Changing Antiretroviral Eligibility Criteria: Impact on the Number and Proportion of Adults Requiring Treatment in Swaziland.

OBJECTIVE: Early initiation of antiretroviral treatment (ART) at CD4 cell count ≥ 500 cells per microliter reduces morbidity and mortality in HIV-infected adults. We determined the proportion of HIV-infected people with high viral load (VL) for whom transmission prevention would be an additional benefit of early treatment. DESIGN: A randomly selected subset of a nationally representative sample of HIV-infected adults in Swaziland in 2012. METHODS: Eight to 12 months after a national survey to determine adult HIV prevalence, 1067 of 5802 individuals identified as HIV-infected were asked to participate in a follow-up cross-sectional assessment. CD4 cell enumeration, VL measurements, and ART status were obtained to estimate the proportion of currently untreated adults and of the entire HIV-infected population with high VL (≥ 1000 copies/mL) whose treatment under a test-and-treat or VL threshold eligibility strategy would reduce HIV transmission. RESULTS: Of the 927 (87% of 1067) participants enrolled, 466 (50%) reported no ART use. Among them, 424 (91%) had VL ≥ 1000 copies per milliliter; of these, 148 (35%) were eligible for ART at the then existing CD4 count threshold of <350 cells per microliter; an additional 107 (25%) were eligible with expanded CD4 criterion of <500 cells per microliter; and 169 (40%) remained ART ineligible. Thus, 36% of the 466 currently untreated and 18% of the total 927 had high VL yet remained ART ineligible under a CD4 criterion of <500 cells per microliter. CONCLUSIONS: A test-and-treat or VL threshold for treatment eligibility is necessary to maximize the HIV transmission prevention benefits of ART.

Estimating influenza disease burden from population-based surveillance data in the United States.

Annual estimates of the influenza disease burden provide information to evaluate programs and allocate resources. We used a multiplier method with routine population-based surveillance data on influenza hospitalization in the United States to correct for under-reporting and estimate the burden of influenza for seasons after the 2009 pandemic. Five sites of the Influenza Hospitalization Surveillance Network (FluSurv-NET) collected data on the frequency and sensitivity of influenza testing during two seasons to estimate under-detection. Population-based rates of influenza-associated hospitalization and Intensive Care Unit admission from 2010-2013 were extrapolated to the U.S. population from FluSurv-NET and corrected for under-detection. Influenza deaths were calculated using a ratio of deaths to hospitalizations. We estimated that influenza-related hospitalizations were under-detected during 2010-11 by a factor of 2.1 (95%CI 1.7-2.9) for age < 18 years, 3.1 (2.4-4.5) for ages 18-64 years, and 5.2 (95%CI 3.8-8.3) for age 65+. Results were similar in 2011-12. Extrapolated estimates for 3 seasons from 2010-2013 included: 114,192-624,435 hospitalizations, 18,491-95,390 ICU admissions, and 4,915-27,174 deaths per year; 54-70% of hospitalizations and 71-85% of deaths occurred among adults aged 65+. Influenza causes a substantial disease burden in the U.S. that varies by age and season. Periodic estimation of multipliers across multiple sites and age groups improves our understanding of influenza detection in sentinel surveillance systems. Adjusting surveillance data using a multiplier method is a relatively simple means to estimate the impact of influenza and the subsequent value of interventions to prevent influenza.

Taxonomy and remote sensing of leaf mass per area (LMA) in humid tropical forests.

Leaf mass per area (LMA) is a trait of central importance to plant physiology and ecosystem function, but LMA patterns in the upper canopies of humid tropical forests have proved elusive due to tall species and high diversity. We collected top-of-canopy leaf samples from 2873 individuals in 57 sites spread across the Neotropics, Australasia, and Caribbean and Pacific Islands to quantify environmental and taxonomic drivers of LMA variation, and to advance remote-sensing measures of LMA. We uncovered strong taxonomic organization of LMA, with species accounting for 70% of the global variance and up to 62% of the variation within a forest stand. Climate, growth habit, and site conditions are secondary contributors (1-23%) to the observed LMA patterns. Intraspecific variation in LMA averages 16%, which is a fraction of the variation observed between species. We then used spectroscopic remote sensing (400-2500 nm) to estimate LMA with an absolute uncertainty of 14-15 g/m2 (r2 = 0.85), or approximately 10% of the global mean. With radiative transfer modeling, we demonstrated the scalability of spectroscopic remote sensing of LMA to the canopy level. Our study indicates that remotely sensed patterns of LMA will be driven by taxonomic variation against a backdrop of environmental controls expressed at site and regional levels.

Large-scale impacts of herbivores on the structural diversity of African savannas.

African savannas are undergoing management intensification, and decision makers are increasingly challenged to balance the needs of large herbivore populations with the maintenance of vegetation and ecosystem diversity. Ensuring the sustainability of Africa's natural protected areas requires information on the efficacy of management decisions at large spatial scales, but often neither experimental treatments nor large-scale responses are available for analysis. Using a new airborne remote sensing system, we mapped the three-dimensional (3-D) structure of vegetation at a spatial resolution of 56 cm throughout 1640 ha of savanna after 6-, 22-, 35-, and 41-year exclusions of herbivores, as well as in unprotected areas, across Kruger National Park in South Africa. Areas in which herbivores were excluded over the short term (6 years) contained 38%-80% less bare ground compared with those that were exposed to mammalian herbivory. In the longer-term (> 22 years), the 3-D structure of woody vegetation differed significantly between protected and accessible landscapes, with up to 11-fold greater woody canopy cover in the areas without herbivores. Our maps revealed 2 scales of ecosystem response to herbivore consumption, one broadly mediated by geologic substrate and the other mediated by hillslope-scale variation in soil nutrient availability and moisture conditions. Our results are the first to quantitatively illustrate the extent to which herbivores can affect the 3-D structural diversity of vegetation across large savanna landscapes.

A contemporary assessment of change in humid tropical forests.

In recent decades the rate and geographic extent of land-use and land-cover change has increased throughout the world's humid tropical forests. The pan-tropical geography of forest change is a challenge to assess, and improved estimates of the human footprint in the tropics are critical to understanding potential changes in biodiversity. We combined recently published and new satellite observations, along with images from Google Earth and a literature review, to estimate the contemporary global extent of deforestation, selective logging, and secondary regrowth in humid tropical forests. Roughly 1.4% of the biome was deforested between 2000 and 2005. As of 2005, about half of the humid tropical forest biome contained 50% or less tree cover. Although not directly comparable to deforestation, geographic estimates of selective logging indicate that at least 20% of the humid tropical forest biome was undergoing some level of timber harvesting between 2000 and 2005. Forest recovery estimates are even less certain, but a compilation of available reports suggests that at least 1.2% of the humid tropical forest biome was in some stage of long-term secondary regrowth in 2000. Nearly 70% of the regrowth reports indicate forest regeneration in hilly, upland, and mountainous environments considered marginal for large-scale agriculture and ranching. Our estimates of the human footprint are conservative because they do not resolve very small-scale deforestation, low-intensity logging, and unreported secondary regrowth, nor do they incorporate other impacts on tropical forest ecosystems, such as fire and hunting. Our results highlight the enormous geographic extent of forest change throughout the humid tropics and the considerable limitations of the science and technology available for such a synthesis.