Viewpoint: Why do we need a point-of-care CD4 test for low-income countries?

In this paper, we discuss the reasons why we urgently need a point-of-care (POC) CD4 test, elaborate the problems we have experienced with the current technology which hampers CD4-count coverage and highlight the ideal characteristics of a universal CD4 POC test. It is high-time that CD4 technology is simplified and adapted for wider use in low-income countries to change the current paradigm of restricted access once and for all

Outcomes and safety of concomitant nevirapine and rifampicin treatment under programme conditions in Malawi.

SETTING: Thyolo District Hospital, rural Malawi. OBJECTIVES: To report on 1) clinical, immunological and virological outcomes and 2) safety among human immunodeficiency virus (HIV) infected patients with tuberculosis (TB) who received concurrent nevirapine (NVP) and rifampicin (RMP) based treatment. DESIGN: Retrospective cohort study. METHODS: Analysis of programme data, June-December 2007. RESULTS: Of a total of 156 HIV-infected TB patients who started NVP-based antiretroviral treatment, 136 (87%) completed TB treatment successfully, 16 (10%) died and 5 (4%) were transferred out. Mean body weight and CD4 gain (adults) were respectively 4.4 kg (95%CI 3.3-5.4) and 140 cells/mm(3) (95%CI 117-162). Seventy-four per cent of patients who completed TB treatment and had a viral load performed (n = 74) had undetectable levels (<50 copies/ml), while 17 (22%) had a viral load of 50-1000 copies/ml. Hepatotoxicity was present in 2 (1.3%) patients at baseline. Two patients developed Grade 2 and one developed Grade 3 alanine transaminase enzyme elevations during TB treatment (incidence rate per 10 years of follow-up 4.2, 95%CI 1.4-13.1). There were no reported deaths linked to hepatotoxicity. CONCLUSIONS: In a rural district in Malawi, concomitant NVP and RMP treatment is associated with good TB treatment outcomes and appears safe. Further follow-up of patients would be useful to ascertain the longer-term effects of this concurrent treatment

Congenital Rubella Syndrome in Fiji, 1995-2010

Setting. A nationwide study in Fiji. Objective. To describe the incidence of congenital rubella syndrome (CRS) and its relationship to the incidence of notified cases of rubella in Fiji from 1995 to 2010. Design. Descriptive, retrospective review of all recorded congenital abnormalities associated with live births in Fiji over 16 years. Results. There were 294 infants who met the criteria for CRS. Of these, 95% were classified as "suspected" cases, 5% were "clinically confirmed," and none were "laboratory confirmed cases". There was a significant linear increase over the study period in the incidence of CRS (odds ratio 1.045 per year, 95% CI 1.019 to 1.071, P ≤ 0.001). There was no significant association between the incidence of CRS and the reported incidence of rubella (P = 0.3). Conclusion. There is a rising trend in reports of suspected CRS cases in Fiji. This highlights the need to strengthen surveillance for CRS through improvements in clinical and laboratory diagnosis to confirm or exclude suspected cases. It is also important to ensure high coverage of rubella vaccination in Fiji

Are HIV-positive presumptive tuberculosis patients without tuberculosis getting the care they need in Zimbabwe?

SETTING: Emakhandeni Clinic provides decentralised and integrated tuberculosis (TB) and human immunodeficiency virus (HIV) care in Bulawayo, Zimbabwe. OBJECTIVES: To compare HIV care for presumptive TB patients with and without TB registered in 2013. DESIGN: Retrospective cohort study using routine programme data. RESULTS: Of 422 registered presumptive TB patients, 26% were already known to be HIV-positive. Among the remaining 315 patients, 255 (81%) were tested for HIV, of whom 190 (75%) tested HIV-positive. Of these, 26% were diagnosed with TB and 71% without TB (3% had no TB result recorded). For the 134 patients without TB, antiretroviral treatment (ART) eligibility data were recorded for 42 (31%); 95% of these were ART eligible. Initiation of cotrimoxazole preventive therapy (CPT) and ART was recorded for respectively 88% and 90% of HIV-positive patients with TB compared with respectively 40% and 38% of HIV-positive patients without TB (P < 0.001). CONCLUSION: Presumptive TB patients without TB had a high HIV positivity rate and, for those with available data, most were ART eligible. Unlike HIV-positive patients diagnosed with TB, CPT and ART uptake for these patients was poor. A 'test and treat' approach and better service linkages could be life-saving for these patients, especially in southern Africa, where there are high burdens of HIV and TB

The published research paper: is it an important indicator of successful operational research at programme level?

Is a published research paper an important indicator of successful operational research at programme level in low-income countries? In academia, publishing in peer-reviewed scientific journals is highly encouraged and strongly pursued for academic recognition and career progression. In contrast, for those who engage in operational research at programme level, there is often no necessity or reward for publishing the results of research studies; it may even be criticized as being an unnecessary detraction from programme-related work. We present arguments to support publishing operational research from low-income countries; we highlight some of the main reasons for failure of publication at programme level and suggest ways forward

Sexual violence in post-conflict Liberia: survivors and their care.

Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors' needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9-17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor's home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care

Management and treatment outcomes of patients enrolled in MDR-TB treatment in Viet Nam.

SETTING: The programmatic management of drug-resistant tuberculosis (TB) in Viet Nam has been rapidly scaled up since 2009. OBJECTIVES: To document the annual numbers of patients enrolled for multidrug-resistant tuberculosis (MDR-TB) treatment during 2010-2014 and to determine characteristics and treatment outcomes of patients initiating treatment during 2010-2012. DESIGN: A retrospective cohort study using national reports and data from the national electronic data system for drug-resistant TB. RESULTS: The number of patients enrolled annually for MDR-TB treatment increased from 97 in 2010 to 1522 in 2014. The majority of patients were middle-aged men who had pulmonary disease and had failed a retreatment regimen; 77% had received ⩾2 courses of TB treatment. Favourable outcomes (cured and treatment completed) were attained in 73% of patients. Unfavourable outcomes included loss to follow-up (12.5%), death (8%) and failure (6.3%). Having had ⩾2 previous treatment courses and being human immunodeficiency virus-positive were associated with unfavourable outcomes. CONCLUSION: Increasing numbers of patients are being treated for MDR-TB each year with good treatment outcomes under national programme management in Viet Nam. However, there is a need to increase case detection-currently at 30% of the estimated 5100 MDR-TB cases per year, reduce adverse outcomes and improve monitoring and evaluation

The rise and fall of tuberculosis in Malawi: associations with HIV infection and antiretroviral therapy.

OBJECTIVES: Since 1985, Malawi has experienced a dual epidemic of HIV and tuberculosis (TB) which has been moderated recently by the advent of antiretroviral therapy (ART). The aim of this study was to describe the association over several decades between HIV/AIDS, the scale-up of ART and TB case notifications. METHODS: Aggregate data were extracted from annual reports of the National TB Control Programme, the Ministry of Health HIV Department and the National Statistics Office. ART coverage was calculated using the total HIV population as denominator (derived from UNAIDS Spectrum software). RESULTS: In 1970, there were no HIV-infected persons but numbers had increased to a maximum of 1.18 million by 2014. HIV prevalence reached a maximum of 10.8% in 2000, thereafter decreasing to 7.5% by 2014. Numbers alive on ART increased from 2586 in 2003 to 536 527 (coverage 45.3%) by 2014. In 1985, there were 5286 TB cases which reached a maximum of 28 234 in 2003 and then decreased to 17 723 by 2014 (37% decline from 2003). There were increases in all types of new TB between 1998-2003 which then declined by 30% for extrapulmonary TB, by 37% for new smear-positive PTB and by 50% for smear-negative PTB. Previously treated TB cases reached a maximum of 3443 in 2003 and then declined by 42% by 2014. CONCLUSION: The rise and fall of TB in Malawi between 1985 and 2014 was strongly associated with HIV infection and ART scale-up; this has implications for ending the TB epidemic in high HIV-TB burden countries