Antiretroviral Therapy With Efavirenz Accentuates Pregnancy-Associated Reduction of Dihydroartemisinin-Piperaquine Exposure During Malaria Chemoprevention.

Dihydroartemisinin (DHA)-piperaquine is promising for malaria chemoprevention in pregnancy. We assessed the impacts of pregnancy and efavirenz-based antiretroviral therapy on exposure to DHA and piperaquine in pregnant Ugandan women. Intensive sampling was performed at 28 weeks gestation in 31 HIV-uninfected pregnant women, in 27 HIV-infected pregnant women receiving efavirenz, and in 30 HIV-uninfected nonpregnant women. DHA peak concentration and area under the concentration time curve (AUC0-8hr ) were 50% and 47% lower, respectively, and piperaquine AUC0-21d was 40% lower in pregnant women compared to nonpregnant women. DHA AUC0-8hr and piperaquine AUC0-21d were 27% and 38% lower, respectively, in pregnant women receiving efavirenz compared to HIV-uninfected pregnant women. Exposure to DHA and piperaquine were lower among pregnant women and particularly in women on efavirenz, suggesting a need for dose modifications. The study of modified dosing strategies for these populations is urgently needed.

Using computerized provider order entry to enforce documentation of tests with pending results at hospital discharge.

BACKGROUND: Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup. OBJECTIVE: Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries. METHODS: We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality. RESULTS: Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming. CONCLUSIONS: A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.

Home-based HIV counselling and testing in western Kenya.

BACKGROUND: The World Health Organisation (WHO) estimates that only 12% of men and 10% of women in sub-Saharan Africa have been tested for HIV and know their test results. Home-based counselling and testing (HBCT) offers a novel approach to complement facility-based provider initiated testing and counselling (PITC) and voluntary counselling and testing (VCT) and could greatly increase HIV prevention opportunities. However, there is almost no evidence that large-scale, door-to-door testing is even feasible in settings with both limited resources and significant stigma around HIV and AIDS. OBJECTIVE: To describe our experience with the feasibility and acceptance of home-based HIV counselling and testing (HBCT) in two large, rural, administrative divisions of western Kenya. DESIGN: The USAID-AMPATH Partnership conducted population-based, house-to-house HIV counselling and testing in western Kenya between June 2007 and June 2009. All individuals aged > or = 13 years and all eligible children were offered HBCT. Children were eligible if they were above 13 years of age, and their mother was either HIV-positive or had unknown HIV serostatus, or if their mother was deceased or whose vital status was unknown. SETTING: Kosirai and Turbo Divisions, Rift Valley Province, Kenya. RESULTS: There were 47,066 households approached in 294 villages: 97% of households allowed entry. Of the 138,026 individuals captured, 101,167 individuals were eligible for testing: 89% of adults and 58% of children consented to HIV testing. The prevalence of HIVin these communities was 3.0%: 2.7% in adults and 3.7% among children. Prevalence was highest in the 36-45 year age group and was almost always higher among women and girls. All persons testing HIV-positive were referred to Academic Model Providing Access to Healthcare (AMPATH) for further assessment and care; all consenting persons were counselled on HIV risk-lowering behaviours. CONCLUSION: Home-based HIV counselling and testing was feasible among this rural population in western Kenya, with a majority of the population accepting to get tested. These data suggest that scaling-up of HBCT is possible and may enable large numbers of individuals to know their HIV serostatus in sub-Saharan Africa. More research is needed to describe the cost-effectiveness and clinical impact of this approach.

Patterns of care in two HIV continuity clinics in Uganda, Africa: a time-motion study.

The study objectives were to identify opportunities to improve the quality of care in resource-limited settings by examining the workflow and patient activities at two large outpatient HIV clinics in Uganda. Using time motion study techniques, we collected detailed data on all activities of patients and clinicians in two government-sponsored HIV clinics in Uganda. Processes measured included amount of time clinicians (physicians, nurse practitioners and clinical officers) spend in clinic, the daily patient census and patient visit-length. We also recorded the time spent on various activities by providers and patients. We found that the mean time in clinic per workday at Masaka was 5.5 hours and at Mbarara 4.9 hours, with about 60% of this time spent in direct and indirect care of patients at both sites. Workday start-times varied by two hours in Masaka and one-and-a half hours in Mbarara and end-times by five and three hours respectively. One-hundred-and-nineteen patients (SD 34) visited Masaka each day and 107 (SD 45) visited Mbarara. The mean duration of the patient visit was 77 minutes at Masaka and 196 minutes at Mbarara, with 66% and 62% of the time spent at respective sites waiting for care. We conclude that clinicians in resource-poor settings spend limited amounts of time at the clinic site, with a large portion of the clinic-time taken up by tasks that do not require specialized patient-care skills. This study demonstrates that opportunities exist to improve clinic productivity and visit experience for patients, and provides a baseline for designing and evaluating the impact of process improvement interventions.

Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult.

OBJECTIVES: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub-Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. METHODS: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3-5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. FINDINGS: We studied 7195 children aged 2-59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. CONCLUSION: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children.

Women and HIV in Busia: their recognition and understanding of the disease.

A cross-sectional survey of women within the age range of 15-63 years was carried out between June and September, 1994 in Busia District. The purpose was to determine women's recognition and understanding of HIV/AIDS.A total of 333 women were orally interviewed by trained investigators using questionnaires.98.8% admitted having heard about AIDS while 1.2% had not; 78.1% had seen at least one or more AIDS patients. Although knowledge about causation of AIDS was extremely poor, 98.0% and 95.2% mentioned at least one correct mode of transmission of HIV and signs/symptoms, respectively. 78.1% had seen one or more patients of AIDS and majority (75.0%) said most of these patients belonged to the young (adolescents/middle) age groups. Most (98.8%) knew there is no cure drug for AIDS presently; however, 89.8% had heard about the condom, 77.5% had seen them. 74.7% knew HIV infection could be prevented or controlled by proper use of the condom.

The 13C-mixed triglyceride breath test in healthy adults: determinants of the 13CO2 response.

Defects in lipolysis due to pancreatic insufficiency can be diagnosed by the mixed triglyceride (MTG) 13CO2 breath test. However, the effects of various test conditions on the 13CO2 response have only been partially elucidated. In healthy adults, we performed the 13CO2 mixed triglyceride breath test and we compared (a) the inter- and intra-individual variation in the 13CO2 response; (b) the effect of two different test meals; (c) the effect of an additional meal during the test; and (d) the effect of physical exercise during the test. Upon repeating the test in the same individual (test meal cream), repeatability coefficients were large, with respect to either time to maximum 13C excretion rate (3.8 h). maximum 13C excretion rate (4.9% 13C dose h-1) or cumulative recovery of 13C over the 9-h study period (22.7% 13C dose). The cumulative 13C expiration over 9 h obtained with the test meal composed of cream was quantitatively similar to that obtained with bread and butter: 42.2 +/- 8.4% and 47.7 +/- 6.3% respectively. Fasting for 9 h during the test resulted in similar 13C expiration rates and cumulative 13C expiration (43.4% +/- 7.2%) when compared with consumption of an additional meal 3 h after the start of the test (38.3 +/- 5.3%). The 13CO2 response increased in five out of seven subjects, but decreased in the other two, when moderate exercise was performed (bicycle ergometer, 50 W for 5 h). We conclude that the repeatability of the MTG test in healthy adults is low. The present results indicate that a solid and a liquid test meal, containing a similar amount of fats, give similar cumulative 13CO2 responses, and that stringent prolonged fasting during the test is unnecessary. Standardization of physical activity seems preferable, since the unequivocal effects of moderate exercise on the 13CO2 response were observed in the individuals studied.

A case control study on human immunodeficiency virus-1 (HIV-1) infection as a risk factor for tuberculosis and leprosy in western Kenya.

A case control study was undertaken in Western Kenya from April 1989 to August 1990 to evaluate HIV-1 infection as a risk factor for tuberculosis and leprosy. The study involved 144 newly diagnosed sputum smear positive tuberculosis cases with 432 age, sex and neighbourhood-matched controls, and 132 diagnosed leprosy cases with 384 matched controls. Odds ratios obtained by conditional logistic regression (matched) analysis were 4.9 (95% CI 2.6, 6.8), and 1.8 (95% CI 0.9, 3.2), for the association between HIV-1 and tuberculosis and leprosy respectively. Approximately 31% of tuberculosis cases among males, and 11% of cases among females, were attributable to HIV infection.

PIP: Between April, 1989, and August 1990. in Busia, Siaya, Kisumu, and South Nyanza districts of Western Kenya, health workers recruited 144 sputum smear positive tuberculosis (TB) cases and 432 age, sex, and neighborhood matched controls. They also recruited 132 newly detected leprosy cases and 384 matched controls. Researchers wanted to determine the association between HIV-1 and TB and between HIV-1 and leprosy. TB cases were more likely to be HIV-1 seropositive than were their controls, regardless of age (odds ratio = 4.9). Less than 30-year-old female TB patients were less likely to be HIV-1 seropositive than were less than 30-year-old male TB patients (OR, 2.8 vs. 8.1), while the opposite was true for older TB patients (OR, 19.6 vs. 2.6). Though not statistically different, the OR was greater for certain TB cases than for possible TB cases (13.7 vs. 3.5) and for BCG negative cases than for BCG positive cases (16.5 vs. 3.1). Etiologic fractions indicated that HIV infection was responsible for 31% of TB cases among males and 11% of TB cases among females. Overall, leprosy cases and controls had lower HIV seropositivity rates than did their TB counterparts (OR, 1.8 vs. 4.9). Even though none of the ORs for the association between HIV infection and leprosy were statistically significant from unity, the fact that ORs were greater than unity in all (1.4-2.4) but 1 group (5-29 year old females, OR = 0.5) indicated a possible trend towards positive association. Though not statistically different, polar lepromatous type of leprosy and the leprosy category of histopathologically confirmed cases had the highest ORs (3.7 and 1.9, respectively). Multibacillary leprosy cases had a higher OR than did paucibacillary leprosy (2 vs. 1.6).

Ecological upheavals with special reference to desertification and predicting health impact.

This paper begins with an introduction that touches on the ecological upheavals of earthquakes, floods, as well as other upheavals that result from sudden huge crowding of people in one place such as in refugee situations and situations of a famine disaster. The point is made that for sudden emergencies the health impact will very much depend on the nature of traumatic physical damage on the people's bodies and property as well as the capacity with which response is organised for assessment of damage and medical management. A number of texts are mentioned with respect to management in emergencies, including health, feeding and water and the point made that familiarity with these texts provides a starting point in responding to emergencies. These have put together information on how one goes about organising the response to save lives. Also mentioned are the consequences of the approach taken to providing food in these situations; whether it is through distribution of dry ration to be taken home, or whether one is dealing with shelter situations. In this introduction, land degradation/desertification is mentioned as being the largest and possibly the most devastating ecological upheaval. The rest of the paper goes on to address this ecological upheaval of land degradation/desertification. The magnitude of this upheaval is presented. The contribution of overcultivation, overgrazing, deforestation and irrigation to desertification are discussed. The health consequence of this process is then presented and finally, there is a discussion on the challenges that social scientists and health professionals could help to address in order to bring about some appropriate interventions that would contribute to arresting and possibly reversing the desertification process.