Defining a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity Among Pregnant Adolescent Girls and Women: A Secondary Analysis of Quantitative 24-h Recalls from Rural Settings in Bangladesh, Burkina Faso, India, and Nepal

Background

The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements.

Objective

This study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15-49 y in LMICs.

Methods

We used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60.

Results

In the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%).

Conclusions

The WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status.

Smartphone Ocular Fundal Photography in the Diagnosis of Raised Intracranial Pressure: A Novel Adaptation to Neurosurgical Practice

Background Consistently raised intracranial pressure (ICP) is a common final pathway to morbidity/mortality in many neurosurgical conditions. This underscores the need for early diagnosis and prompt management of raised ICP. This study aims to determine whether smartphone fundal photography features of raised ICP can accurately predict the computed tomography (CT) findings suggestive of elevated ICP in neurosurgery patients. Methods Dilated ocular fundal photography examinations using an ophthalmoscope adapter mounted on a smartphone were done on 82 patients with clinical suspicion of raised ICP. Fundal photography findings were recorded as pictures/videos for disc analysis. Patients subsequently had neuroimaging with results analyzed for radiological features of raised ICP. These were correlated with fundal photography findings. Results A total of 82 adult patients participated in this study. Chi-square analysis showed a relationship between radiological signs of raised ICP and the absence of spontaneous retinal venous pulsation (SRVP) (p=0.001). There was no relationship observed between papilledema and radiological signs of raised ICP. However, when the fundal photography signs were aggregated, there was a significant relationship between the fundal signs of raised ICP and radiological signs of raised ICP (p=0.004). The sensitivity and specificity of smartphone-fundoscopy-detected papilledema in predicting radiological signs of raised ICP were 43.2% and 100%, respectively, while those of absent SRVP were 100% and 92.6%, respectively. Conclusion Smartphone ophthalmoscopy is a reliable screening tool for evaluating ICP in neurosurgical patients. It should be introduced into the neurosurgeon's tools for prompt evaluation of raised ICP, especially in developing/resource-poor settings where CT or magnetic resonance imaging is not readily available.

Clinical Performance of Self-Collected Nasal Swabs and Antigen Rapid Tests for SARS-CoV-2 Detection in Resource-Poor Settings

Background: In resource-poor countries, antigen-based rapid tests (Ag-RDTs) performed at primary healthcare and community settings improved access to SARS-CoV-2 diagnostics. However, the technical skills and biosafety requirements inherent to nasopharyngeal and oropharyngeal (OP) specimens limit the scale-up of SARS-CoV-2 testing. The collection of nasal-swabs is programmatically viable, but its performance has not been evaluated in resource-poor settings. Methods: We first evaluated the performance of SteriPack self-collected nasal swabs for the detection of SARS-CoV-2 by real-time PCR in 1498 consecutively enrolled patients with suspected infection. Next, we evaluated the clinical performance of three nasal swab-based Ag-RDTs against real-time PCR on OP specimens. Results: The sensitivity of nasal swabs was 80.6% [95% CI: 75.3−85.2%] compared to OP specimens. There was a good correlation (r = 0.58; p < 0.0001) between Ct values of 213 positive cases obtained using nasal and OP swabs. Our findings show sensitivities of 79.7% [95% CI: 73.3−85.1%] for Panbio COVID-19 Ag-RDT, 59.6% [95% CI: 55.2−63.8%] for COVIOS Ag-RDT, and 78.0% [95% CI: 73.5−82.0%] for the LumiraDx SARS-CoV-2 Ag-RDT. Conclusions: In our setting, the COVIOS Ag-RDT did not meet WHO requirements. Nasal swab-based Ag-RDTs for SARS-CoV-2 detection constitute a viable and accurate diagnostic option in resource-poor settings.

Patient Assessment: Using the Oncology Nurse Navigator Patient Assessment for Rural and Other Resource-Poor Settings

Oncology nurse navigators (ONNs) rely on assessment tools to identify patient priorities so that care may be expedited along the cancer continuum. Few nonproprietary assessment tools exist for ONNs who work in rural and other resource-poor settings to reliably identify and track patient needs and barriers for seamless and timely oncology care.

Introducing new point-of-care tests for common infections in publicly funded clinics in South Africa: a qualitative study with primary care clinicians

Broad-spectrum antibiotics are routinely prescribed empirically in the resource-poor settings for suspected acute common infections, which drive antimicrobial resistance. Point-of-care testing (POCT) might increase the appropriateness of decisions about whether and which antibiotic to prescribe, but implementation will be most effective if clinician's perspectives are taken into account.

OBJECTIVES

To explore the perceptions of South African primary care clinicians working in publicly funded clinics about: making antibiotic prescribing decisions for two common infection syndromes (acute cough, urinary tract infection); their experiences of existing POCTs; their perceptions of the barriers and opportunities for introducing (hypothetical) new POCTs.

DESIGN, METHOD, PARTICIPANTS, SETTING

Qualitative semistructured interviews with 23 primary care clinicians (nurses and doctors) at publicly funded clinics in the Western Cape Metro district, South Africa. Data were analysed using thematic analysis.

RESULTS

Clinicians reported that their antibiotic prescribing decisions were influenced by their clinical assessment, patient comorbidities, social factors (eg, access to care) and perceived patient expectations. Their experiences with currently available POCTs were largely positive, and they were optimistic about the potential for new POCTs to: support evidence-based prescribing decisions that might reduce unnecessary antibiotic prescriptions; reduce the need for further investigations; support effective communication with patients, especially when antibiotics were unlikely to be of benefit. Resources and workflow disruption were seen as the main barriers to uptake into routine care.

CONCLUSIONS

Clinicians working in publicly funded clinics in the Western Cape Metro of South Africa saw POCTs as potentially useful for positively addressing both clinical and social drivers of the overprescribing of broad-spectrum antibiotics, but were concerned about the resource implications and disruption of existing patient workflows.

Does Village Chicken-Keeping Contribute to Young Children's Diets and Growth? A Longitudinal Observational Study in Rural Tanzania

There is substantial current interest in linkages between livestock-keeping and human nutrition in resource-poor settings. These may include benefits of improved diet quality, through animal-source food consumption and nutritious food purchases using livestock-derived income, and hazards of infectious disease or environmental enteric dysfunction associated with exposure to livestock feces. Particular concerns center on free-roaming chickens, given their proximity to children in rural settings, but findings to date have been inconclusive. This longitudinal study of 503 households with a child under 24 months at enrolment was conducted in villages of Manyoni District, Tanzania between May 2014, and May 2016. Questionnaires encompassed demographic characteristics, assets, livestock ownership, chicken housing practices, maternal education, water and sanitation, and dietary diversity. Twice-monthly household visits provided information on chicken numbers, breastfeeding and child diarrhea, and anthropometry was collected six-monthly. Multivariable mixed model analyses evaluated associations between demographic, socioeconomic and livestock-associated variables and (a) maternal and child diets, (b) children’s height-for-age and (c) children’s diarrhea frequency. Alongside modest contributions of chicken-keeping to some improved dietary outcomes, this study importantly (and of substantial practical significance if confirmed) found no indication of a heightened risk of stunting or greater frequency of diarrhea being associated with chicken-keeping or the practice of keeping chickens within human dwellings overnight.

Development of a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity in Women of Reproductive Age

Background: Dietary diversity is a key element of diet quality, but diets of women of reproductive age (WRA; aged 15-49 y) in resource-poor settings are often deficient in a range of micronutrients. Previous work showed associations between simple food-group diversity indicators (FGIs) and micronutrient adequacy among WRA. For operational and advocacy purposes, however, there is strong demand for a dichotomous indicator reflecting an acceptable level of dietary diversity. Objective: The aim of the study was to develop a dichotomous indicator of dietary diversity in WRA. Methods: We performed a secondary analysis of 9 data sets containing quantitative dietary data from WRA in resource-poor settings (total n = 4166). From the raw dietary data, we calculated an individual "mean probability of adequacy" (MPA) across 11 micronutrients. Several candidate FGIs were constructed. Indicator performance in predicting an MPA >0.60 was assessed within each data set by using receiver-operating characteristic analysis and sensitivity and specificity analysis at various FGI cutoffs. The analysis was performed separately for nonpregnant and nonlactating (NPNL) women and for lactating women. Results: We identified 2 "best candidate" dichotomous indicators on the basis of 9- or 10-point food-group scores (FGI-9 and FGI-10) with a cutoff of ≥5 food groups. Both were significantly correlated to MPA in each site (P < 0.001). Areas under the curve were moderate, ranging from 0.62 to 0.82 among NPNL women and from 0.56 to 0.90 among lactating women. Comparisons of results slightly favored FGI-10 for all women. Conclusions: When resource-intensive dietary methods are not feasible, a simple dichotomous indicator based on a cutoff of ≥5 of 10 defined food groups reflects "minimum dietary diversity for women of reproductive age." According to the conclusions of a consensus meeting of experts, this indicator is well suited for population-level assessment, advocacy, and possibly also for tracking of change in dietary diversity across time.

The Ugandan Youth Quality of Life index: assessing the relevance of incorporating perceived importance into the quality of life measure and factors associated with the quality of life among youth in slum areas of Kampala, Uganda

Background

While quality of life (QoL) has long been an explicit policy goal for international development programmes, no instruments have specifically been developed for measuring health-related QoL in resource-limited settings. The aim of this study was to develop and validate a QoL instrument for use in international aid and development programmes and to assess factors associated with QoL among youth participating in a civic engagement project in Kampala.

Design

Using systematic random sampling, data were collected on 663 participants aged between 13 and 24 years in Kampala. The QoL questionnaire included 36 questions divided into a two-part scale: 18 questions rated for satisfaction (Part 1) and 18 other questions rated on importance (Part 2). The total sample was randomly divided into two split-half samples: one for the exploratory factor analysis (EFA; N=310) and the other for the confirmatorty factor analysis (CFA; N=353). The effect of demographic, socio-economic, and lifestyle factors on QoL was assessed using linear regressions.

Results

The EFA yielded three factors: living conditions and lifestyle (seven items, α=0.84), social relationships (five items, α=0.86), and personal independence (five items, α=0.76). In the CFA, the initial model demonstrated a poor to marginal fit model. Its re-specification by examining modification indices resulted in a good model fit: Comparative Fit Index=0.95, Root Mean Square Error of Approximation=0.06, and p of Close Fit >0.05. The model incorporating perceived importance had lower Akaike Information Criteria and Bayesian Information Criteria values than the unweighted model, thereby providing very strong support to weight satisfaction scores with importance ratings when measuring QoL in Uganda. Poor QoL was associated with poor educational attainment, drug and substance misuse, and family disruption.

Conclusions

The findings suggest that there is a relationship between QoL and lifestyle and structural issues among youth in Uganda. The study provides the first validated QoL measure to allow government and non-government organisations in low- and middle-income countries to track progress of international aid and development programmes.

Improving the Sensitivity and Functionality of Mobile Webcam-Based Fluorescence Detectors for Point-of-Care Diagnostics in Global Health

Resource-poor countries and regions require effective, low-cost diagnostic devices for accurate identification and diagnosis of health conditions. Optical detection technologies used for many types of biological and clinical analysis can play a significant role in addressing this need, but must be sufficiently affordable and portable for use in global health settings. Most current clinical optical imaging technologies are accurate and sensitive, but also expensive and difficult to adapt for use in these settings. These challenges can be mitigated by taking advantage of affordable consumer electronics mobile devices such as webcams, mobile phones, charge-coupled device (CCD) cameras, lasers, and LEDs. Low-cost, portable multi-wavelength fluorescence plate readers have been developed for many applications including detection of microbial toxins such as C. Botulinum A neurotoxin, Shiga toxin, and S. aureus enterotoxin B (SEB), and flow cytometry has been used to detect very low cell concentrations. However, the relatively low sensitivities of these devices limit their clinical utility. We have developed several approaches to improve their sensitivity presented here for webcam based fluorescence detectors, including (1) image stacking to improve signal-to-noise ratios; (2) lasers to enable fluorescence excitation for flow cytometry; and (3) streak imaging to capture the trajectory of a single cell, enabling imaging sensors with high noise levels to detect rare cell events. These approaches can also help to overcome some of the limitations of other low-cost optical detection technologies such as CCD or phone-based detectors (like high noise levels or low sensitivities), and provide for their use in low-cost medical diagnostics in resource-poor settings.

Problem-based learning in resource-poor settings: lessons from a medical school in Ghana

Problem-based learning (PBL) is arguably one of the most important innovations in medical education in the last century. The evident benefits of PBL and the changing face of medicine and medical education have led many institutions including those in resource-poor settings to consider the adoption of PBL curricula. However, experts are uncertain about how successful PBL will be in such settings, as literature on the implementation of PBL in resource-poor settings appears to be inadequate. The University of Cape Coast is located in a resource-poor setting, however, its medical school has used PBL curriculum since 2007. In a descriptive prose, this article discusses the PBL implementation processes, the challenges faced, the mitigation strategies employed, and the lessons learned at University of Cape Coast School of Medical Sciences (UCCSMS). The arguments fall under the broad themes of curricular structure, resource constraints, faculty development, and assessment. The peculiar socioeconomic situation of Ghana, challenges in funding of tertiary education, and the resource implications of PBL provided the context for the arguments. It emerged out of the discussion that PBL has to be implemented as whole curriculum to be effective. Regular faculty development activities on PBL and the alignment of assessment methods with PBL also emerged as important issues in the discussion. The article argues that in spite of its cost implication, a PBL curriculum can be successfully implemented in resource-constrained settings.

Promotion and Reporting of Research from Resource-Limited Settings

Driven by global burden of disease and inequalities in health care, research activities in resource-poor settings have radically increased. However, a corresponding increase in reporting of research from these settings has not been observed. This article critically explores the importance of promoting and reporting of health research from resource-poor settings, current trends, and practices, and discusses the key challenges faced by researchers from such settings. These challenges include changing face of open-access (OA) and online publishing, the threat of predatory OA journals, authorship and international partnership ethics, attitudinal problems hindering research reporting, and a lack of alternative publishing spaces. A combined, decisive effort is needed to bridge the gap between research activity and reporting in resource-poor settings.

Disclosure among HIV-positive women: the role of HIV/AIDS support groups in rural Kenya

Disclosure by people living with HIV or AIDS is critical for HIV prevention and care. However, many women choose not to disclose their HIV status for fear of negative outcomes, such as blame and rejection. The World Health Organization suggests that HIV/AIDS support groups help to encourage women to disclose their status, but little is known about the role of such groups in Kenya. This study used qualitative research methods to gain insight into rural women's experience of disclosing a positive HIV status and it explores opinions about the role of support groups in relation to disclosure. Focus group discussions and semi-structured interviews were conducted with HIV/AIDS support group members and leaders. Thematic analysis showed that the women felt a sense of duty to inform others of their HIV status, particularly in order to prevent HIV transmission and to encourage sexual partners to be tested. There were multiple problems associated with disclosure, and negative outcomes such as blame and rejection were common. Support groups gave the women confidence and provided emotional support, which may have assisted them with coping with the negative outcomes of disclosure. The findings demonstrate that such support may improve women's experience of HIV-status disclosure and possibly even promote disclosure. However, initiatives such as these must protect those who disclose and therefore should take into account the local cultural and economic context.

Children as caregivers of older relatives living with HIV and AIDS in Nyang'oma division of western Kenya

There is growing debate about the situations of children who care for a relative with HIV-related illness, especially in developing countries with high HIV prevalence. In particular, there is inadequate information on the long-term consequences of children taking on this caregiving role. The article reanalyses data collected between January and November 2006 in a rural setting in western Kenya where 19 children caring for a total of 15 people living with HIV or AIDS (PLHIV) participated. Data were collected through in-depth interviews, participant observation, focus group discussions and narratives. The findings show that children regularly become involved in caregiving due to lack of a responsible adult to perform the role, which may be as a result of HIV stigma and rejection of the care recipient by extended family members and neighbours or because of cultural barriers. Fulfilling the responsibilities of caregiving had profound repercussions for the children's lives, including psychological distress, physical burden, dropping out of school, participation in wage labour, and forced early marriage. Financial needs pushed some girls into transactional sexual relations, predisposing them to the risks of unwanted pregnancy or sexually transmitted infections. Since the children providing care for PLHIV are themselves vulnerable, we recommend that they should be targeted with support.

Altered mental status is an indicator of mortality and associated with both infectious and non-communicable disease in Lilongwe, Malawi

Little is known about diseases associated with altered mental status (AMS) in resource-limited settings. We studied adult medicine patients presenting with AMS in Lilongwe, Malawi and found that AMS and HIV infection were each significantly associated with mortality. It is therefore critical that evaluation and management in this patient population is improved.

"When I was no longer able to see and walk, that is when I was affected most": experiences of disability in people living with HIV in South Africa

PURPOSE

HIV-related disability is an emerging issue in countries where HIV is endemic. This study aimed to understand experiences of disability in patients living with HIV in South Africa using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework.

METHODS

In-depth interviews were conducted with 19 HIV-positive people receiving ART through a public hospital in KwaZulu-Natal. Data were analyzed using collaborative qualitative content analysis.

RESULTS

Participants described a variety of impairments related to mental, sensory, neuromusculoskeletal, skin, cardiovascular, digestive or reproductive systems. A tenuous relationship was evident between HIV and mental health impairments and the experience of other disabilities. Impairments affected participants' activity levels, especially mobility, domestic life, self-care and ability to work. Activity limitations affecting livelihood were often of more concern to participants than the impairments. Furthermore, women and men appeared to experience disability related to activities relevant to gendered norms in their cultural context.

CONCLUSIONS

More understanding of the intersections among HIV, disability, gender and livelihood is needed. To respond to the increased need to manage disability within HIV care in Africa, HIV programs should include rehabilitative approaches, address concerns related to livelihoods in households with disability and consider gender differences in the experience of disability.

IMPLICATIONS FOR REHABILITATION

HIV, its opportunistic infections and the treatments associated to them are related to health conditions and impairments that have the potential to develop into disability. Rehabilitation professionals in HIV endemic countries have therefore a larger and changing number of people living with HIV and need to consider the impact of the disease on the rehabilitation process. Mental health issues and disability might be interrelated and affect antiretroviral treatment (ART) adherence. Hence, rehabilitation has to use a holistic approach and integrate different therapy approaches (e.g. physiotherapy and mental health). The experience of living with HIV and developing disability has unreflected gender dynamics that need to be considered in rehabilitative care. Hence, the rehabilitation process has to consider the cultural realities and gendered experience of the condition. The study highlights the interrelationship between disability levels, the influence of environmental and social factors, and the changing experience related to gender. Hence, rehabilitation professionals in resource-poor settings have to go beyond the clinical response and therapy approaches in order to improve the activity and participation of people with disabilities and those living with HIV in their homes and communities. Community or home-based care might be avenues to further explore.

Why tuberculosis service providers do not follow treatment guideline in Ethiopia: a qualitative study

AIM

Little is known about the reasons why tuberculosis (TB) service providers do not follow TB treatment guidelines. A better understanding of their real-world experiences associated with non-compliance with guideline may highlight opportunities for enhanced TB care. Whether the problem is actual or perceived may also affect the type of intervention needed to overcome the barrier. This study aimed to explore TB service providers' reasons for not complying with TB treatment guidelines.

METHOD

A descriptive qualitative design was used. Focus group discussions were held with 39 service providers involved in TB care. The study was carried out in the Tigray region of Ethiopia, in four of the six zonal hospitals. Data were analysed using content analysis.

RESULTS

The main reasons for non-compliance with TB treatment guidelines were: (1) insufficient diagnostic modalities, limiting the capacity to correctly diagnose TB and provide the right regimen; (2) ambiguity in guideline recommendations especially for specific subgroups of patients, making it difficult to prioritize them to the right regimen; and (3) poor documentation concerning referred patients, with no appropriate examination and difficulty obtaining information from previously treated patients.

CONCLUSION

Non-compliance may reflect valid questions about the applicability of guideline recommendations in the local context of health care. Special consideration should be given to previously treated patients, as an important factor influencing guideline compliance. Guideline compliance may also be improved by a better strategy to retest those patients whose initial tests are negative in health care contexts where TB is frequently missed.

Resilience through participation and coping-enabling social environments: the case of HIV-affected children in sub-Saharan Africa

Many children and youths living in low-resource and high-HIV-prevalence communities in sub-Saharan Africa are presented with daily hardships that few of us can even imagine. It is therefore no surprise that most research reporting on the experiences of HIV-affected children in resource-poor settings focuses on their poor health and development outcomes, casting them as victims. However, there is a growing trend to draw on more strengths-based conceptualisations in the study and support of HIV-affected children and youths. In this introduction to a special issue of The African Journal of AIDS Research, we cement this trend by providing a theoretical exposition and critique of the ‘coping’ and ‘resilience’ concepts and draw on the 11 empirical studies that make up this special issue to develop a framework that appropriates the concepts for a particular context and area of study: HIV-affected children in sub-Saharan Africa. The articles included here show, albeit in different ways and to different degrees, that the resilience of HIV-affected children in the region is an outcome of their agency and interactions with their social environment. Policy actors and practitioners working to support HIV-affected children in Africa should take heed of the proposed framework and draw on the research presented here to build coping-enabling social environments—presenting children and youths in Africa with greater opportunity to actively deal with hardship and work towards a more promising future.

Validity of a screening instrument for neurologic disability in resource-poor African communities

BACKGROUND

There have been no recent population-based studies on all-cause adult neurological morbidity in sub-Saharan Africa. We have developed a screening survey to improve the feasibility in performing these studies.

METHODS

Our screening instrument contains both history questions and examination items. We pilot tested this instrument in the Hai District, Tanzania, and Butajira, Ethiopia using trained individuals from the local communities. To measure sensitivity, we applied the instrument blindly to 25 previously-identified subjects with Parkinson's disease, stroke or epilepsy. To measure specificity, we examined 42 randomly selected previously screened subjects. We also compared the validity of the entire instrument to the history-only section.

RESULTS

There were 669 adult subjects screened in both communities (150 screen-positives, and 519 screen-negatives). The sensitivity of the instrument was 100% (95% CI 84.2-100%) and the specificity was 82.4% (95% CI 66.1-92.0%). However, when restricting the instrument to the history-only section, the sensitivity remained unchanged, but the specificity became 91.2% (95% CI 76.3-97.7%; p=0.48).

CONCLUSIONS

We have created a valid tool to screen adults for neurologic morbidity in resource-poor communities. The use of the history-only section of the tool is adequate as a screen and will improve feasibility.

Implementing evidence-based alcohol interventions in a resource-limited setting: novel delivery strategies in Tomsk, Russia

Effective implementation of evidence-based interventions in "real-world" settings can be challenging. Interventions based on externally valid trial findings can be even more difficult to apply in resource-limited settings, given marked differences-in provider experience, patient population, and health systems-between those settings and the typical clinical trial environment. Under the auspices of the Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis Patients (IMPACT) study, a randomized, controlled effectiveness trial, and as an integrated component of tuberculosis treatment in Tomsk, Russia, we adapted two proven alcohol interventions to the delivery of care to 200 patients with alcohol use disorders. Tuberculosis providers performed screening for alcohol use disorders and also delivered naltrexone (with medical management) or a brief counseling intervention either independently or in combination as a seamless part of routine care. We report the innovations and challenges to intervention design, training, and delivery of both pharmacologic and behavioral alcohol interventions within programmatic tuberculosis treatment services. We also discuss the implications of these lessons learned within the context of meeting the challenge of providing evidence-based care in resource-limited settings.

Why HIV/AIDS should be treated as exceptional: arguments from sub-Saharan Africa and Eastern Europe

The idea that HIV and AIDS gets too much attention and funding emerged in 2008 with a call to end 'AIDS exceptionalism.' This article outlines a short history of AIDS exceptionalism - the idea that HIV and AIDS require a response above and beyond 'normal' health interventions and is privileged in terms of attention and resources when compared with other diseases - and the reasons for the backlash to this idea. We argue that in some settings HIV and AIDS must be treated as exceptional. These are the hyperendemic countries of southern Africa, where HIV epidemics have shown substantial and lasting demographic and social impact, and parts of Eastern Europe where the epidemic is augmenting troubling demographic changes, such as declines in fertility rates and population growth, and impacting society in nuanced ways. Also included are resource-poor settings, mostly in Africa, where the combination of the high number of HIV infections and the cost of treatment have created issues concerning donor dependency and sustainable responses. An HIV epidemic must be seen as a long-wave event, with complex challenges to both HIV prevention and treatment responses. The article reviews the available data and literature to provide evidence for our arguments. We conclude that the perception that AIDS exceptionalism is outdated ignores the complexity of different HIV epidemics and obfuscates the challenges to effective responses.

Making family planning accessible in resource-poor settings

It is imperative to make family planning more accessible in low resource settings. The poorest couples have the highest fertility, the lowest contraceptive use and the highest unmet need for contraception. It is also in the low resource settings where maternal and child mortality is the highest. Family planning can contribute to improvements in maternal and child health, especially in low resource settings where overall access to health services is limited. Four critical steps should be taken to increase access to family planning in resource-poor settings: (i) increase knowledge about the safety of family planning methods; (ii) ensure contraception is genuinely affordable to the poorest families; (iii) ensure supply of contraceptives by making family planning a permanent line item in healthcare system's budgets and (iv) take immediate action to remove barriers hindering access to family planning methods. In Africa, there are more women with an unmet need for family planning than women currently using modern methods. Making family planning accessible in low resource settings will help decrease the existing inequities in achieving desired fertility at individual and country level. In addition, it could help slow population growth within a human rights framework. The United Nations Population Division projections for the year 2050 vary between a high of 10.6 and a low of 7.4 billion. Given that most of the growth is expected to come from today's resource-poor settings, easy access to family planning could make a difference of billions in the world in 2050.

Programmatic implementation of rapid DST for Mycobacterium tuberculosis in Peru

BACKGROUND

Performance characteristics of novel rapid drug susceptibility tests (DST) for Mycobacterium tuberculosis may change when moving from research to implementation in actual public health practice. We describe the performance characteristics of a direct, rapid DST when implemented in Lima, Peru.

METHODS

A district laboratory validated conventional proportions and nitrate reductase methods. We collected data on samples submitted for DST from January 2005 to June 2007 and calculated frequency of testing and results, and median time to test results.

RESULTS

A total of 4102 DSTs were performed by conventional DST and 895 by nitrate reductase. Results were obtained from 72.8% of samples by conventional DST and from 70.2% of those processed by Griess; respectively 26.4% and 31.5% were multidrug-resistant tuberculosis. The median time from sample collection to test result was 31 days for Griess vs. 99 days for conventional DST.

CONCLUSIONS

Preliminary experience with the Griess method demonstrates favorable performance under program conditions.

Medicine in resource-poor settings: time for a paradigm shift?

The current global health system, which concentrates on a few and neglects billions of people who live in resource-poor settings and carry the largest burden of global diseases, is unacceptable. The weight of medical practice patterns ought to shift from the therapeutic phase of medical care to prevention. Achieving better health for the majority of humanity requires innovation, improved resources, new cooperation between the rich and the poor, and a clear ethical vision, consolidated by goal-oriented and system-focused strategic health planning. Development assistance from wealthier nations to developing countries must shift from the current donor-driven agendas to country-driven sector-wide approaches for health development with adequate accountability and sustainability. There must be a fundamental departure from classical universalism to new universalism, reoriented by a new public health, and reinforced by a new solidarity, using holistic approaches to ensure better health for the whole of humanity.