Process Evaluation of Services for HIV-Infected Post-Partum Women and HIV-Exposed Infants in Primary Health Care Blantyre Malawi

HIV testing among HIV-exposed infants (HEI) in Malawi is below global targets and, affected by low utilisation of health services after birth. We conducted a mixed methods evaluation of the implementation of services for early infant diagnosis (EID) of HIV against national guidelines in Blantyre, Malawi, to inform the development of strategies to improve EID services uptake. We estimated coverage of HEI enrolment in HIV care and HIV testing at 6 weeks through a retrospective data review. We qualitatively explored implementation gaps in EID services through process mapping of 8 mother-infant pairs (MIP); and investigated healthcare workers' (HCW) perspectives on the implementation gaps through group interviews with 16 HCWs. We analysed the quantitative data descriptively and conducted a thematic content analysis of qualitative data. Of 163 HEIs born at the study sites, 39 (24%) were enrolled in an HIV care clinic before post-natal discharge, and 85 (52%) received HIV testing by 6 weeks. The median time for MIP to receive EID services was 4 (1-8) hours. The implementation gaps observed during process mapping included: failure to identify and enrol HEI in HIV care clinic; lack of immunisation, counselling for HEI testing, HIV testing, drug refilling, and family planning; and different appointment dates for mother and infant. HCWs reported delays and gaps influencing optimal service provision including: lack of screening to identify MIP, limited supervision for student HCWs when providing services, inadequate capacity of point of care machines, challenges with integrating services, and role confusion. Use of unique identifiers for MIP and establishing a booking system to schedule appointments to suit point of care machine capacity were primary service improvement recommendations. This study identified suboptimal EID services in Malawi due to process, capacity, and system factors. Context-appropriate interventions accommodating systems thinking are needed to enhance service provision.

Asthma symptoms, spirometry and air pollution exposure in schoolchildren in an informal settlement and an affluent area of Nairobi, Kenya

BACKGROUND

Although 1 billion people live in informal (slum) settlements, the consequences for respiratory health of living in these settlements remain largely unknown. This study investigated whether children living in an informal settlement in Nairobi, Kenya are at increased risk of asthma symptoms.

METHODS

Children attending schools in Mukuru (an informal settlement in Nairobi) and a more affluent area (Buruburu) were compared. Questionnaires quantified respiratory symptoms and environmental exposures; spirometry was performed; personal exposure to particulate matter (PM2.5) was estimated.

RESULTS

2373 children participated, 1277 in Mukuru (median age, IQR 11, 9-13 years, 53% girls), and 1096 in Buruburu (10, 8-12 years, 52% girls). Mukuru schoolchildren were from less affluent homes, had greater exposure to pollution sources and PM2.5. When compared with Buruburu schoolchildren, Mukuru schoolchildren had a greater prevalence of symptoms, 'current wheeze' (9.5% vs 6.4%, p=0.007) and 'trouble breathing' (16.3% vs 12.6%, p=0.01), and these symptoms were more severe and problematic. Diagnosed asthma was more common in Buruburu (2.8% vs 1.2%, p=0.004). Spirometry did not differ between Mukuru and Buruburu. Regardless of community, significant adverse associations were observed with self-reported exposure to 'vapours, dusts, gases, fumes', mosquito coil burning, adult smoker(s) in the home, refuse burning near homes and residential proximity to roads.

CONCLUSION

Children living in informal settlements are more likely to develop wheezing symptoms consistent with asthma that are more severe but less likely to be diagnosed as asthma. Self-reported but not objectively measured air pollution exposure was associated with increased risk of asthma symptoms.

Preterm birth, birth weight, infant weight gain and their associations with childhood asthma and spirometry: a cross-sectional observational study in Nairobi, Kenya

BACKGROUND

In sub-Saharan Africa, the origins of asthma and high prevalence of abnormal lung function remain unclear. In high-income countries (HICs), associations between birth measurements and childhood asthma and lung function highlight the importance of antenatal and early life factors in the aetiology of asthma and abnormal lung function in children. We present here the first study in sub-Saharan Africa to relate birth characteristics to both childhood respiratory symptoms and lung function.

METHODS

Children attending schools in two socioeconomically contrasting but geographically close areas of Nairobi, Kenya, were recruited to a cross-sectional study of childhood asthma and lung function. Questionnaires quantified respiratory symptoms and preterm birth; lung function was measured by spirometry; and parents were invited to bring the child's immunisation booklet containing records of birth weight and serial weights in the first year.

RESULTS

2373 children participated, 52% girls, median age (IQR), 10 years (8-13). Spirometry data were available for 1622. Child immunisation booklets were available for 500 and birth weight and infant weight gain data were available for 323 and 494 children, respectively. In multivariable analyses, preterm birth was associated with the childhood symptoms 'wheeze in the last 12 months'; OR 1.64, (95% CI 1.03 to 2.62), p=0.038; and 'trouble breathing' 3.18 (95% CI 2.27 to 4.45), p<0.001. Birth weight (kg) was associated with forced expiratory volume in 1 s z-score, regression coefficient (β) 0.30 (0.08, 0.52), p=0.008, FVC z-score 0.29 (95% CI 0.08 to 0.51); p=0.008 and restricted spirometry, OR 0.11 (95% CI 0.02 to 0.78), p=0.027.

CONCLUSION

These associations are in keeping with those in HICs and highlight antenatal factors in the aetiology of asthma and lung function abnormalities in sub-Saharan Africa.

"Honestly, this problem has affected me a lot": a qualitative exploration of the lived experiences of people with chronic respiratory disease in Sudan and Tanzania

BACKGROUND

Over 500 million people live with chronic respiratory diseases globally and approximately 4 million of these, mostly from the low- and middle-income countries including sub-Saharan Africa, die prematurely every year. Despite high CRD morbidity and mortality, only very few studies describe CRDs and little is known about the economic, social and psychological dimensions of living with CRDs in sub-Saharan Africa. We aimed to gain an in-depth understanding of the social, livelihood and psychological dimensions of living with CRD to inform management of CRDs in Sudan and Tanzania.

METHOD

We conducted 12 in-depth interviews in 2019 with people with known or suspected CRD and 14 focus group discussions with community members in Gezira state, Sudan and Dodoma region, Tanzania, to share their understanding and experience with CRD. The data was analysed using thematic framework analysis.

RESULTS

People with CRD in both contexts reported experiences under two broad themes: impact on economic wellbeing and impact on social and psychological wellbeing. Capacity to do hard physical work was significantly diminished, resulting in direct and indirect economic impacts for them and their families. Direct costs were incurred while seeking healthcare, including expenditures on transportation to health facility and procurement of diagnostic tests and treatments, whilst loss of working hours and jobs resulted in substantial indirect costs. Enacted and internalised stigma leading to withdrawal and social exclusion was described by participants and resulted partly from association of chronic cough with tuberculosis and HIV/AIDS. In Sudan, asthma was described as having negative impact on marital prospects for young women and non-disclosure related to stigma was a particular issue for young people. Impaired community participation and restrictions on social activity led to psychological stress for both people with CRD and their families.

CONCLUSION

Chronic respiratory diseases have substantial social and economic impacts among people with CRD and their families in Sudan and Tanzania. Stigma is particularly strong and appears to be driven partly by association of chronic cough with infectiousness. Context-appropriate measures to address economic impacts and chronic cough stigma are urgently needed as part of interventions for chronic respiratory diseases in these sub-Saharan African contexts.

'If I am on ART, my new-born baby should be put on treatment immediately': Exploring the acceptability, and appropriateness of Cepheid Xpert HIV-1 Qual assay for early infant diagnosis of HIV in Malawi

Early infant diagnosis of HIV (EID-HIV) is key to reducing paediatric HIV mortality. Traditional approaches for diagnosing HIV in exposed infants are usually unable to optimally contribute to EID. Point-of-care testing such as Cepheid Xpert HIV-1 Qual assay-1 (XPertHIV) are available and could improve EID-HIV in resource constrained and high HIV burden contexts. We investigated the acceptability and perceived appropriateness of XpertHIV for EID-HIV in Mulanje Hospital, Malawi. Qualitative cross-sectional study using semi-structured interviews (SSI) among caregivers and health care workers at Mulanje District Hospital. The qualitative study was nested within a larger diagnostic study that evaluated the performance of XpertHIV using whole-blood-sample in a resource limited and high burden setting. A total of 65 SSIs were conducted among caregivers (n = 60) and health care providers (n = 5). Data were coded using deductive and inductive approaches while thematic approach was used to analyse data. Point-of-care XPertHIV was perceived to be acceptable among caregivers and health care providers. Caregivers' motivations for accepting XPertHIV HIV-testing for their infants included perceived risk of HIV emanating from child's exposure and validation of caregiver's own HIV sero-status. Although concerns about pain of testing and blood sample volumes taken from an infant remained amplified, overall, both caregivers and health care providers felt XpertHIV was appropriate because of its quick result turn-around-time which decreased anxiety and stress, the prospect of early treatment initiation and reduction in hospital visits and related costs. Implementation of XpertHIV has a great potential to improve EID-HIV in Malawi because of its quick turn-around-time and associated benefits including overcoming access-related barriers. Scaled implementation of this diagnostic technology require a robust community engagement strategy for managing caregivers and community myths and misconceptions towards the amount of blood sample collected from infants.

Costing and cost-effectiveness of Cepheid Xpert HIV -1 Qual Assay using whole blood protocol versus PCR by Abbott Systems in Malawi

Background

Timely diagnosis of HIV in infants and children is an urgent priority. In Malawi, 40,000 infants annually are HIV exposed. However, gold standard polymerase-chain-reaction (PCR) based testing requires centralised laboratories, causing turn-around times (TAT) of 2 to 3 months and significant loss to follow-up. If feasible and acceptable, minimising diagnostic delays through HIV Point-of-care-testing (POCT) may be cost-effective. We assessed whether POCT Cepheid Xpert HIV-1 Qual assay whole blood (XpertHIV) was more cost-effective than PCR.

Methods

From July-August 2018, 700 PCR Abbott tests using dried blood spots (DBS) were performed on 680 participants who enrolled on the feasibility, acceptability and performance of the XpertHIV study. Newly identified HIV-positive We conducted a cost-minimisation and cost-effectiveness analysis of XpertHIV against PCR, as the standard of care. A random sample of 200 caregivers from the 680 participants had semi-structured interviews to explore costs from a societal perspective of XpertHIV at Mulanje District Hospital, Malawi. Analysis used TAT as the primary outcome measure. Results were extrapolated from the study period (29 days) to a year (240 working days). Sensitivity analyses characterised individual and joint parameter uncertainty and estimated patient cost per test.

Results

During the study period, XpertHIV was cost-minimising at $42.34 per test compared to $66.66 for PCR. Over a year, XpertHIV remained cost-minimising at $16.12 compared to PCR at $27.06. From the patient perspective (travel, food, lost productivity), the cost per test of XpertHIV was $2.45. XpertHIV had a mean TAT of 7.10 hours compared to 153.15 hours for PCR. Extrapolates accounting for equipment costs, lab consumables and losses to follow up estimated annual savings of $2,193,538.88 if XpertHIV is used nationally, as opposed to PCR.

Conclusions

This preliminary evidence suggests that adopting POCT XpertHIV will save time, allowing HIV-exposed infants to receive prompt care and may improve outcomes. The Malawi government will pay less due to XpertHIV's cost savings and associated benefits.

An exploration of practices affecting research integrity in global health partnerships

Background

Research integrity is central to good research practice yet it is under-researched in global health.

Aim

To identify and explore factors which promote or constrain adherence to research integrity principles in global health research partnerships, specifically at a UK higher education institution (HEI) and its low-to-middle-income country (LMIC) partners.

Methods

Qualitative study using key informant interviews among researchers at a HEI and a number of its LMIC partners exploring their understanding of the principles of research integrity and experience of its implementation in relation to research.

Results

Thirteen interviews, five from HEI and eight from partner organisations, were conducted. Analysis found that understanding of research integrity focused on issues relating to rigour and did not include ‘care and respect’. Barriers to research integrity included, supra institutional factors such as funding flows, inequitable power relations, the competitive culture of the global health ecosystem and institutional psychosocial safety. Most respondents had direct or indirect knowledge of incidences of research misconduct.

Conclusion

Improved recognition of the importance of care and respect is key to improving the integrity of research conduct within global health partnerships.

What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries

OBJECTIVES

Chronic respiratory diseases (CRD) are among the top four non-communicable diseases globally. They are associated with poor health and approximately 4 million deaths every year. The rising burden of CRD in low/middle-income countries will strain already weak health systems. This study aimed to explore the perspectives of healthcare workers and other health policy stakeholders on the barriers to effective diagnosis and management of CRD in Kenya, Malawi, Sudan, Tanzania and Uganda.

STUDY DESIGN

Qualitative descriptive study.

SETTINGS

Primary, secondary and tertiary health facilities, government agencies and civil society organisations in five sub-Saharan African countries.

PARTICIPANTS

We purposively selected 60 national and district-level policy stakeholders, and 49 healthcare workers, based on their roles in policy decision-making or health provision, and conducted key informant interviews and in-depth interviews, respectively, between 2018 and 2019. Data were analysed through framework approach.

RESULTS

We identified intersecting vicious cycles of neglect of CRD at strategic policy and healthcare facility levels. Lack of reliable data on burden of disease, due to weak information systems and diagnostic capacity, negatively affected inclusion in policy; this, in turn, was reflected by low budgetary allocations for diagnostic equipment, training and medicines. At the healthcare facility level, inadequate budgetary allocations constrained diagnostic capacity, quality of service delivery and collection of appropriate data, compounding the lack of routine data on burden of disease.

CONCLUSION

Health systems in the five countries are ill-equipped to respond to CRD, an issue that has been brought into sharp focus as countries plan for post-COVID-19 lung diseases. CRD are underdiagnosed, under-reported and underfunded, leading to a vicious cycle of invisibility and neglect. Appropriate diagnosis and management require health systems strengthening, particularly at the primary healthcare level.

Household food insecurity, maternal nutrition, environmental risks and infants' health outcomes: protocol of the IMPALA birth cohort study in Uganda

INTRODUCTION

In low- and middle-income countries (LMICs), food insecurity and undernutrition disproportionately affect women of reproductive age, infants and young children. The disease burden from undernutrition in these vulnerable sections of societies remains a major concern in LMICs. Biomass fuel use for cooking is also common in LMICs. Empirical evidence from high-income countries indicates that early life nutritional and environmental exposures and their effect on infant lung function are important; however, data from sub-Saharan Africa are scarce.

AIM

To estimate the association between infant lung function and household food insecurity, energy poverty and maternal dietary diversity.

METHODS AND ANALYSIS

Pregnant women will be recruited in an existing Health and Demographic Surveillance Site in South-West Uganda. Household food insecurity, sources and uses of energy, economic measures and maternal dietary diversity will be collected during pregnancy and after birth. Primary health outcomes will be infant lung function determined by tidal breath flow and volume analysis at 6-10 weeks of age. Infant weight and length will also be collected.A household Food Consumption Score and Minimum Dietary Diversity for Women (MDD-W) indicator will be constructed. The involved cost of dietary diversity will be estimated based on MDD-W. The association between household level and mothers' food access indicators and infant lung function will be evaluated using regression models. The Multidimensional Energy Poverty Index (MEPI) will be estimated and used as an indicator of households' environmental exposures. The association between household MEPI and infant lung function will be assessed using econometric models.

ETHICS AND DISSEMINATION

Ethical approvals have been obtained from Liverpool School of Tropical Medicine (18-059), the Uganda Virus Research Institute Ethics Committee (097/2018) and Uganda National Council for Science and Technology (SS 4846). Study results will be shared with participants, policy-makers, other stakeholders and published in peer-reviewed journals.

Adolescent mental health research in Tanzania: a study protocol for a priority setting exercise and the development of an interinstitutional capacity strengthening programme

INTRODUCTION

Poor adolescent mental health is a barrier to achieving several sustainable development goals in Tanzania, where adolescent mental health infrastructure is weak. This is compounded by a lack of community and policy maker awareness or understanding of its burden, causes and solutions. Research addressing these knowledge gaps is urgently needed. However, capacity for adolescent mental health research in Tanzania remains limited. The existence of a National Institute for Medical Research (NIMR), with a nationwide mandate for research conduct and oversight, presents an opportunity to catalyse activity in this neglected area. Rigorous research priority setting, which includes key stakeholders, can promote efficient use of limited resources and improve both quality and uptake of research by ensuring that it meets the needs of target populations and policy makers. We present a protocol for such a research priority setting study and how it informs the design of an interinstitutional adolescent mental health research capacity strengthening strategy in Tanzania.

METHODS AND ANALYSIS

From May 2021, this 6 month mixed-methods study will adapt and merge the James Lind Alliance approach and validated capacity strengthening methodologies to identify priorities for research and research capacity strengthening in adolescent mental health in Tanzania. Specifically, it will use online questionnaires, face-to-face interviews, focus groups, scoping reviews and a consensus meeting to consult expert and adolescent stakeholders. Key evidence-informed priorities will be collaboratively ranked and documented and an integrated strategy to address capacity gaps will be designed to align with the nationwide infrastructure and overall strategy of NIMR.

ETHICS AND DISSEMINATION

National and institutional review board approvals were sought and granted from the National Health Research Ethics Committee of the NIMR Medical Research Coordinating Committee (Tanzania) and the Liverpool School of Tropical Medicine (United Kingdom). Results will be disseminated through a national workshop involving all stakeholders, through ongoing collaborations and published commentaries, reviews, policy briefs, webinars and social media.

Changing lung function and associated health-related quality-of-life: A five-year cohort study of Malawian adults

BACKGROUND

In Sub-Saharan Africa cross-sectional studies report a high prevalence of abnormal lung function indicative of chronic respiratory disease. The natural history and health impact of this abnormal lung function in low-and middle-income countries is largely unknown.

METHODS

A cohort of 1481 adults representative of rural Chikwawa in Malawi were recruited in 2014 and followed-up in 2019. Respiratory symptoms and health-related quality of life (HRQoL) were quantified. Lung function was measured by spirometry.

FINDINGS

1232 (83%) adults participated; spirometry was available for 1082 (73%). Mean (SD) age 49.5 (17.0) years, 278(23%) had ever smoked, and 724 (59%) were women. Forced expiratory volume in one second (FEV₁) declined by 53.4 ml/year (95% CI: 49.0, 57.8) and forced vital capacity (FVC) by 45.2 ml/year (95% CI: 39.2, 50.5) . Chronic airflow obstruction increased from 9.5% (7.6, 11.6%) in 2014 to 17.5% (15.3, 19.9%) in 2019. There was no change in diagnosed asthma or in spirometry consistent with asthma or restriction. Rate of FEV₁ decline was not associated with diagnosed Chronic obstructive pulmonary disease (COPD), asthma, or spirometry consistent with asthma, COPD, or restriction. HRQoL was adversely associated with respiratory symptoms (dyspnoea, wheeze, cough), previous tuberculosis, declining FEV₁ and spirometry consistent with asthma or restriction. These differences exceeded the minimally important difference.

INTERPRETATION

In this cohort, the increasing prevalence of COPD is associated with the high rate of FEV₁ decline and lung function deficits present before recruitment. Respiratory symptoms and sub-optimal lung function are independently associated with reduced HRQoL.

Consensus statement on measures to promote equitable authorship in the publication of research from international partnerships

Despite the acknowledged injustice and widespread existence of parachute research studies conducted in low‐ or middle‐income countries by researchers from institutions in high‐income countries, there is currently no pragmatic guidance for how academic journals should evaluate manuscript submissions and challenge this practice. We assembled a multidisciplinary group of editors and researchers with expertise in international health research to develop this consensus statement. We reviewed relevant existing literature and held three workshops to present research data and holistically discuss the concept of equitable authorship and the role of academic journals in the context of international health research partnerships. We subsequently developed statements to guide prospective authors and journal editors as to how they should address this issue. We recommend that for manuscripts that report research conducted in low‐ or middle‐income countries by collaborations including partners from one or more high‐income countries, authors should submit accompanying structured reflexivity statements. We provide specific questions that these statements should address and suggest that journals should transparently publish reflexivity statements with accepted manuscripts. We also provide guidance to journal editors about how they should assess the structured statements when making decisions on whether to accept or reject submitted manuscripts. We urge journals across disciplines to adopt these recommendations to accelerate the changes needed to halt the practice of parachute research.

Management of chronic lung diseases in Sudan and Tanzania: how ready are the country health systems?

Background

Chronic lung diseases (CLDs), responsible for 4 million deaths globally every year, are increasingly important in low- and middle-income countries where most of the global mortality due to CLDs currently occurs. As existing health systems in resource-poor contexts, especially sub-Saharan Africa (SSA), are not generally oriented to provide quality care for chronic diseases, a first step in re-imagining them is to critically consider readiness for service delivery across all aspects of the existing system.

Methods

We conducted a mixed-methods assessment of CLD service readiness in 18 purposively selected health facilities in two differing SSA health system contexts, Tanzania and Sudan. We used the World Health Organization’s (WHO) Service Availability and Readiness Assessment checklist, qualitative interviews of key health system stakeholders, health facility registers review and assessed clinicians’ capacity to manage CLD using patient vignettes. CLD service readiness was scored as a composite of availability of service-specific tracer items from the WHO service availability checklist in three domains: staff training and guidelines, diagnostics and equipment, and basic medicines. Qualitative data were analysed using the same domains.

Results

One health facility in Tanzania and five in Sudan, attained a CLD readiness score of ≥ 50 % for CLD care. Scores ranged from 14.9 % in a dispensary to 53.3 % in a health center in Tanzania, and from 36.4 to 86.4 % in Sudan. The least available tracer items across both countries were trained human resources and guidelines, and peak flow meters. Only two facilities had COPD guidelines. Patient vignette analysis revealed significant gaps in clinicians’ capacity to manage CLD. Key informants identified low prioritization as key barrier to CLD care.

Conclusions

Gaps in service availability and readiness for CLD care in Tanzania and Sudan threaten attainment of universal health coverage in these settings. Detailed assessments by health systems researchers in discussion with stakeholders at all levels of the health system can identify critical blockages to reimagining CLD service provision with people-centered, integrated approaches at its heart.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06759-9.

'If not TB, what could it be?' Chest X-ray findings from the 2016 Kenya Tuberculosis Prevalence Survey

BACKGROUND

The prevalence of diseases other than TB detected during chest X-ray (CXR) screening is unknown in sub-Saharan Africa. This represents a missed opportunity for identification and treatment of potentially significant disease. Our aim was to describe and quantify non-TB abnormalities identified by TB-focused CXR screening during the 2016 Kenya National TB Prevalence Survey.

METHODS

We reviewed a random sample of 1140 adult (≥15 years) CXRs classified as 'abnormal, suggestive of TB' or 'abnormal other' during field interpretation from the TB prevalence survey. Each image was read (blinded to field classification and study radiologist read) by two expert radiologists, with images classified into one of four major anatomical categories and primary radiological findings. A third reader resolved discrepancies. Prevalence and 95% CIs of abnormalities diagnosis were estimated.

FINDINGS

Cardiomegaly was the most common non-TB abnormality at 259 out of 1123 (23.1%, 95% CI 20.6% to 25.6%), while cardiomegaly with features of cardiac failure occurred in 17 out of 1123 (1.5%, 95% CI 0.9% to 2.4%). We also identified chronic pulmonary pathology including suspected COPD in 3.2% (95% CI 2.3% to 4.4%) and non-specific patterns in 4.6% (95% CI 3.5% to 6.0%). Prevalence of active-TB and severe post-TB lung changes was 3.6% (95% CI 2.6% to 4.8%) and 1.4% (95% CI 0.8% to 2.3%), respectively.

INTERPRETATION

Based on radiological findings, we identified a wide variety of non-TB abnormalities during population-based TB screening. TB prevalence surveys and active case finding activities using mass CXR offer an opportunity to integrate disease screening efforts.

FUNDING

National Institute for Health Research (IMPALA-grant reference 16/136/35).

Interventions for adolescent alcohol consumption in Africa: protocol for a scoping review including an overview of reviews

BACKGROUND

Harmful alcohol use is a leading risk to the health of populations worldwide. Within Africa, where most consumers are adolescents, alcohol use represents a key public health challenge. Interventions to prevent or substantially delay alcohol uptake and decrease alcohol consumption in adolescence could significantly decrease morbidity and mortality, through both immediate effects and future improved adult outcomes. In Africa, these interventions are urgently needed; however, key data necessary to develop them are lacking as most evidence to date relates to high-income countries. The purpose of this review is to examine and map the range of interventions in use and create an evidence base for future research in this area.

METHODS

In the first instance, we will conduct a review of systematic reviews relevant to global adolescent alcohol interventions. We will search the Cochrane Database of Systematic Reviews, MEDLINE (Ovid), CINAHL, Web of Science, Global Health and PubMed using a broad search. In the second instance we will conduct a scoping review by drawing on the methodological framework proposed by Arksey and O'Malley. We will search for all study designs and grey literature using the Cochrane Database of Systematic Reviews, MEDLINE (Ovid), CINAHL, Web of Science and Global Health, Google searches and searches in websites of relevant professional bodies and charities. An iterative approach to charting, collating, summarising and reporting the data will be taken, with the development of charting forms and the final presentation of results led by the extracted data. In both instances, the inclusion and exclusion criteria have been pre-defined, and two reviewers will independently screen abstracts and full text to determine eligibility of articles.

DISCUSSION

It is anticipated that our findings will map intervention strategies aiming to reduce adolescent alcohol consumption in Africa. These findings are likely to be useful in informing future research, policy and public health strategies. Findings will be disseminated widely through peer-reviewed publication and in various media, for example, conferences, congresses or symposia.

PROTOCOL REGISTRATION

This protocol was submitted to the Open Science Framework on May 03, 2021. www.osf.io/qnvba.

Study protocol: analysis of regional lung health policies and stakeholders in Africa

Background

Lung health is a critical area for research in sub-Saharan Africa. The International Multidisciplinary Programme to Address Lung Health and TB in Africa (IMPALA) is a collaborative programme that seeks to fill evidence gaps to address high-burden lung health issues in Africa. In order to generate demand for and facilitate use of IMPALA research by policy-makers and other decision-makers at the regional level, an analysis of regional lung health policies and stakeholders will be undertaken to inform a programmatic strategy for policy engagement.

Methods and analysis

This analysis will be conducted in three phases. The first phase will be a rapid desk review of regional lung health policies and stakeholders that seeks to understand the regional lung health policy landscape, which issues are prioritised in existing regional policy, key regional actors, and opportunities for engagement with key stakeholders. The second phase will be a rapid desk review of the scientific literature, expanding on the work in the first phase by looking at the external factors that influence regional lung health policy, the ways in which regional bodies influence policy at the national level, investments in lung health, structures for discussion and advocacy, and the role of evidence at the regional level. The third phase will involve a survey of IMPALA partners and researchers as well as interviews with key regional stakeholders to further shed light on regional policies, including policy priorities and gaps, policy implementation status and challenges, stakeholders, and platforms for engagement and promoting uptake of evidence.

Discussion

Health policy analysis provides insights into power dynamics and the political nature of the prioritisation of health issues, which are often overlooked. In order to ensure the uptake of new knowledge and evidence generated by IMPALA, it is important to consider these complex factors.

Cohort profile: The Chikwawa lung health cohort; a population-based observational non-communicable respiratory disease study of adults in Malawi

PURPOSE

The aim of this article is to provide a detailed description of the Chikwawa lung health cohort which was established in rural Malawi to prospectively determine the prevalence and causes of lung disease amongst the general population of adults living in a low-income rural setting in Sub-Saharan Africa.

PARTICIPANTS

A total of 1481 participants were randomly identified and recruited in 2014 for the baseline study. We collected data on demographic, socio-economic status, respiratory symptoms and potentially relevant exposures such as smoking, household fuels, environmental exposures, occupational history/exposures, dietary intake, healthcare utilization, cost (medication, outpatient visits and inpatient admissions) and productivity losses. Spirometry was performed to assess lung function. At baseline, 56.9% of the participants were female, mean age was 43.8 (SD:17.8) and mean body mass index (BMI) was 21.6 Kg/m2 (SD: 3.46).

FINDINGS TO DATE

The cohort has reported the prevalence of chronic respiratory symptoms (13.6%, 95% confidence interval [CI], 11.9-15.4), spirometric obstruction (8.7%, 95% CI, 7.0-10.7), and spirometric restriction (34.8%, 95% CI, 31.7-38.0). Additionally, an annual decline in forced expiratory volume in one second [FEV1] of 30.9mL/year (95% CI: 21.6 to 40.1) and forced vital capacity [FVC] by 38.3 mL/year (95% CI: 28.5 to 48.1) has been reported.

FUTURE PLANS

The ongoing phases of follow-up will determine the annual rate of decline in lung function as measured through spirometry and the development of airflow obstruction and restriction, and relate these to morbidity, mortality and economic cost of airflow obstruction and restriction. Population-based mathematical models will be developed driven by the empirical data from the cohort and national population data for Malawi to assess the effects of interventions and programmes to address the lung burden in Malawi. The present follow-up study started in 2019.

"I wanted evidence that my status had changed, so that is why I tested": experiences with HIV self-testing among female sex workers in Malawi

HIV testing among female sex workers (FSWs) is an established global health priority. HIV self-testing (HIVST) seems to have the potential to address issues of confidentiality, privacy and convenience among this key population. HIVST, however, may result in unintended consequences as its implementation unfolds in a complex sex work context characterised by unequal power relations, stigma and high HIV prevalence. We aimed to explore the experiences of FSWs with HIVST in the context of retesting and antiretroviral usage in Blantyre, Malawi. We used an ethnographic approach to understand meanings and views around HIVST and retesting. We found high levels of retesting, especially among those on antiretroviral, two of which received "false-negative" results. We identified three broad narratives: (1) retesting in response to experiences in the sex work context, (2) retesting driven by the desire to self-monitor HIV-negative status, and (3) retesting in the hope of sero-reversion. The FSWs' experiences indicate that the implementation of HIVST in this context is complex with potential for unintended harms such as coercive testing. HIVST programmes must include clear and appropriate messaging to reduce retesting while on ART and implement strategies to address FSW concerns and anxieties about the accuracy of their HIV-positive test results.

"He is suitable for her, of course he is our relative": a qualitative exploration of the drivers and implications of child marriage in Gezira State, Sudan

Introduction

Child marriage is a fundamental development challenge for women and girls, with significant negative health and social outcomes. Sudan has a high rate of child marriage, with 34% of women aged 20–24 married before their 18th birthday. Since limited preventive interventions exist, we aimed to inform the evidence base to strengthen strategic action, using mixed qualitative methods to enhance study credibility. This study is the first to conduct a rigorous qualitative examination of the drivers of child marriage from the perspective of key stakeholders involved in marriage decision making within Sudan, and makes a significant contribution towards global knowledge by developing an evidence-based conceptual framework.

Methods

Initially, we completed 14 focus group discussions separated by gender with mothers, fathers, and girls married as adolescents, and 23 key informant interviews. We then used a critical incident case study approach to explore 11 ‘cases’ of child marriage (46 interviews).

Results

Findings indicate that gendered social norms and values, underpinned by religious beliefs and educational accessibility, interconnect to shape marriage decisions. In this context, many child marriages are triggered by an intrakinship proposal and further enabled by the relative lack of autonomy and influence of girls and women in marriage decision-making processes.

Discussion

Interconnected drivers demand context-specific holistic and multisectoral approaches, which should include simultaneous strategies to expand access to education, health services and livelihood opportunities, and evoke legal change, and participatory social and attitudinal processes that include the engagement of religious leaders and men.

Assessing ethical climates in critical care and their impact on patient outcomes

Intensive care units with a "good" ethical environment are more likely to identify perceived excessive patient care. Patients with perceived excessive care were more likely to die and time to death was shorter in units with a "good" ethical environment. http://ow.ly/vnFP30neAZN.

A 'mystery client' evaluation of adolescent sexual and reproductive health services in health facilities from two regions in Tanzania

Unwelcoming behaviours and judgemental attitudes have long been recognised as a barrier to young people's access to reproductive health services. Over the last decade youth friendly reproductive health services have been promoted and implemented world-wide. However, long term evidence of the impact of these programmes is lacking. We report the results of a large mystery client evaluation of adolescent sexual and reproductive health services in Tanzania, a country that has had a long established youth friendly policy. Forty-eight visits made to thirty-three health facilities were conducted by twelve young people (six in each region) trained to perform three different scripted scenarios (i.e., condom request, information on sexually transmitted infections and family planning). The study revealed barriers in relation to poor signage and reception for services. In addition health workers demonstrated paternalistic attitudes as well as lack of knowledge about adolescent sexual and reproductive health services. In some cases, health workers discouraged young people from using services such as condoms and family planning methods. Lack of confidentiality and privacy were also noted to be common challenges for the young people involved. Intervention strategies that focus on changing health workers' mind-set in relation to adolescent sexual and reproductive health are crucial for ensuring quality provision of sexual and reproductive health services to young people. The study identified the importance of reception or signs at the health units, as this can facilitate young people's efforts in seeking sexual and reproductive health services. Likewise, improvement of health workers knowledge of existing policy and practice on sexual and reproductive health services and youth friendly services is much needed.

"There are bugs in condoms": Tanzanian close-to-community providers' ability to offer effective adolescent reproductive health services

Objectives

Young people in Tanzania are known to access reproductive health services from a range of close-to-community providers outside formal health settings such as drug stores, village AIDS committees, traditional healers and traditional birth attendants (TBAs). However, questions remain about the quality of services such agents provide. This study investigated their capacity to provide adolescent reproductive health (ARH) services and explored their readiness and ability to integrate with the mainstream health sector through community referral interventions.

Methods

Thirty-five focus group discussions exploring close-to-community provider experiences and attitudes to ARH service provision were carried out in two districts in Northern Tanzania. Discussions were conducted in Kiswahili, digitally recorded, verbatim-transcribed, translated and back-translated from Swahili to English. A thematic analysis was conducted using NVivo 9.

Results

The major close-to-community cadres providing reproductive health services were drug stores, traditional healers, TBAs and village health workers. They reported being the first port of call for adolescents seeking reproductive health services, but their knowledge of ARH needs was poor. They had negative attitudes to, and lacked the necessary resources for, the provision of such services for adolescents. Some were particularly unwilling to provide condom services and were prejudiced against adolescents using them. There was poor integration between the close-to-community providers and the formal health sector, further limiting their ability to provide adequate services.

Conclusions

Although close-to-community providers are considered a key resource in the community, most have limited capacity to provide ARH services. Without capacity-building investments such as training and cooperation with the mainstream health sector, their contribution to positive reproductive health outcomes is limited, or could indeed lead to adverse outcomes.

Scaling up a school-based sexual and reproductive health intervention in rural Tanzania: a process evaluation describing the implementation realities for the teachers

Little is known about the nature and mechanisms of factors that facilitate or inhibit the scale-up and subsequent implementation of school-based adolescent sexual and reproductive health (ASRH) interventions. We present process evaluation findings examining the factors that affected the 10-fold scale-up of such an intervention, focussing on teachers' attitudes and experiences. Qualitative interviews and focus group discussions with teachers, head teachers, ward education coordinators and school committees from eight schools took place before, during and after intervention implementation. The results were triangulated with observations of training sessions and training questionnaires. The training was well implemented and led to some key improvements in teachers' ASRH knowledge, attitudes and perceived self-efficacy, with substantial improvements in knowledge about reproductive biology and attitudes towards confidentiality. The trained teachers were more likely to consider ASRH a priority in schools and less likely to link teaching ASRH to the early initiation of sex than non-trained teachers. Facilitating factors included teacher enjoyment, their recognition of training benefits, the participatory teaching techniques, support from local government as well as the structured nature of the intervention. Challenges included differential participation by male and female teachers, limited availability of materials and high turnover of trained teachers.

A process evaluation of the scale up of a youth-friendly health services initiative in northern Tanzania

Background

While there are a number of examples of successful small-scale, youth-friendly services interventions aimed at improving reproductive health service provision for young people, these projects are often short term and have low coverage. In order to have a significant, long-term impact, these initiatives must be implemented over a sustained period and on a large scale. We conducted a process evaluation of the 10-fold scale up of an evaluated youth-friendly services intervention in Mwanza Region, Tanzania, in order to identify key facilitating and inhibitory factors from both user and provider perspectives.

Methods

The intervention was scaled up in two training rounds lasting six and 10 months. This process was evaluated through the triangulation of multiple methods: (i) a simulated patient study; (ii) focus group discussions and semi-structured interviews with health workers and trainers; (iii) training observations; and (iv) pre- and post-training questionnaires. These methods were used to compare pre- and post-intervention groups and assess differences between the two training rounds.

Results

Between 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time, trainers' confidence and ability to lead sessions improved. The district-led training significantly improved knowledge relating to HIV/AIDS and puberty (RR ranged from 1.06 to 2.0), attitudes towards condoms, confidentiality and young people's right to treatment (RR range: 1.23-1.36). Intervention health units scored higher in the family planning and condom request simulated patient scenarios, but lower in the sexually transmitted infection scenario than the control health units. The scale up faced challenges in the selection and retention of trained health workers and was limited by various contextual factors and structural constraints.

Conclusions

Youth-friendly services interventions can remain well delivered, even after expansion through existing systems. The scaling-up process did affect some aspects of intervention quality, and our research supports others in emphasizing the need to train more staff (both clinical and non-clinical) per facility in order to ensure youth-friendly services delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale up.

Partnering to proceed: scaling up adolescent sexual reproductive health programmes in Tanzania. Operational research into the factors that influenced local government uptake and implementation

Background

Little is known about how to implement promising small-scale projects to reduce reproductive ill health and HIV vulnerability in young people on a large scale. This evaluation documents and explains how a partnership between a non-governmental organization (NGO) and local government authorities (LGAs) influenced the LGA-led scale-up of an innovative NGO programme in the wider context of a new national multisectoral AIDS strategy.

Methods

Four rounds of semi-structured interviews with 82 key informants, 8 group discussions with 49 district trainers and supervisors (DTS), 8 participatory workshops involving 52 DTS, and participant observations of 80% of LGA-led and 100% of NGO-led meetings were conducted, to ascertain views on project components, flow of communication and decision-making and amount of time DTS utilized undertaking project activities.

Results

Despite a successful ten-fold scale-up of intervention activities in three years, full integration into LGA systems did not materialize. LGAs contributed significant human resources but limited finances; the NGO retained control over finances and decision-making and LGAs largely continued to view activities as NGO driven. Embedding of technical assistants (TAs) in the LGAs contributed to capacity building among district implementers, but may paradoxically have hindered project integration, because TAs were unable to effectively transition from an implementing to a facilitating role. Operation of NGO administration and financial mechanisms also hindered integration into district systems.

Conclusions

Sustainable intervention scale-up requires operational, financial and psychological integration into local government mechanisms. This must include substantial time for district systems to try out implementation with only minimal NGO support and modest output targets. It must therefore go beyond the typical three- to four-year project cycles. Scale-up of NGO pilot projects of this nature also need NGOs to be flexible enough to adapt to local government planning cycles and ongoing evaluation is needed to ensure strategies employed to do so really do achieve full intervention integration.

Dusty discos and dangerous desires: community perceptions of adolescent sexual and reproductive health risks and vulnerability and the potential role of parents in rural Mwanza, Tanzania

This paper presents villagers' assessments of young people's sexual and reproductive health vulnerability and of community-based interventions that may reduce both vulnerability and risk in rural Mwanza, Tanzania. The primary methods used were 28 group discussions and 18 in-depth interviews with representatives of various social groups in four villages. The majority of participants attributed young people's sexual and reproductive health risks to a combination of modernisation (and its impact on family and community life), socioeconomic conditions, social norms in rural/lakeshore communities and the difficulties parents and other adults face in raising adolescents in contemporary Tanzania. Community life has limited opportunities for positive development but contains many risky situations. Young and old agreed that parents have a strong influence on young people's health but are failing in their parental responsibility. Parents acknowledged the multiple influences on sexual risk behaviour. They expressed a need for knowledge and skills related to parenting so that they can address these influences both through family- and community-based strategies.

The effectiveness of sex education and HIV education interventions in schools in developing countries

OBJECTIVE

To review the impact of sex education and HIV education interventions in schools in developing countries on both risk behaviours for HIV and the psychosocial factors that affect them.

METHODS

We conducted a systematic review. Searches identified studies in developing countries that evaluated interventions using either experimental or strong quasi-experimental designs and measured the impact of the intervention on sexual risk behaviours. Each study was summarized and coded, and the results were tabulated by type of intervention.

FINDINGS

Twenty-two intervention evaluations met the inclusion criteria: 17 were based on a curriculum and 5 were not, and 19 were implemented primarily by adults and 3 by peers. These 22 interventions significantly improved 21 out of 55 sexual behaviours measured. Only one of the interventions (a non-curriculum-based peer-led intervention) increased any measure of reported sexual intercourse; 7 interventions delayed the reported onset of sex; 3 reduced the reported number of sexual partners; and 1 reduced the reported frequency of sexual activity. Furthermore, 16 of the 22 interventions significantly delayed sex, reduced the frequency of sex, decreased the number of sexual partners, increased the use of condoms or contraceptives or reduced the incidence of unprotected sex. Of the 17 curriculum-based interventions, 13 had most of the characteristics believed to be important according to research in developed and developing countries and were taught by adults. Of these 13 studies, 11 significantly improved one or more reported sexual behaviours, and the remaining 2 showed non-significant improvements in reported sexual behaviour. Among these 13 studies, interventions led by both teachers and other adults had strong evidence of positive impact on reported behaviour. Of the 5 non-curriculum-based interventions, 2 of 4 adult-led and the 1 peer-led intervention improved one or more sexual behaviours.

CONCLUSIONS

A large majority of school-based sex education and HIV education interventions reduced reported risky sexual behaviours in developing countries. The curriculum-based interventions having the characteristics of effective interventions in the developed and developing world should be implemented more widely. All types of school-based interventions need additional rigorous evaluation, and more rigorous evaluations of peer-led and non-curriculum-based interventions are necessary before they can be widely recommended.

Risk factors influencing HIV infection incidence in a rural African population: a nested case-control study

BACKGROUND

Risk factors influencing the incidence of human immunodeficiency virus (HIV) infection were investigated in a case-control study nested within a community-randomized trial of treatment of syndromic sexually transmitted infections (STIs) in rural Tanzania.

METHODS

Case patients were persons who became HIV positive, and control subjects were randomly selected from among persons who remained HIV negative. For each sex, we obtained adjusted odds ratios (ORs) and population-attributable fractions (PAFs) for biomedical and behavioral factors.

RESULTS

We analyzed 92 case patients and 903 control subjects. In both sexes, the incidence of HIV infection was significantly higher in subjects with an HIV-positive spouse than in those with HIV-negative spouse (men: OR, 25.1; women: OR, 34.0). The incidence of HIV infection was significantly higher in those who became positive for herpes simplex virus type 2 (HSV-2) (men: OR, 5.60; women: OR, 4.76) and those who were HSV-2-positive at baseline (men: OR, 3.66; women: OR, 2.88) than in subjects who were HSV-2 negative. In women, living elsewhere (OR, 3.22) and never having given birth (OR, 4.27) were significant risk factors. After adjustment, the incidence of HIV infection was not significantly associated with a history of injections or STIs in either sex.

CONCLUSION

HSV-2 infection was the most important risk factor for HIV infection, which highlights the need for HSV-2 interventions in HIV infection control, and there were particularly strong associations with recent HSV-2 seroconversion. The PAF associated with having an HIV-positive spouse was low, but this is likely to increase during the epidemic.

Geographical variations in the prevalence of HIV and other sexually transmitted infections in rural Tanzania

The prevalence and incidence of HIV and other sexually transmitted infections (STIs) were recorded in two lake-island and eight rural mainland communities in Mwanza, Tanzania. The prevalence and incidence of HIV and syphilis were lower on the islands, but this pattern was not seen for herpes simplex virus type-2, gonorrhoea, chlamydia, male urethritis or antenatal prevalences of Trichomonas vaginalis. Island men reported fewer sexual partners than mainland men but no differences were found for women. Island men were more likely to be circumcised, island women less mobile and there were differences in marriage patterns. Possible explanations for the differences in HIV and syphilis include: slower introduction of HIV into the islands because of geographical isolation, more core-group sexual contact on the mainland, higher prevalence of male circumcision on the islands and differences in marital status. Differences in transmission dynamics may lead to geographical patterns that vary between STIs.

Herpes simplex virus type 2 infection increases HIV incidence: a prospective study in rural Tanzania

OBJECTIVES

To quantify the association between prevalent or incident Herpes simplex virus type-2 (HSV2) infection and the incidence of HIV seroconversion among adults in the general population in rural Tanzania.

STUDY POPULATION

Adults aged 15-54 years sampled randomly from 12 rural communities in Mwanza Region, Tanzania and recruited to a randomized trial of improved treatment of sexually transmitted diseases.

STUDY DESIGN

Unmatched case-control study nested within trial cohort.

METHODS

Participants included 127 cases who seroconverted to HIV during the 2-year follow-up period and 636 randomly selected controls who remained HIV negative. Subjects were tested for HSV2 serology at baseline and follow-up, and associations between HIV and HSV2 were analysed with adjustment for socio-demographic and behavioural factors.

RESULTS

After adjusting for confounding factors, a strong association between HSV2 infection and HIV seroconversion was observed in men (test for trend: P < 0.001), with adjusted odds ratios (OR) of 6.12 [95% confidence interval (CI), 2.52-14.9] in those HSV2 positive at baseline, and 16.8 (95% CI, 6.06-46.3) in those acquiring HSV2 infection during follow-up. A weaker association was observed in women (tests for trend: P = 0.14), with adjusted OR of 1.32 (95% CI, 0.62-2.78) and 2.36 (95% CI, 0.81-6.84), respectively. Population attributable fractions of incident HIV infection due to HSV2 were estimated as 74% in men and 22% in women.

CONCLUSIONS

The results suggest that HSV2 plays an important role in the transmission of HIV infection in this population. There is an urgent need to identify effective HSV2 control measures in order to reduce HIV incidence in Africa.

Antibody to herpes simplex virus type 2 as a marker of sexual risk behavior in rural Tanzania

A serosurvey was conducted in a random sample of 259 women and 231 men in 12 rural communities in Mwanza Region, Tanzania, using a type-specific ELISA for Herpes simplex virus type 2 (HSV-2) infection. Seroprevalence rose steeply with age to approximately 75% in women >=25 years old and 60% in men >=30. After adjusting for age and residence, HSV-2 prevalence was higher in women who were married, in a polygamous marriage, Treponema pallidum hemagglutination assay (TPHA)-positive, had more lifetime sex partners, or who had not traveled. Prevalence was higher in men who were married, had lived elsewhere, had more lifetime partners, had used condoms, or were TPHA-positive. HSV-2 infection was significantly associated with recent history of genital ulcer. The association between HSV-2 infection and lifetime sex partners was strongest in those <25 years old in both sexes. This association supports the use of HSV-2 serology as a marker of risk behavior in this population, particularly among young people.

Risk factors for tuberculosis in patients with AIDS in London: a case-control study

OBJECTIVE

To identify risk factors for the acquired immune-deficiency syndrome (AIDS) associated with tuberculosis, in patients with AIDS attending 11 of the largest human immunodeficiency virus (HIV)/AIDS Units in London.

DESIGN

Case-control study nested in a retrospective cohort of 2048 HIV-1 positive patients. Cases were defined as patients with a definitive diagnosis of tuberculosis, and controls as patients with AIDS and without tuberculosis during follow-up.

RESULTS

Of 627 patients diagnosed with AIDS, 121 had a definitive diagnosis of tuberculosis. Significant risk factors for tuberculosis in the univariate analysis were sex, ethnicity, age, HIV exposure category and hospital attended, and in the multiple regression analysis ethnicity, age and hospital attended. African ethnicity was the strongest risk factor for tuberculosis (adjusted odds ratio [AOR] 5.9, 95% confidence interval 3.4-10.2). The risk of tuberculosis was higher in the younger age groups (test for trend P < 0.001). The hospital-associated risk of tuberculosis was more heterogeneous in the non-African group, and non-Africans attending Hospital 1 had an increased risk of tuberculosis which was statistically significant.

CONCLUSIONS

The risk factors for AIDS-associated tuberculosis in London are sub-Saharan African origin, younger age group, and, among the non-Africans only, attending one hospital in east London. Different transmission patterns and mechanisms for the development of tuberculosis may operate in different settings depending on the background risk of tuberculous infection. Screening for tuberculosis infection and disease among HIV-positive individuals in London is important for the provision of preventive or curative therapy, and prophylaxis policies need to be designed in accordance with the transmission patterns and mechanisms of disease.

Disease progression and survival in HIV-1-infected Africans in London

OBJECTIVE

To examine differences in progression to AIDS and death between HIV-1-positive Africans (most infected in sub-Saharan Africa and therefore with non-B subtypes) and HIV-1-positive non-Africans in London.

DESIGN

Retrospective cohort study of 2048 HIV-1-positive individuals.

SETTING

HIV-1-infected individuals attending 11 of the largest HIV/AIDS units in London.

PATIENTS

Subjects were 1056 Africans and 992 non-Africans seen between 1982-1995.

RESULTS

There were no differences in crude survival from presentation to death between Africans and non-Africans (median 82 and 78 months, respectively; P = 0.22). Africans progressed more rapidly to AIDS [hazard ratio (HR), 1.21; 95% confidence interval (CI), 1.02-1.45] but after adjustment for age, sex, Centers for Disease Control and Prevention category B symptoms and CD4+ lymphocyte count at presentation, year of HIV diagnosis and hospital attended, this difference was no longer significant (adjusted HR, 1.15; 95% CI, 0.93-1.43). Africans with AIDS had a reduced risk of death compared with non-Africans (HR, 0.78; 95% CI, 0.63-0.96) but not after adjustment for age, CD4+ lymphocyte count at AIDS, initial AIDS-defining conditions (ADC) and hospital attended (HR, 0.98; 95% CI, 0.76-1.27). Tuberculosis as the first ADC was associated with a 64% reduction in the risk of death. CD4+ lymphocyte decline was not significantly different between Africans and non-Africans (P = 0.18).

CONCLUSIONS

Differences in progression to AIDS and death and CD4+ lymphocyte decline between HIV-1-infected Africans and non-Africans in London could not be attributed to ethnicity or different viral subtypes. Age and the clinical and immunological stage at presentation, or AIDS, were the major determinants of outcome. Compared with other diagnoses, tuberculosis as the initial ADC was associated with increased survival. Lack of access to health care and exposure to environmental pathogens are the most likely causes of reduced survival with AIDS in Africa, rather than inherently different rates of progression of immune deficiency due to racial differences or viral subtypes.

Disease progression and survival following specific AIDS-defining conditions: a retrospective cohort study of 2048 HIV-infected persons in London

OBJECTIVE

To assess the impact of specific AIDS-defining conditions on survival in HIV-infected persons, with emphasis on the effect of tuberculosis.

METHODS

A retrospective cohort analysis of HIV-infected Africans and non-Africans attending 11 specialist HIV/AIDS units in London enrolled for a comparison of the natural history of HIV/AIDS in different ethnic groups.

RESULTS

A total of 2048 patients were studied of whom 627 (31%) developed 1306 different AIDS indicator diseases. Pneumocystis carinii pneumonia accounted for 159 (25%) of initial AIDS episodes and tuberculosis for 103 (16%). In patients with HIV disease, tuberculosis had the lowest risk [relative risk (RR), 1.11; 95% confidence interval (CI), 0.75-1.63], and high-grade lymphoma had the highest risk (RR, 20.56; 95% CI, 2.70-156.54) for death. For patients with a prior AIDS-defining illness, the development of subsequent AIDS indicator diseases such as Pneumocystis carinii pneumonia (RR, 1.18; 95% CI, 0.77-1.83) and tuberculosis (RR, 1.36; 95% CI, 0.76-2.47) had the best survival, and non-Hodgkin's lymphoma had the worst survival (RR, 9.67; 95% CI, 1.26-74.33). Patients with tuberculosis had a lower incidence of subsequent AIDS-defining conditions than persons with other initial AIDS diagnoses (rate ratio, 0.47; 95% CI, 0.37-0.59).

CONCLUSIONS

Considerable variation exists in the relative risk of death following different AIDS-defining conditions. The development of any subsequent AIDS-defining condition is associated with an increased risk of death that differs between diseases, and this risk should be considered when evaluating the impact of specific conditions. Like other AIDS-defining conditions, incident tuberculosis was associated with adverse outcome compared with the absence of an AIDS-defining event, but we found no evidence of major acceleration of HIV disease attributable to tuberculosis.

Spectrum of disease in Africans with AIDS in London

OBJECTIVE

To compare the spectrum of disease, severity of immune deficiency and chemoprophylaxis prescribed in HIV-infected African and non-African patients in London.

DESIGN

Retrospective review of case notes of all HIV-infected Africans and a comparison group of non-Africans attending 11 specialist HIV/AIDS Units in London.

MAIN OUTCOME MEASURES

Comparison of demographic information, first and subsequent AIDS-defining conditions, levels of immune deficiency, and chemoprophylactic practices between the African and non-African groups.

RESULTS

A total of 1056 Africans (313 developing AIDS) and 992 non-Africans (314 developing AIDS) were studied. Africans presented later than non-Africans (median CD4+ lymphocyte counts at diagnosis 238 and 371 x 10(6)/l, respectively). Tuberculosis accounted for 27% of initial episodes of AIDS in Africans and 5% in non-Africans; Pneumocystis carinii pneumonia (PCP) was the initial AIDS-defining condition in 34% of non-Africans and 17% of Africans. The incidence of tuberculosis in Africans with another AIDS-indicator disease was 16 per 100 person-years. PCP prophylaxis was prescribed for 40% Africans and 32% non-Africans; only 8% of Africans received tuberculosis preventive therapy.

CONCLUSIONS

HIV-infected African patients presented at lower levels of CD4+ lymphocyte count, at a more advanced clinical stage, and with different AIDS-indicator diseases as compared with non-Africans. Prophylaxis against tuberculosis should be considered for all HIV-infected African patients in industrialized countries. The high incidence of diseases that are indicative of advanced immunodeficiency (e.g., cytomegalovirus disease) in African patients contrasts with data from Africa, suggesting better survival chances in the UK.

Plasma progesterone levels during oestrous cycle and their relationship with the ovulation rate in Red Sokoto (Maradi) goats

Twenty-five 2-3-year-old cycling does weighing 17-25 kg were obtained from semi-nomadic farmers and managed under controlled conditions while simulating the traditional management system. Oestrus was synchronized using progestogen impregnated vaginal pessaries. Blood samples were collected daily for progesterone assay from the day of pessary withdrawal up to one complete oestrous cycle. Oestrus was checked twice daily using vasectomized bucks. Ovulation rate was determined by direct observation of the ovaries following laparotomy on day 5-7 of the oestrous cycle. Following oestrus synchronization, mean ovulation rate was 1.68 +/- 0.13. Mean oestrous cycle length and duration of oestrus were 21.30 +/- 0.28 days and 21.37 +/- 0.24 hours respectively. Plasma progesterone concentrations ranged from non-detectable levels on the day of oestrus to 5.2 +/- 0.28 ng ml at mid-cycle. The duration of elevated progesterone level (greater than 2 ng/ml) was about 12 days. The peak progesterone values did not differ between animals with different ovulation rates. However, the plasma progesterone concentration during the early cycle (days 0-6) was significantly lower in the single ovulators compared with others. There were no major differences in plasma progesterone levels during the oestrous cycle of Red Sokoto does with different ovulation rates.