Patient level benefits associated with decentralisation of antiretroviral therapy services to primary health facilities in Malawi and Uganda

BACKGROUND: The Lablite project captured information on access to antiretroviral therapy (ART) at larger health facilities (‘hubs’) and lower-level health facilities (‘spokes’) in Phalombe district, Malawi and in Kalungu district, Uganda. METHODS: We conducted a cross-sectional survey among patients who had transferred to a spoke after treatment initiation (Malawi, n=54; Uganda, n=33), patients who initiated treatment at a spoke (Malawi, n=50; Uganda, n=44) and patients receiving treatment at a hub (Malawi, n=44; Uganda, n=46). RESULTS: In Malawi, 47% of patients mapped to the two lowest wealth quintiles (Q1–Q2); patients at spokes were poorer than at a hub (57% vs 23% in Q1–Q2; p<0.001). In Uganda, 7% of patients mapped to Q1–Q2; patients at the rural spoke were poorer than at the two peri-urban facilities (15% vs 4% in Q1–Q2; p<0.001). The median travel time one way to a current ART facility was 60 min (IQR 30–120) in Malawi and 30 min (IQR 20–60) in Uganda. Patients who had transferred to the spokes reported a median reduction in travel time of 90 min in Malawi and 30 min in Uganda, with reductions in distance and food costs. CONCLUSIONS: Decentralizing ART improves access to treatment. Community-level access to treatment should be considered to further minimize costs and time

A global outlook to the interruption of education due to COVID-19 Pandemic: Navigating in a time of uncertainty and crisis

Uncertain times require prompt reflexes to survive and this study is a collaborative reflex to better understand uncertainty and navigate through it. The Coronavirus (Covid-19) pandemic hit hard and interrupted many dimensions of our lives, particularly education. As a response to interruption of education due to the Covid-19 pandemic, this study is a collaborative reaction that narrates the overall view, reflections from the K12 and higher educational landscape, lessons learned and suggestions from a total of 31 countries across the world with a representation of 62.7% of the whole world population. In addition to the value of each case by country, the synthesis of this research suggests that the current practices can be defined as emergency remote education and this practice is different from planned practices such as distance education, online learning or other derivations. Above all, this study points out how social injustice, inequity and the digital divide have been exacerbated during the pandemic and need unique and targeted measures if they are to be addressed. While there are support communities and mechanisms, parents are overburdened between regular daily/professional duties and emerging educational roles, and all parties are experiencing trauma, psychological pressure and anxiety to various degrees, which necessitates a pedagogy of care, affection and empathy. In terms of educational processes, the interruption of education signifies the importance of openness in education and highlights issues that should be taken into consideration such as using alternative assessment and evaluation methods as well as concerns about surveillance, ethics, and data privacy resulting from nearly exclusive dependency on online solutions

Asthma inflammatory phenotypes on four continents: most asthma is non-eosinophilic.

BACKGROUND: Most studies assessing pathophysiological heterogeneity in asthma have been conducted in high-income countries (HICs), with little known about the prevalence and characteristics of different asthma inflammatory phenotypes in low-and middle-income countries (LMICs). This study assessed sputum inflammatory phenotypes in five centres, in Brazil, Ecuador, Uganda, New Zealand (NZ) and the United Kingdom (UK). METHODS: We conducted a cross-sectional study of 998 asthmatics and 356 non-asthmatics in 2016-20. All centres studied children and adolescents (age range 8-20 years), except the UK centre which involved 26-27 year-olds. Information was collected using questionnaires, clinical characterization, blood and induced sputum. RESULTS: Of 623 asthmatics with sputum results, 39% (243) were classified as eosinophilic or mixed granulocytic, i.e. eosinophilic asthma (EA). Adjusted for age and sex, with NZ as baseline, the UK showed similar odds of EA (odds ratio 1.04, 95% confidence interval 0.37-2.94) with lower odds in the LMICs: Brazil (0.73, 0.42-1.27), Ecuador (0.40, 0.24-0.66) and Uganda (0.62, 0.37-1.04). Despite the low prevalence of neutrophilic asthma in most centres, sputum neutrophilia was increased in asthmatics and non-asthmatics in Uganda. CONCLUSIONS: This is the first time that sputum induction has been used to compare asthma inflammatory phenotypes in HICs and LMICs. Most cases were non-eosinophilic, including in settings where corticosteroid use was low. A lower prevalence of EA was observed in the LMICs than in the HICs. This has major implications for asthma prevention and management, and suggests that novel prevention strategies and therapies specifically targeting non-eosinophilic asthma are required globally

Hydrogeology of an urban weathered basement aquifer in Kampala, Uganda

Weathered basement aquifers are vital sources of drinking water in Africa. In order to better understand their role in the urban water balance, in a weathered basement aquifer in Kampala, Uganda, this study installed a transect of monitoring piezometers, carried out spring flow and high-frequency groundwater level monitoring, slug tests and hydrochemical analyses, including stable isotopes and groundwater residence time indicators. Findings showed a typical weathered basement aquifer with a 20–50-m thickness. Groundwater recharge was 3–50 mm/year, occurring during sustained rainfall. Recharge to a deep groundwater system within the saprock was slow and prolonged, while recharge to the springs on the valley slopes was quick and episodic, responding rapidly to precipitation. Springs discharged shallow groundwater, mixed with wastewater infiltrating from onsite sanitation practices and contributions from the deeper aquifer and were characterised by low flow rates (< 0.001 m3/s), low pH (<5), high nitrate values (61–190 mg/L as NO3), and residence times of <30 years. The deeper groundwater system occurred in the saprolite/saprock, had low transmissivity (< 1 × 10−5 m2/s), lower nitrate values (<20 mg/L as NO3), pH 6–6.5 and longer residence times (40–60 years). Confined groundwater conditions in the valleys were created by the presence of clay-rich alluvium and gave rise to artesian conditions where groundwater had lower nitrate concentrations. The findings provide new insights into weathered basement aquifers in the urban tropics and show that small-scale abstractions are more sustainable in the deeper groundwater system in the valleys, where confined conditions are present

She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B+

Background: Malawi, Uganda, and Zimbabwe have recently adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled 'defaulters' or 'lost-to-follow-up' patients. Methods: We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe. Findings: Lost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs' liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track 'defaulters'. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients' choice. Conclusions: CHWs provide essential linkages between health services and patients; they embody the role of 'extension workers', a bridge between a novel health policy and 'non-compliant patients'. Option B+ offers a powerful narrative of the construction of a unilateral 'moral economy', which requires the full compliance of patients newly initiated on treatment