"Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi

Background: In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT. Methods: We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2–4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches. Results: Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services. Conclusion: PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required

Lack of growth enhancement by exogenous growth hormone treatment in yellow perch (Perca flavescens) in four separate experiments

Author Posting. © The Authors, 2005. This is the author's version of the work. It is posted here by permission of Elsevier B. V. for personal use, not for redistribution. The definitive version was published in Aquaculture 250 (2005): 471-479, doi:10.1016/j.aquaculture.2005.03.019.The effect of exogenous growth hormone (GH) treatment on the growth of juvenile yellow perch (Perca flavescens) was investigated in four experiments. In the first two experiments, juvenile yellow perch were reared at either 13°C or 21°C, and injected weekly with bovine GH (bGH) at 0.1, 1.0 or 10.0 μg/g body weight for 84 days. No significant growth enhancement in GH-treated fish was measured in fish in either of the experiments. In the third experiment, juvenile yellow perch were treated with estradiol-17β (E2, 15 μg/g of diet), bGH (1.0 μg/g body weight) injected weekly or both hormones for 70 days at 21°C. E2 alone stimulated growth, but no further growth stimulation occurred in the E2 + bGH-treated fish. In addition, no growth enhancement was found in fish treated with bGH alone. We measured no difference in serum insulin-like growth factor-I (IGF-I) levels between the treatment groups at 12 and 24 h after the final injection of GH; however, a drop in IGF-I levels after 24 h was observed. In a fourth study, the effect of recombinant yellow perch GH (rypGH, 0.2 or 1.0 μg/g body weight) injected weekly was evaluated in yellow perch juveniles. The fish were reared for 42 days at 18°C. Neither GH dosages improved growth compared to control-injected and non-injected fish. Taken together, the lack of effect of mammalian GH or rypGH in our experiments suggests (1) low binding affinity between these hormones and the GH receptor in yellow perch, (2) that the endogenous GH levels were already at biologically maximal levels or (3) that other endocrine factors are needed in order for GH to promote yellow perch growth. The reduction in IGF-I levels 24 h after handling suggests a negative effect of handling stress on the GH-IGF-I axis in yellow perch.This work was supported by the University of Wisconsin-Madison College of Agricultural and Life Sciences and School of Natural Resources; the Wisconsin Department of Natural Resources; the University of Wisconsin Sea Grant College Program, National Oceanic and Atmospheric Administration, US Department of Commerce; the State of Wisconsin (Federal Grant NA46RG0481, Project No. R/AQ-38); and the USDA NOAA Project R/A-05-99, grant #NA86RG0048 to FG and SR. This study was also funded by the Norwegian Research Council (NFR)

A cropping system assessment framework-Evaluating effects of introducing legumes into crop rotations

Methods are needed for the design and evaluation of cropping systems, in order to test the effects of introducing or reintroducing crops into rotations. The interaction of legumes with other crops (rotational effects) requires an assessment at the cropping system scale. The objective of this work is to introduce a cropping system framework to assess the impacts of changes in cropping systems in a participatory approach with experts, i.e., the integration of legumes into crop rotations and to demonstrate its application in two case studies. The framework consists of a rule-based rotation generator and a set of algorithms to calculate impact indicators. It follows a three-step approach: (i) generate rotations, (ii) evaluate crop production activities using environmental, economic and phytosanitary indicators, and (iii) design cropping systems and assess their impacts. Experienced agronomists and environmental scientists were involved at several stages of the framework development and testing in order to ensure the practicability of designed cropping systems. The framework was tested in Vastra Gotaland (Sweden) and Brandenburg (Germany) by comparing cropping systems with and without legumes. In both case studies, cropping systems with legumes reduced nitrous oxide emissions with comparable or slightly lower nitrate-N leaching, and had positive phytosanitary effects. In arable systems with grain legumes, gross margins were lower than in cropping systems without legumes despite taking pre-crop effects into account. Forage cropping systems with legumes had higher or equivalent gross margins and at the same time higher environmental benefits than cropping systems without legumes. The framework supports agronomists to design sustainable legume-supported cropping systems and to assess their impacts. (C) 2015 The Authors. Published by Elsevier B.V.Peer reviewe

Improving PMTCT outcomes for mother-infant pairs through community-facility linkage: Results from a mixed methods study in Malawi

To improve MIP care retention in Malawi, several prevention of mother-to-child transmission of HIV (PMTCT) care delivery models have emerged to strengthen community-facility linkage (CFL), a concept defined as any “formalized connection between a health facility and the communities it serves to support improved health outcomes.” Similar to other settings in sub-Saharan Africa, three models have been widely implemented to complement Malawi’s National PMTCT Programme: 1) mentor mothers; 2) expert clients; and 3) community health workers. While the rationale underpinning these models has been substantiated by evidence generated from general antiretroviral therapy and PMTCT programs across SSA, a clear and rigorous description of each model, including characterization of supervisory structures, training, and relationships with clinical services, is currently unavailable. Equally important, the comparative impact of these models and their components on MIP care retention and other health outcomes have not been well characterized, particularly in the era of test and start. In the USAID-funded Project SOAR “Maternal-Infant Retention Study” reported here, we have attempted to address these existing evidence gaps by rigorously characterizing these community-facility linkage models and comparing their impact against each other and the “traditional” standard of care according to routinely collected health outcomes for mother-infant pairs (MIPs), including maternal retention in care and viral suppression, and infant HIV-free survival. To this end, specific objectives of this study were to: (1) establish a clear typology for CFL models by describing the main components of, and patient and key stakeholder perspectives on, three such models in Malawi; (2) describe MIP health outcomes in each model, and compare outcomes across models; and (2a) examine associations between individual components of CFL models and MIP health outcomes, controlling for confounding

Community-facility linkage models and maternal and infant health outcomes in Malawi’s PMTCT/ART program: a cohort study

Background: In sub-Saharan Africa, 3 community-facility linkage (CFL) models—Expert Clients, Community Health Workers (CHWs), and Mentor Mothers—have been widely implemented to support pregnant and breastfeeding women (PBFW) living with HIV and their infants to access and sustain care for prevention of mother-to-child transmission of HIV (PMTCT), yet their comparative impact under real-world conditions is poorly understood. Methods and findings: We sought to estimate the effects of CFL models on a primary outcome of maternal loss to follow-up (LTFU), and secondary outcomes of maternal longitudinal viral suppression and infant “poor outcome” (encompassing documented HIV-positive test result, LTFU, or death), in Malawi’s PMTCT/ART program. We sampled 30 of 42 high-volume health facilities (“sites”) in 5 Malawi districts for study inclusion. At each site, we reviewed medical records for all newly HIV-diagnosed PBFW entering the PMTCT program between July 1, 2016 and June 30, 2017, and, for pregnancies resulting in live births, their HIV-exposed infants, yielding 2,589 potentially eligible mother–infant pairs. Of these, 2,049 (79.1%) had an available HIV treatment record and formed the study cohort. A randomly selected subset of 817 (40.0%) cohort members underwent a field survey, consisting of a questionnaire and HIV biomarker assessment. Survey responses and biomarker results were used to impute CFL model exposure, maternal viral load, and early infant diagnosis (EID) outcomes for those missing these measures to enrich data in the larger cohort. We applied sampling weights in all statistical analyses to account for the differing proportions of facilities sampled by district. Of the 2,049 mother–infant pairs analyzed, 62.2% enrolled in PMTCT at a primary health center, at which time 43.7% of PBFW were ≤24 years old, and 778 (38.0%) received the Expert Client model, 640 (31.2%) the CHW model, 345 (16.8%) the Mentor Mother model, 192 (9.4%) ≥2 models, and 94 (4.6%) no model. Maternal LTFU varied by model, with LTFU being more likely among Mentor Mother model recipients (adjusted hazard ratio [aHR]: 1.45; 95% confidence interval [CI]: 1.14, 1.84; p = 0.003) than Expert Client recipients. Over 2 years from HIV diagnosis, PBFW supported by CHWs spent 14.3% (95% CI: 2.6%, 26.1%; p = 0.02) more days in an optimal state of antiretroviral therapy (ART) retention with viral suppression than women supported by Expert Clients. Infants receiving the Mentor Mother model (aHR: 1.24, 95% CI: 1.01, 1.52; p = 0.04) and ≥2 models (aHR: 1.44, 95% CI: 1.20, 1.74; p < 0.001) were more likely to undergo EID testing by age 6 months than infants supported by Expert Clients. Infants receiving the CHW and Mentor Mother models were 1.15 (95% CI: 0.80, 1.67; p = 0.44) and 0.84 (95% CI: 0.50, 1.42; p = 0.51) times as likely, respectively, to experience a poor outcome by 1 year than those supported by Expert Clients, but not significantly so. Study limitations include possible residual confounding, which may lead to inaccurate conclusions about the impacts of CFL models, uncertain generalizability of findings to other settings, and missing infant medical record data that limited the precision of infant outcome measurement. Conclusions: In this descriptive study, we observed widespread reach of CFL models in Malawi, with favorable maternal outcomes in the CHW model and greater infant EID testing uptake in the Mentor Mother model. Our findings point to important differences in maternal and infant HIV outcomes by CFL model along the PMTCT continuum and suggest future opportunities to identify key features of CFL models driving these outcome differences

Immune correlates of CD4 decline in HIV-infected patients experiencing virologic failure before undergoing treatment interruption

<p>Abstract</p> <p>Background</p> <p>The advantage of treatment interruptions (TIs) in salvage therapy remains controversial. Regardless, characterizations of the correlates of CD4 count fall during TI are important to identify since patients with virologic failure commonly stop antiretroviral (ARV) therapy. The objective of this study was to determine the predictive value of pre-TI proliferative capacity and cell surface markers for CD4 count change in HIV-infected patients experiencing virologic failure before undergoing TI.</p> <p>Methods</p> <p>Peripheral blood mononuclear cells (PBMCs) from 13 HIV-infected patients experiencing virologic failure at baseline time points before the TI were tested for proliferation using the 5,6-carboxyfluorescein diacetate succinimidyl ester (CFSE) dilution assay and a Gag p55 peptide pool, staphylococcus enterotoxin B (SEB), cytomegalovirus (CMV) recall antigen, and anti-CD3 antibody as stimuli. CD28 and CD57 expression on CD4+ and CD8+ T-cells was measured.</p> <p>Results</p> <p>The median changes in the CD4+ T-cell count and viral load from baseline to the TI time point corresponding to the CD4 count nadir were -44 cells/mm³{Interquartile range (IQR) -17, -104} and +85,332 copies/mL (IQR +11,198, +283,327), respectively. CD4+ T-cell proliferation to CMV, pre-TI CD4+ T-cell count, and percent CD4+CD57+ cells correlated negatively with CD4 count change during TI (r = -0.59, p = 0.045, r = -0.61, p = 0.030 and r = -0.69, p = 0.0095, respectively; Spearman correlation). The presence of HIV-specific proliferative responses was not associated with a reduced decline in CD4 count during TI.</p> <p>Conclusion</p> <p>The use of pre-TI immune proliferative responses and cell surface markers may have predictive value for CD4 count decline during TI.</p

Detecting and predicting forest degradation: A comparison of ground surveys and remote sensing in Tanzanian forests

Funder: Critical Ecosystem Partnership Fund; Id: http://dx.doi.org/10.13039/100013724Funder: Global Environment Facility; Id: http://dx.doi.org/10.13039/100011150Funder: Danish International Development Agency; Id: http://dx.doi.org/10.13039/501100011054Funder: Scottish Government’s Rural and Environment Science and Analytical Services DivisionFunder: Finnish International Development AgencyFunder: Leverhulme Trust; Id: http://dx.doi.org/10.13039/501100000275Societal Impact Statement: Large areas of tropical forest are degraded. While global tree cover is being mapped with increasing accuracy from space, much less is known about the quality of that tree cover. Here we present a field protocol for rapid assessments of forest condition. Using extensive field data from Tanzania, we show that a focus on remotely‐sensed deforestation would not detect significant reductions in forest quality. Radar‐based remote sensing of degradation had good agreement with the ground data, but the ground surveys provided more insights into the nature and drivers of degradation. We recommend the combined use of rapid field assessments and remote sensing to provide an early warning, and to allow timely and appropriately targeted conservation and policy responses. Summary: Tropical forest degradation is widely recognised as a driver of biodiversity loss and a major source of carbon emissions. However, in contrast to deforestation, more gradual changes from degradation are challenging to detect, quantify and monitor. Here, we present a field protocol for rapid, area‐standardised quantifications of forest condition, which can also be implemented by non‐specialists. Using the example of threatened high‐biodiversity forests in Tanzania, we analyse and predict degradation based on this method. We also compare the field data to optical and radar remote‐sensing datasets, thereby conducting a large‐scale, independent test of the ability of these products to map degradation in East Africa from space. Our field data consist of 551 ‘degradation’ transects collected between 1996 and 2010, covering >600 ha across 86 forests in the Eastern Arc Mountains and coastal forests. Degradation was widespread, with over one‐third of the study forests—mostly protected areas—having more than 10% of their trees cut. Commonly used optical remote‐sensing maps of complete tree cover loss only detected severe impacts (≥25% of trees cut), that is, a focus on remotely‐sensed deforestation would have significantly underestimated carbon emissions and declines in forest quality. Radar‐based maps detected even low impacts (<5% of trees cut) in ~90% of cases. The field data additionally differentiated types and drivers of harvesting, with spatial patterns suggesting that logging and charcoal production were mainly driven by demand from major cities. Rapid degradation surveys and radar remote sensing can provide an early warning and guide appropriate conservation and policy responses. This is particularly important in areas where forest degradation is more widespread than deforestation, such as in eastern and southern Africa

Quantifying Queensland patients with cancer health service usage and costs: study protocol

Introduction: The overall mortality rate for cancer has declined in Australia. However, socioeconomic inequalities exist and the out-of-pocket costs incurred by patients in Australia are high compared with some European countries. There is currently no readily available data set to provide a systematic means of measuring the out-of-pocket costs incurred by patients with cancer within Australia. The primary aim of the project is to quantify the direct out-of-pocket healthcare expenditure of individuals in the state of Queensland, who are diagnosed with cancer.\ud \ud Methods and analysis: This project will build Australia's first model (called CancerCostMod) of out-of-pocket healthcare expenditure of patients with cancer using administrative data from Queensland Cancer Registry, for all individuals diagnosed with any cancer in Queensland between 1 July 2011 and 30 June 2012, linked to their Admitted Patient Data Collection, Emergency Department Information System, Medicare Benefits Schedule and Pharmaceutical Benefits Scheme records from 1 July 2011 to 30 June 2015. No identifiable information will be provided to the authors. The project will use a combination of linear and logistic regression modelling, Cox proportional hazards modelling and machine learning to identify differences in survival, total health system expenditure, total out-of-pocket expenditure and high out-of-pocket cost patients, adjusting for demographic and clinical confounders, and income group, Indigenous status and geographic location. Results will be analysed separately for different types of cancer

Long-term out of pocket expenditure of people with cancer: comparing health service cost and use for indigenous and non-indigenous people with cancer in Australia

Abstract Background Indigenous Australians diagnosed with cancer have poorer survival compared to non-Indigenous Australians. We aim to: 1) identify differences by Indigenous status in out-of-pocket expenditure for the first three-years post-diagnosis; 2) identify differences in the quantity and cost of healthcare services accessed; and 3) estimate the number of additional services required if access was equal between Indigenous and non-Indigenous people with cancer. Methods We used CancerCostMod, a model using linked administrative data. The base population was all persons diagnosed with cancer in Queensland, Australia (01JUL2011 to 30JUN2012) (n = 25,553). Each individual record was then linked to their Admitted Patient Data Collection, Emergency Data Information System, Medicare Benefits Schedule (MBS), and Pharmaceutical Benefits Scheme (PBS) records (01JUL2011 to 30JUN2015). We then weighted the population to be representative of the Australian population (approximately 123,900 Australians, 1.7% Indigenous Australians). The patient co-payment charged for each MBS service and PBS prescription was summed for each month from date of diagnosis to 36-months post-diagnosis. We then limited our model to MBS items to identify the quantity and type of healthcare services accessed during the first three-years. Results On average Indigenous people with cancer had less than half the out-of-pocket expenditure for each 12-month period (0–12 months: mean $401 Indigenous vs$1074 non-Indigenous; 13–24 months: mean $200 vs$484; and 25–36 months: mean $181 vs$441). A stepwise generalised linear model of out-of-pocket expenditure found that Indigenous status was a significant predictor of out of pocket expenditure. We found that Indigenous people with cancer on average accessed 236 services per person, however, this would increase to 309 services per person if Indigenous people had the same rate of service use as non-Indigenous people. Conclusions Indigenous people with cancer had lower out-of-pocket expenditure, but also accessed fewer Medicare services compared to their non-Indigenous counterparts. Indigenous people with cancer were less likely to access specialist attendances, pathology tests, and diagnostic imaging through MBS, and more likely to access primary health care, such as services provided by general practitioners