 = mild, Grade 2 = moderate, Grade 3 = severe, Grade 4 = potentially life-threatening</p><p>4. Abbreviations: VCT = Voluntary Counseling and Testing, DTC = Diagnostic Testing and Counseling, PITC = Provider Initiated Testing and Counseling; Tb = tuberculosis, PMTCT = Prevention of Mother to Child Transmission, TMP/SMX = trimethoprim/sulfamethoxazole, D4T = stavudine, 3TC = lamivudine, NVP = nevirapine, EFV = efavirenz, AZT = zidovudine, TDF = tenofovir</p><p>Baseline Characteristics of the CLinic-based ART Diagnostic Evaluation (CLADE) Trial Participants.</p

Kericho CLinic-Based ART Diagnostic Evaluation (CLADE): Design, Accrual, and Baseline Characteristics of a Randomized Controlled Trial Conducted in Predominately Rural, District-Level, HIV Clinics of Kenya

<div><p>Background</p><p>Prospective clinical trial data regarding routine HIV-1 viral load (VL) monitoring of antiretroviral therapy (ART) in non-research clinics of Sub-Saharan Africa are needed for policy makers.</p><p>Methods</p><p><u>CL</u>inic-based <u>A</u>RT <u>D</u>iagnostic <u>E</u>valuation (CLADE) is a randomized, controlled trial (RCT) evaluating feasibility, superiority, and cost-effectiveness of routine VL vs. standard of care (clinical and immunological) monitoring in adults initiating dual nucleoside reverse transcriptase inhibitor (NRTI)+non-NRTI ART. Participants were randomized (1:1) at 7 predominately rural, non-research, district-level clinics of western Kenya. Descriptive statistics present accrual patterns and baseline cohort characteristics.</p><p>Results</p><p>Over 15 months, 820 adults enrolled at 7 sites with 86–152 enrolled per site. Monthly site enrollment ranged from 2–92 participants. Full (100%) informed consent compliance was independently documented. Half (49.9%) had HIV diagnosed through voluntary counseling and testing. Study arms were similar: mostly females (57.6%) aged 37.6 (SD = 9.0) years with low CD4 (166 [SD = 106]) cells/m³). Notable proportions had WHO Stage III or IV disease (28.7%), BMI <18.5 kg/m² (23.1%), and a history of tuberculosis (5.6%) or were receiving tuberculosis treatment (8.2%) at ART initiation. In the routine VL arm, 407/409 (99.5%) received baseline VL (234,577 SD = 151,055 copies/ml). All participants received lamivudine; 49.8% started zidovudine followed by 38.4% stavudine and 11.8% tenofovir; and, 64.4% received nevirapine as nNRTI (35.6% efavirenz).</p><p>Conclusions</p><p>A RCT can be enrolled successfully in rural, non-research, resource limited, district-level clinics in western Kenya. Many adults presenting for ART have advanced HIV/AIDS, emphasizing the importance of universal HIV testing and linkage-to-care campaigns.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT01791556" target="_blank">NCT01791556</a></p></div

Participant Enrollment by Month in the CLinic-based ART Diagnostic Evaluation (CLADE) Trial (n = 820).

<p>Participant Enrollment by Month in the CLinic-based ART Diagnostic Evaluation (CLADE) Trial (n = 820).</p

Participating Sites in the Clinic-based ART Diagnostic Evaluation (CLADE) Trial.

<p>Map data courtesy of Kenya Open Data (<a href="https://opendata.go.ke" target="_blank">https://opendata.go.ke</a>).</p

Baseline Characteristics of the CLinic-based ART Diagnostic Evaluation (CLADE) Trial Participants.

<p>Notes:</p><p>1. Data presented as mean (SD) or n (%)</p><p>2. Two participants who were randomized but did not continue ART are excluded.</p><p>3. Categorical grades based upon the DAIDS Toxicity tables: Grade 1 = mild, Grade 2 = moderate, Grade 3 = severe, Grade 4 = potentially life-threatening</p><p>4. Abbreviations: VCT = Voluntary Counseling and Testing, DTC = Diagnostic Testing and Counseling, PITC = Provider Initiated Testing and Counseling; Tb = tuberculosis, PMTCT = Prevention of Mother to Child Transmission, TMP/SMX = trimethoprim/sulfamethoxazole, D4T = stavudine, 3TC = lamivudine, NVP = nevirapine, EFV = efavirenz, AZT = zidovudine, TDF = tenofovir</p><p>Baseline Characteristics of the CLinic-based ART Diagnostic Evaluation (CLADE) Trial Participants.</p

Participant Recruitment and Accrual in the Clinic-based ART Diagnostic Evaluation Trial (CLADE).

<p>Participant Recruitment and Accrual in the Clinic-based ART Diagnostic Evaluation Trial (CLADE).</p