The effect of an intervention to promote isoniazid preventive therapy on leadership and management abilities.

BACKGROUND: Across sub-Saharan Africa, mid-level healthcare managers oversee implementation of national guidelines. It remains unclear whether leadership and management training can improve population health outcomes. METHODS: We sought to evaluate leadership/management skills among district-level health managers in Uganda participating in the SEARCH-IPT randomised trial to promote isoniazid preventive therapy (IPT) for persons with HIV (PWH). The intervention, which led to higher IPT rates, included annual leadership/management training of managers. We conducted a cross-sectional survey assessing leadership/management skills among managers at trial completion. The survey evaluated self-reported use of leadership/management tools and general leadership/management. We conducted a survey among a sample of providers to understand the intervention's impact. Targeted minimum loss-based estimation (TMLE) was used to compare responses between trial arms. RESULTS: Of 163 managers participating in the SEARCH-IPT trial, 119 (73%) completed the survey. Intervention managers reported more frequent use of leadership/management tools taught in the intervention curriculum than control managers (+3.64, 95% CI 1.98-5.30, P < 0.001). There were no significant differences in self-reported leadership skills in the intervention as compared to the control group. Among providers, the average reported quality of guidance and supervision was significantly higher in intervention vs control districts (+1.08, 95% CI 0.63-1.53, P = 0.001). CONCLUSIONS: A leadership and management training intervention increased the use of leadership/management tools among mid-level managers and resulted in higher perceived quality of supervision among providers in intervention vs control districts in Uganda. These findings suggest improved leadership/management among managers contributed to increased IPT use among PWH in the intervention districts of the SEARCH-IPT trial.

CONTEXTE: Dans toute l'Afrique subsaharienne, les gestionnaires de soins de santé de niveau intermédiaire supervisent la mise en œuvre des directives nationales. Il n'est toujours pas clair si la formation en leadership et en gestion peut améliorer les résultats en matière de santé de la population. MÉTHODES: Nous avons cherché à évaluer les compétences en leadership et en gestion des responsables de la santé au niveau des districts en Ouganda participant à l'essai randomisé SEARCH-IPT visant à promouvoir le traitement préventif à l'isoniazide (TPI) pour les personnes vivant avec le VIH (PWH, pour l'anglais « people living with HIV ¼). L'intervention, qui a permis d'augmenter les taux de TPI, comprenait une formation annuelle en leadership et en gestion des gestionnaires. Nous avons mené une enquête transversale pour évaluer les compétences en leadership et en gestion des gestionnaires à la fin de l'essai. L'enquête a évalué l'utilisation autodéclarée d'outils de leadership et de gestion et de leadership et de gestion en général. Nous avons mené une enquête auprès d'un échantillon de prestataires pour comprendre l'impact de l'intervention. L'estimation ciblée basée sur les pertes minimales (TMLE, « Targeted minimum loss-based estimation ¼) a été utilisée pour comparer les réponses entre les groupes de l'essai. RÉSULTATS: Sur les 163 gestionnaires qui ont participé à l'essai SEARCH-IPT, 119 (73%) ont répondu au sondage. Les gestionnaires d'intervention ont déclaré utiliser plus fréquemment les outils de leadership/gestion enseignés dans le programme d'intervention que les gestionnaires de contrôle (+3,64 ; IC à 95% 1,98­5,30 ; P < 0,001). Il n'y avait pas de différences significatives dans les compétences de leadership autodéclarées dans l'intervention par rapport au groupe témoin. Parmi les prestataires, la qualité moyenne déclarée de l'orientation et de la supervision était significativement plus élevée dans les districts d'intervention que dans les districts témoins (+1,08 ; IC à 95% 0,63­1,53 ; P = 0,001). CONCLUSIONS: Une intervention de formation au leadership et à la gestion a permis d'accroître l'utilisation d'outils de leadership et de gestion parmi les cadres intermédiaires et d'améliorer la perception de la qualité de la supervision parmi les prestataires dans les districts d'intervention par rapport aux districts de contrôle en Ouganda. Ces résultats suggèrent que l'amélioration du leadership et de la gestion chez les gestionnaires a contribué à l'augmentation de l'utilisation du TPI chez les personnes handicapées dans les districts d'intervention de l'essai SEARCH-IPT.

Achieving the UNAIDS 90-90-90 targets: a comparative analysis of four large community randomised trials delivering universal testing and treatment to reduce HIV transmission in sub-Saharan Africa.

BACKGROUND: Four large community-randomized trials examining universal testing and treatment (UTT) to reduce HIV transmission were conducted between 2012-2018 in Botswana, Kenya, Uganda, Zambia and South Africa. In 2014, the UNAIDS 90-90-90 targets were adopted as a useful metric to monitor coverage. We systematically review the approaches used by the trials to measure intervention delivery, and estimate coverage against the 90-90-90 targets. We aim to provide in-depth understanding of the background contexts and complexities that affect estimation of population-level coverage related to the 90-90-90 targets. METHODS: Estimates were based predominantly on "process" data obtained during delivery of the interventions which included a combination of home-based and community-based services. Cascade coverage data included routine electronic health records, self-reported data, survey data, and active ascertainment of HIV viral load measurements in the field. RESULTS: The estimated total adult populations of trial intervention communities included in this study ranged from 4,290 (TasP) to 142,250 (Zambian PopART Arm-B). The estimated total numbers of PLHIV ranged from 1,283 (TasP) to 20,541 (Zambian PopART Arm-B). By the end of intervention delivery, the first-90 target (knowledge of HIV status among all PLHIV) was met by all the trials (89.2%-94.0%). Three of the four trials also achieved the second- and third-90 targets, and viral suppression in BCPP and SEARCH exceeded the UNAIDS target of 73%, while viral suppression in the Zambian PopART Arm-A and B communities was within a small margin (~ 3%) of the target. CONCLUSIONS: All four UTT trials aimed to implement wide-scale testing and treatment for HIV prevention at population level and showed substantial increases in testing and treatment for HIV in the intervention communities. This study has not uncovered any one estimation approach which is superior, rather that several approaches are available and researchers or policy makers seeking to measure coverage should reflect on background contexts and complexities that affect estimation of population-level coverage in their specific settings. All four trials surpassed UNAIDS targets for universal testing in their intervention communities ahead of the 2020 milestone. All but one of the trials also achieved the 90-90 targets for treatment and viral suppression. UTT is a realistic option to achieve 95-95-95 by 2030 and fast-track the end of the HIV epidemic.

[Louse-borne-relapsing-fever in refugees from the Horn of Africa; a case series of 25 patients]. / 25 Fälle von Läuserückfallfieber bei Flüchtlingen aus Ostafrika.

Background | Relapsing fever is divided into tick borne relapsing fever (TBRF) and louse borne relapsing fever (LBRF). This report describes 25 refugees from East Africa who were diagnosed to suffer from LBRF within a period of 6 month only at a single hospital in Munich / Germany. Material & Methods | The aim was to point out common clinical features as well as laboratory findings and clinical symptoms before and after initiation of treatment in 25 patients with louse borne relapsing fever (LBRF) who were diagnosed and treated at Klinikum München Schwabing from August 2015 to January 2016. To the best of our knowledge this is the largest case series of LBRF in the western world for decades. Main focus of the investigation was put on clinical aspects. Results | All 25 patients suffered from acute onset of high fever with chills, headache and severe prostration. Laboratory analysis showed high CRP and a marked thrombocytopenia. A Giemsa blood stain was procured immediately in order to look for malaria. In the blood smear spirochetes with typical shape and aspect of borrelia species could be detected.The further PCR analysis confirmed infection with Borrelia recurrentis. Treatment with Doxycycline was started forthwith. The condition improved already on the second day after treatment was started and all were restored to health in less than a week. Apart from a mild to moderate Jarisch-Herxheimer-reaction we didn`t see any side effects of the therapy. Conclusion | LBRF has to be taken into account in feverish patients who come as refugees from East-Africa. It seems that our patients belong to a cluster which probably has its origin in Libya and more patients are to be expected in the near future. As LBRF might cause outbreaks in refugee camps it is pivotal to be aware of this emerging infectious disease in refugees from East-Africa.

Genetic risk and longitudinal disease activity in systemic lupus erythematosus using targeted maximum likelihood estimation.

Systemic lupus erythematous (SLE) is a chronic autoimmune disease associated with genetic and environmental risk factors. However, the extent to which genetic risk is causally associated with disease activity is unknown. We utilized longitudinal-targeted maximum likelihood estimation to estimate the causal association between a genetic risk score (GRS) comprising 41 established SLE variants and clinically important disease activity as measured by the validated Systemic Lupus Activity Questionnaire (SLAQ) in a multiethnic cohort of 942 individuals with SLE. We did not find evidence of a clinically important SLAQ score difference (>4.0) for individuals with a high GRS compared with those with a low GRS across nine time points after controlling for sex, ancestry, renal status, dialysis, disease duration, treatment, depression, smoking and education, as well as time-dependent confounding of missing visits. Individual single-nucleotide polymorphism (SNP) analyses revealed that 12 of the 41 variants were significantly associated with clinically relevant changes in SLAQ scores across time points eight and nine after controlling for multiple testing. Results based on sophisticated causal modeling of longitudinal data in a large patient cohort suggest that individual SLE risk variants may influence disease activity over time. Our findings also emphasize a role for other biological or environmental factors.