Characteristics of TPT initiation and completion among people living with HIV.

BACKGROUND: TB preventive treatment (TPT) reduces morbidity and mortality among people living with HIV (PLHIV). Despite the successful scale-up of TPT in Malawi, monitoring and evaluation have been suboptimal. We utilized the Malawi Population-Based HIV Impact Assessment (MPHIA) 2020-2021 survey data to estimate TPT uptake and completion among self-reported HIV-positive persons. METHODS: We estimated the proportion of HIV-positive respondents who had ever undergone TPT, and determined the percentage of those currently on TPT who had completed more than 6 months of treatment. Bivariate and multivariable logistic regression were performed to calculate the odds ratios for factors associated with ever-taking TPT. All variables were self-reported, and the analysis was weighted and accounted for in the survey design. RESULTS: Of the HIV+ respondents, 38.8% (95% CI 36.4-41.3) had ever taken TPT. The adjusted odds of ever taking TPT were 8.0 and 5.2 times as high in the Central and Southern regions, respectively, compared to the Northern region; 1.9 times higher among those in the highest wealth quintile, and 2.1 times higher for those on antiretroviral therapy >10 years. Of those currently taking TPT, 56.2% completed >6 months of TPT. CONCLUSION: These results suggest low TPT uptake and >6 months' completion rates among self-reported HIV+ persons. Initiatives to create demand and strengthen adherence would improve TPT uptake.

CONTEXTE: Le traitement préventif de la TB (TPT) réduit la morbidité et la mortalité chez les personnes vivant avec le VIH (PVVIH). Malgré l'extension réussie du TPT au Malawi, le suivi et l'évaluation n'ont pas été optimaux. Nous avons utilisé les données de l'enquête MPHIA (Malawi Population-Based HIV Impact Assessment) 2020­2021 pour estimer l'adoption et l'achèvement du TPT parmi les personnes se déclarant séropositives. MÉTHODES: Nous avons estimé la proportion de répondants séropositifs qui avaient déjà subi un TPT et déterminé le pourcentage de ceux qui sont actuellement sous TPT et qui ont terminé plus de 6 mois de traitement. Une régression logistique bivariée et multivariable a été effectuée pour calculer les rapports de cotes des facteurs associés au fait d'avoir déjà pris un TPT. Toutes les variables étaient autodéclarées et l'analyse a été pondérée et prise en compte dans la conception de l'enquête. RÉSULTATS: Parmi les répondants séropositifs, 38,8% (IC 95% 36,4­41,3) avaient déjà pris du TPT. Les probabilités ajustées de prise de TPT étaient 8,0 et 5,2 fois plus élevées dans les régions du centre et du sud, respectivement, que dans la région du nord ; 1,9 fois plus élevées chez les personnes appartenant au quintile de richesse le plus élevé, et 2,1 fois plus élevées chez les personnes suivant une thérapie antirétrovirale depuis plus de 10 ans. Parmi ceux qui prennent actuellement un TPT, 56,2% ont terminé >6 mois de TPT. CONCLUSION: Ces résultats suggèrent un faible taux d'utilisation du TPT et des taux d'achèvement de >6 mois parmi les personnes déclarées séropositives. Des initiatives visant à créer une demande et à renforcer l'adhésion permettraient d'améliorer l'utilisation du TPT.

Comprehensive cancer predisposition testing within the prospective MASTER trial identifies hereditary cancer patients and supports treatment decisions for rare cancers.

BACKGROUND: Germline variant evaluation in precision oncology opens new paths toward the identification of patients with genetic tumor risk syndromes and the exploration of therapeutic relevance. Here, we present the results of germline variant analysis and their clinical implications in a precision oncology study for patients with predominantly rare cancers. PATIENTS AND METHODS: Matched tumor and control genome/exome and RNA sequencing was carried out for 1485 patients with rare cancers (79%) and/or young adults (77% younger than 51 years) in the National Center for Tumor Diseases/German Cancer Consortium (NCT/DKTK) Molecularly Aided Stratification for Tumor Eradication Research (MASTER) trial, a German multicenter, prospective, observational precision oncology study. Clinical and therapeutic relevance of prospective pathogenic germline variant (PGV) evaluation was analyzed and compared to other precision oncology studies. RESULTS: Ten percent of patients (n = 157) harbored PGVs in 35 genes associated with autosomal dominant cancer predisposition, whereof up to 75% were unknown before study participation. Another 5% of patients (n = 75) were heterozygous carriers for recessive genetic tumor risk syndromes. Particularly, high PGV yields were found in patients with gastrointestinal stromal tumors (GISTs) (28%, n = 11/40), and more specifically in wild-type GISTs (50%, n = 10/20), leiomyosarcomas (21%, n = 19/89), and hepatopancreaticobiliary cancers (16%, n = 16/97). Forty-five percent of PGVs (n = 100/221) supported treatment recommendations, and its implementation led to a clinical benefit in 40% of patients (n = 10/25). A comparison of different precision oncology studies revealed variable PGV yields and considerable differences in germline variant analysis workflows. We therefore propose a detailed workflow for germline variant evaluation. CONCLUSIONS: Genetic germline testing in patients with rare cancers can identify the very first patient in a hereditary cancer family and can lead to clinical benefit in a broad range of entities. Its routine implementation in precision oncology accompanied by the harmonization of germline variant evaluation workflows will increase clinical benefit and boost research.

Regional analysis of inflammation and contractile function in reperfused acute myocardial infarction by in vivo 19F cardiovascular magnetic resonance in pigs.

Inflammatory cell infiltration is central to healing after acute myocardial infarction (AMI). The relation of regional inflammation to edema, infarct size (IS), microvascular obstruction (MVO), intramyocardial hemorrhage (IMH), and regional and global LV function is not clear. Here we noninvasively characterized regional inflammation and contractile function in reperfused AMI in pigs using fluorine (19F) cardiovascular magnetic resonance (CMR). Adult anesthetized pigs underwent left anterior descending coronary artery instrumentation with either 90 min occlusion (n = 17) or without occlusion (sham, n = 5). After 3 days, in surviving animals a perfluorooctyl bromide nanoemulsion was infused intravenously to label monocytes/macrophages. At day 6, in vivo 1H-CMR was performed with cine, T2 and T2* weighted imaging, T2 and T1 mapping, perfusion and late gadolinium enhancement followed by 19F-CMR. Pigs were sacrificed for subsequent ex vivo scans and histology. Edema extent was 35 ± 8% and IS was 22 ± 6% of LV mass. Six of ten surviving AMI animals displayed both MVO and IMH (3.3 ± 1.6% and 1.9 ± 0.8% of LV mass). The 19F signal, reflecting the presence and density of monocytes/macrophages, was consistently smaller than edema volume or IS and not apparent in remote areas. The 19F signal-to-noise ratio (SNR) > 8 in the infarct border zone was associated with impaired remote systolic wall thickening. A whole heart value of 19F integral (19F SNR × milliliter) > 200 was related to initial LV remodeling independently of edema, IS, MVO, and IMH. Thus, 19F-CMR quantitatively characterizes regional inflammation after AMI and its relation to edema, IS, MVO, IMH and regional and global LV function and remodeling.

Determinants of the use of insecticide-treated mosquito nets in pregnant women: a mixed-methods study in Ghana.

BACKGROUND: Malaria in pregnancy remains a significant cause of morbidity and mortality, affecting the highly endemic countries of sub-Saharan Africa (SSA). Insecticide-treated nets (ITNs) are effective for malaria prevention. However, poor adherence in SSA remains a challenge. METHODS: We conducted a standard questionnaire survey among 710 pregnant women from 37 primary care clinics in the Upper West Region of Ghana from January through May 2019. Using a sequential explanatory design, we integrated the survey data from six focus group discussions with pregnant women. RESULTS: While 67% of women had some general knowledge about malaria prevention, only 19% knew the specific risks in pregnancy. Determinants of ITN use included ITN ownership (odds ratio [OR] 2.4 [95% confidence interval {CI} 1.3 to 4.4]), good maternal knowledge of the risks of malaria in pregnancy (OR 2.4 [95% CI 1.3 to 4.3]) and more antenatal care (ANC) contacts (OR 1.3 [95% CI 1.0 to 1.5)]. Focus group discussions showed that non-use of ITNs resulted from inappropriate hanging infrastructure, a preference for other malaria prevention alternatives, allergy and heat. CONCLUSIONS: Specific maternal knowledge of malaria risks in pregnancy was low and influenced the regular use of ITNs. Community and ANC-based malaria interventions should prioritize increasing knowledge of the specific risks of malaria.

Hydroclimate footprint of pan-Asian monsoon water isotope during the last deglaciation.

Oxygen isotope speleothem records exhibit coherent variability over the pan-Asian summer monsoon (AM) region. The hydroclimatic representation of these oxygen isotope records for the AM, however, has remained poorly understood. Here, combining an isotope-enabled Earth system model in transient experiments with proxy records, we show that the widespread AM δ18Oc signal during the last deglaciation (20 to 11 thousand years ago) is accompanied by a continental-scale, coherent hydroclimate footprint, with spatially opposite signs in rainfall. This footprint is generated as a dynamically coherent response of the AM system primarily to meltwater forcing and secondarily to insolation forcing and is further reinforced by atmospheric teleconnection. Hence, widespread δ18Op depletion in the AM region is accompanied by a northward migration of the westerly jet and enhanced southwesterly monsoon wind, as well as increased rainfall from South Asia (India) to northern China but decreased rainfall in southeast China.

Holography and criticality in matchgate tensor networks.

The AdS/CFT correspondence conjectures a holographic duality between gravity in a bulk space and a critical quantum field theory on its boundary. Tensor networks have come to provide toy models to understand these bulk-boundary correspondences, shedding light on connections between geometry and entanglement. We introduce a versatile and efficient framework for studying tensor networks, extending previous tools for Gaussian matchgate tensors in 1 + 1 dimensions. Using regular bulk tilings, we show that the critical Ising theory can be realized on the boundary of both flat and hyperbolic bulk lattices, obtaining highly accurate critical data. Within our framework, we also produce translation-invariant critical states by an efficiently contractible tensor network with the geometry of the multiscale entanglement renormalization ansatz. Furthermore, we establish a link between holographic quantum error-correcting codes and tensor networks. This work is expected to stimulate a more comprehensive study of tensor network models capturing bulk-boundary correspondences.

CMR-guidance of passively tracked endomyocardial biopsy in an in vivo porcine model.

Endomyocardial biopsy (EMB) is considered to be the diagnostic gold-standard in detection of myocardial-inflammation. EMB is usually conducted under fluoroscopy without any specific target information. Specific target-information provided by cardiovascular magnetic resonance (CMR) may improve specificity of EMB. The aim was to investigate feasibility and safety of CMR-guided and targeted EMB in a preclinical-model using passively-tracked devices. Procedures were performed on a MRI-System equipped with an Interventional Software-Platform for real-time imaging. Ex vivo experiments were conducted to optimize visibility of the guide-sheath. In vivo experiments were conducted in 2 pigs for technical feasibility assessment and in 4 pigs after acute myocardial infarction to test feasibility of guided and lesion targeted EMB. For anatomical real-time imaging a single-shot-balanced-SSFP-sequence was applied. Myocardial targets were identified under real-time imaging (single-shot-T2 (sshT2) and single-shot Late-Gadolinium-Enhancement (sshLGE) sequences). Ex vivo experiments demonstrated best visibility of continuously labelled guide-sheath. CMR-guided EMB was feasible in all cases without major complications. Likewise, lesion-targeting endomyocardial biopsy was feasible in two cases. Biopsies exhibited appropriate sizes and qualities. Real-time lesion sequences revealed comparable CNR values to clinical-protocols. Real-time imaging of lesions showed following signal- and contrast-to-noise ratios (SNR/CNR): SNR of sshT2- and sshLGE was 124 ± 35 and 67 ± 51 respectively, whereas CNR was 81 ± 30 and 57 ± 44. This study demonstrates feasibility and safety of CMR-guided and basically targeted EMB with passively-tracked devices. Signal-to-noise ratios of real-time sequences is non-inferior to standard sequences for lesion detection. CMR-guidance may improve diagnostic accuracy of EMB since CMR can detect myocardial-targets under real-time-imaging.

Efficacy and safety of methylene blue in the treatment of malaria: a systematic review.

BACKGROUND: Methylene blue (MB) was the first synthetic antimalarial to be discovered and was used during the late 19th and early 20th centuries against all types of malaria. MB has been shown to be effective in inhibiting Plasmodium falciparum in culture, in the mouse model and in rhesus monkeys. MB was also shown to have a potent ex vivo activity against drug-resistant isolates of P. falciparum and P. vivax. In preclinical studies, MB acted synergistically with artemisinin derivates and demonstrated a strong effect on gametocyte reduction in P. falciparum. MB has, thus, been considered a potentially useful partner drug for artemisinin-based combination therapy (ACT), particularly when elimination is the final goal. The aim of this study was to review the scientific literature published until early 2017 to summarise existing knowledge on the efficacy and safety of MB in the treatment of malaria. METHODS: This systematic review followed PRISMA guidelines. Studies reporting on the efficacy and safety of MB were systematically searched for in relevant electronic databases according to a pre-designed search strategy. The search (without language restrictions) was limited to studies of humans published until February 2017. RESULTS: Out of 474 studies retrieved, a total of 22 articles reporting on 21 studies were eligible for analysis. The 21 included studies that reported data on 1504 malaria patients (2/3 were children). Older studies were case series and reports on MB monotherapy while recent studies were mainly controlled trials of combination regimens. MB was consistently shown to be highly effective in all endemic areas and demonstrated a strong effect on P. falciparum gametocyte reduction and synergy with ACT. MB treatment was associated with mild urogenital and gastrointestinal symptoms as well as blue coloration of urine. In G6PD-deficient African individuals, MB caused a slight but clinically non-significant haemoglobin reduction. CONCLUSIONS: More studies are needed to define the effects of MB in P. falciparum malaria in areas outside Africa and against P. vivax malaria. Adding MB to ACT could be a valuable approach for the prevention of resistance development and for transmission reduction in control and elimination programs. SYSTEMATIC REVIEW REGISTRATION: This study is registered at PROSPERO (registration number CRD42017062349 ).

Prevention of mother-to-child transmission of HIV: a cross-sectional study in Malawi.

OBJECTIVE: To estimate the use and outcomes of the Malawian programme for the prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). METHODS: In a cross-sectional analysis of 33 744 mother-infant pairs, we estimated the weighted proportions of mothers who had received antenatal HIV testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or HIV testing. We calculated the ratios of MTCT at 4-26 weeks postpartum for subgroups that had missed none or at least one of these four steps. FINDINGS: The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant HIV testing was 53.2%. Estimated ratios of MTCT were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed HIV testing (adjusted odds ratio, aOR: 4.9; 95% confidence interval, CI: 2.3-10.6) and infant prophylaxis (aOR: 6.9; 95% CI: 1.2-38.9) than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis (aOR: 15.4; 95% CI: 7.2-32.9) and infant testing (aOR: 13.7; 95% CI: 4.2-83.3) than women who had. CONCLUSION: Most women used the Malawian programme for the prevention of MTCT. The risk of MTCT increased if any of the main steps in the programme were missed.

Decompensated labyrinthine weakness presenting as de novo peripheral vertigo: a discrete clinical entity?

OBJECTIVE: A distinct subgroup of patients, presenting with apparently spontaneous onset of vertigo, is described. RESULTS: Although vestibular evaluation revealed caloric weakness, the proximate cause of vertigo was not labyrinthine dysfunction, but rather the loss of vestibular compensation for an older and previously compensated labyrinthine injury. CONCLUSION: Instead of addressing the vestibular weakness, effective management needs to focus on the condition that has caused the loss of compensation.

Benign positional vertigo and endolymphatic hydrops: what is the connection?

BACKGROUND: Although benign paroxysmal positional vertigo and endolymphatic hydrops are considered to be distinct diagnoses, a minority of vertiginous patients exhibit features of both conditions. This coincidence has been reported previously in the literature, and is reviewed here in terms of possible aetiology. RESULTS AND CONCLUSION: A new hypothesis to account for both conditions is offered, implicating free-floating degenerating debris from the otolithic apparatus. It is postulated that the gelatinous/proteinaceous component may account for an osmotically induced hydrops, while the calcified fragments may induce positional vertigo.

ENVIRONMENTAL DOSIMETRY WITH THE BeOSL PERSONAL DOSEMETER.

In the course of this work, a dosemeter for measurement of ambient dose equivalent H*(10) based on the BeOSL dosimetry system was designed. Calculations of the energy response of the two-element BeOSL personal dosemeter in terms of H*(10) showed that the response does not fulfil the requirements of IEC 62387 Especially, the response for photon energies of 60-100 keV is too low. It is possible to correct this under-response using a BeOSL two-element dosemeter, a linear algorithm and an additional cover for the dosemeter. The Hp(0.07) element is shielded with lead, and with the help of a linear algorithm, corrections of the energy response are possible. So, the national requirements for an H*(10) area dosemeter in Germany can be fulfilled. The requirements of IEC 62387 are fulfilled for angles of radiation incidence from 0° to 60° for a rotation around the vertical and horizontal axis through the dosemeter, whereas for angles of incidence from 75° to 90°, the requirements are only fulfilled for rotation around the vertical axis through both elements.

Scale-up of ART in Malawi has reduced case notification rates in HIV-positive and HIV-negative tuberculosis.

Setting: For 30 years, Malawi has experienced a dual epidemic of human immunodeficiency virus (HIV) infection and tuberculosis (TB) that has recently begun to be attenuated by the scale-up of antiretroviral therapy (ART). Objective: To report on the correlation between ART scale-up and annual national TB case notification rates (CNR) in Malawi, stratified by HIV-positive and HIV-negative status, from 2005 to 2015. Design: A retrospective descriptive ecological study using aggregate data from national reports. Results: From 2005 to 2015, ART was scaled up in Malawi from 28 470 to 618 488 total patients, with population coverage increasing from 2.4% to 52.2%. During this time, annual TB notifications declined by 35%, from 26 344 to 17 104, and the TB CNR per 100 000 population declined by 49%, from 206 to 105. HIV testing uptake increased from 51% to 92%. In known HIV-positive TB patients, the CNR decreased from a high of 1247/100 000 to 710/100 000, a 43% decrease. In known HIV-negative TB patients, the CNR also decreased, from a high of 66/100 000 to 49/100 000, a 26% decrease. Conclusion: TB case notifications have continued to decline in association with ART scale-up, with the decline seen more in HIV-positive than HIV-negative TB. These findings have programmatic implications for national TB control efforts.

Contexte : Pendant 30 ans, le Malawi a connu une double épidémie du virus de l'immunodéficience humaine (VIH) et de la tuberculose (TB) qui s'est atténuée récemment avec l'expansion du traitement antirétroviral (TAR).Objectif : Etablir la corrélation entre l'expansion du TAR et les notifications annuelles de cas de TB, stratifiés en fonction de leur statut VIH positif ou négatif, au Malawi, de 2005 à 2015.Schéma : Une étude rétrospective descriptive écologique reposant sur les données agrégées des rapports nationaux.Résultats : De 2005 à 2015, le Malawi a étendu le TAR de 28 470 à 618 488 patients, avec une couverture de la population passant de 2,4% à 52,2%. Pendant ce temps, les notifications annuelles de TB ont décliné de 35%, de 26 344 à 17 104, et le taux de notification des cas de TB par 100 000 population a décliné de 49%, de 206 à 105. L'utilisation du test VIH a augmenté de 51% à 92%. Chez les patients TB-VIH positifs, les taux de notification des cas ont diminué d'un niveau élevé de 1247/100 000 à 710/100 000 (diminution de 43%). Chez les patients TB-VIH négatifs connus, les taux de notification des cas ont également décru d'un taux élevé de 66/100 000 à 49/100 000 (diminution de 26%).Conclusion : Les notifications de cas de TB ont continué à décliner en association avec l'expansion du TAR, avec un déclin davantage constaté chez les patients TB-VIH positifs que chez les patients TB-VIH négatifs. Ces constatations ont des implications pour les programmes nationaux de lutte contre la TB.

Marco de referencia: Durante 30 años se ha presentado en Malawi una epidemia doble de infección por el virus de la inmunodeficiencia humana (VIH) y tuberculosis (TB), que se ha moderado en tiempos recientes gracias a la ampliación de escala de administración del tratamiento antirretrovírico (TAR).Objetivo: Evaluar la relación entre la ampliación de escala del TAR y la tasa anual nacional de notificación de casos de TB, estratificada por la situación frente al VIH, en Malawi del 2005 al 2015.Método: Fue este un estudio retrospectivo descriptivo ecológico a partir de los datos agregados de notificación a escala nacional.Resultados: Del 2005 al 2015 se amplió la escala de administración del TAR en Malawi de 28 470 a 618 488 casos, con un aumento de la cobertura del 2,4% al 52,2% de la población. Durante este período disminuyó un 35% la notificación anual de TB, de 26 344 a 17 104 casos, y un 49% la tasa de notificación, que pasó de 206 por 100 000 habitantes a 105/100 000. La aceptación de la prueba diagnóstica del VIH aumentó del 51% al 92%. En los pacientes positivos frente al VIH, la tasa de notificación de TB disminuyó de 1 247/100 000 a 710/100 000 (disminución del 43%). En los pacientes negativos frente al VIH, las tasas de notificación de TB también disminuyeron de 66/100 000 a 49/100 000 (disminución del 26%).Conclusión: La notificación de casos de TB ha continuado su disminución en paralelo con la ampliación de escala de administración del TAR; la disminución es mayor en los pacientes positivos frente al VIH que en los pacientes negativos. Estos resultados tienen consecuencias programáticas sobre las iniciativas nacionales de control de la TB.

PROPERTIES OF THE BEOSL DOSIMETRY SYSTEM IN THE FRAMEWORK OF A LARGE-SCALE PERSONAL MONITORING SERVICE.

The Individual Monitoring Service of the Helmholtz Zentrum München is currently using the BeOSL dosimetry system for monitoring ∼15 000 persons per month. This dosimetry system has a modular structure and represents a complete new concept on handling dosemeters in a large-scale dosimetry service. It is based on optically stimulated luminescence dosemeters made of beryllium oxide. The dosimetric and operational properties of the system are shown and discussed.

[Poliomyelitis--Challenges for the Last Mile of the Eradication Programme]. / Poliomyelitis--Herausforderungen in der Endphase des globalen Eradikationsprogramms.

The World Health Organisation initiated the Global Polio Eradication Initiative in the year 1988. With the large-scale application of routine and mass vaccinations in children under the age of 5 years, polio disease has become restricted to only 3 endemic countries (Afghanistan, Pakistan and Nigeria) by today. However, since the beginning of the 21st century, increasing numbers of secondary polio epidemics have been observed which were triggered through migration, political turmoil and weak health systems. In addition, there emerged serious technical (e. g., back-mutations of oral vaccine virus to wild virus) and socio-political (refusal of vaccinations in Muslim populations of Nigeria and Pakistan) problems with the vaccination in the remaining endemic countries. It thus appears questionable if the current eradiation initiative will reach its goal in the foreseeable future.

Decline in adverse outcomes and death in tuberculosis patients in Malawi: association with HIV interventions.

Between 2000 and 2012, the annual numbers of patients treated for tuberculosis (TB) in Malawi declined by 28%, from 28 234 to 20 463. During this time, the proportion of TB patients tested for the human immunodeficiency virus (HIV) increased from 6% to 87%. Most HIV-infected patients received cotrimoxazole preventive therapy, and the proportion receiving antiretroviral therapy increased to 88%. Between 2000 and 2008 there was a significant decline in all adverse outcomes (from 31% to 14%), and particularly in deaths (from 23% to 10%) and loss to follow-up (from 5.2% to 1.9%, P < 0.001). After 2008, there was no decrease in any adverse outcome. Ways to further reduce TB-associated mortality are discussed.

Entre 2000 et 2012, le nombre annuel de patients traités pour tuberculose (TB) au Malawi a décliné de 28%, passant de 28 234 à 20 463. Pendant cette période, la proportion de patients TB testés pour le virus de l'immunodéficience humaine (VIH) a augmenté de 6% à 87%, la majorité des patients infectés par le VIH a bénéficié d'un traitement préventif par cotrimoxazole et la proportion de patients recevant un traitement antirétroviral est passée à 88%. Entre 2000 et 2008, il y a eu un déclin significatif de toutes les évolutions défavorables (de 31% à 14%), en particulier des décès (de 23% à 10%) et des perdus de vue (de 5,2% à 1,9%; P < 0,001). Après 2008, il n'y a plus eu de diminution des évolutions défavorables. L'article discute des manières de poursuivre la réduction de la mortalité associée à la TB.

Del año 2000 al 2012, el número anual de pacientes tratados por tuberculosis (TB) en Malawi disminuyó un 28%, de 28 234 a 20 463. Durante este período, la proporción de pacientes TB en quienes se practicó la prueba diagnóstica de infección por el virus de la inmunodeficiencia humana (VIH) aumentó del 6% al 87%. La mayoría de los pacientes VIH positivo recibió tratamiento preventivo con cotrimoxazol, y la proporción de pacientes que recibía tratamiento antirretrovírico aumentó al 88%. Del 2000 al 2008 se observó una disminución considerable de todos los desenlaces desfavorables (del 31% al 14%) y sobre todo de las muertes (del 23% al 10%) y las pérdidas durante el seguimiento (del 5,2% al 1,9%; P < 0,001). Después del 2008, no se presentó disminución en ninguno de los desenlaces desfavorables. En el artículo se analizan modalidades que permitan disminuir aun más la mortalidad asociada con la TB.

The impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in Burkina Faso.

BACKGROUND: User fee removal policies have been extensively evaluated in relation to their impact on access to care, but rarely, and mostly poorly, in relation to their impact on household out-of-pocket (OOP) spending. This paucity of evidence is surprising given that reduction in household economic burden is an explicit aim for such policies. Our study assessed the equity impact on household OOP spending for facility-based delivery of the user fee reduction policy implemented in Burkina Faso since 2007 (i.e., subsidised price set at 900 Communauté Financière Africaine francs (CFA) for all, but free for the poorest). Taking into account the challenges linked to implementing exemption policies, we aimed to test the hypothesis that the user fee reduction policy had favoured the least poor more than the poor. METHODS: We used data from six consecutive rounds (2006-2011) of a household survey conducted in the Nouna Health District. Primary outcomes are the proportion of households being fully exempted (the poorest 20% according to the policy) and the actual level of household OOP spending on facility-based delivery. The estimation of the effects relied on a Heckman selection model. This allowed us to estimate changes in OOP spending across socio-economic strata given changes in service utilisation produced by the policy. FINDINGS: A total of 2,316 women reported a delivery between 2006 and 2011. Average household OOP spending decreased from 3,827 CFA in 2006 to 1,523 in 2011, without significant differences across socio-economic strata, neither in terms of households being fully exempted from payment nor in terms of the amount paid. Payment remained regressive and substantially higher than the stipulated 900 CFA. CONCLUSIONS: The Burkinabè policy led to a significant and sustained reduction in household OOP health spending across all socio-economic groups, but failed to properly target the poorest by ensuring a progressive payment system.

Cohort analysis of antenatal care and delivery outcomes in pregnancy: a basis for improving maternal health.

Cohort analysis has been the cornerstone of tuberculosis (TB) monitoring and evaluation for nearly two decades; these principles have been adapted for patients with the human immunodeficiency virus/acquired immune-deficiency syndrome on antiretroviral treatment and patients with diabetes mellitus and hypertension. We now make the case for using cohort analyses for monitoring pregnant women during antenatal care, up to and including childbirth. We believe that this approach would strengthen the current monitoring and evaluation systems used in antenatal care by providing more precise information at regular time intervals. Accurate real-time data on how many pregnant women are enrolled in antenatal care, their characteristics, the interventions they are receiving and the outcomes for mother and child should provide a solid basis for action to reduce maternal mortality.

Une analyse de cohorte a été la pierre angulaire du suivi et évaluation de la tuberculose pendant près de deux décennies ; ces principes ont été adaptés aux patients atteints de virus de l'immunodéficience humaine/syndrome de l'immunodéficience acquise sous traitement antiretroviral, ainsi qu'aux patients ayant un diabète et une hypertension. Nous recommandons maintenant l'utilisation d'analyse de cohorte pour le suivi des femmes enceintes en consultation prénatale et jusqu'à l'accouchement inclus. Nous pensons que cette approche renforcerait le système actuel de suivi et évaluation utilisé en consultation prénatale en fournissant des informations plus précises à intervalles réguliers. Des données exactes en temps réel sur le nombre de femmes enceintes enrôlées en consultation prénatale, leurs caractéristiques, l'intervention mise en place et les résultats vis-à-vis de la mère et de l'enfant, devraient fournir une solide base d'action visant à diminuer la mortalité maternelle.

El análisis de cohortes ha constituido la piedra angular del seguimiento y de la evaluación de la tuberculosis durante cerca de dos decenios; estos principios se adaptaron a los pacientes coinfectados por el virus de la inmunodeficiencia humana y la síndrome de la inmunodeficiencia adquirida que reciben tratamiento antirretrovírico y a los pacientes con diabetes e hipertensión. En el presente artículo se defiende la oportunidad de utilizar los análisis de cohortes en el seguimiento de las embarazadas durante el cuidado prenatal, hasta incluir el nacimiento. Se propone que esta estrategia reforzaría los sistemas de seguimiento y evaluación que se practican actualmente en la atención prenatal, pues aportaría información más precisa y a intervalos regulares. Obtener los datos exactos y en tiempo real sobre la forma como las embarazadas se inscriben a la atención prenatal, sus características, las principales intervenciones que reciben y los desenlaces de la madre y el niño aportaría fundamentos sólidos a las actividades encaminadas a disminuir la mortalidad materna.

Decline in national tuberculosis notifications with national scale-up of antiretroviral therapy in Malawi.

From 2000 to 2012, Malawi scaled up antiretroviral therapy (ART) from <3000 to 404 905 persons living with HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome), representing an ART coverage of 40.6% among those living with HIV. During this time, annual tuberculosis (TB) notifications declined by 28%, from 28 234 to 20 463. Percentage declines in annual TB case notifications were as follows: new TB (26%), recurrent TB (40%), new smear-positive pulmonary TB (19%), new smear-negative pulmonary TB (42%), extra-pulmonary TB (19%), HIV-positive TB (30%) and HIV-negative TB (10%). The decline in TB notifications is associated with ART scale-up, supporting its value in controlling TB in high HIV prevalence areas in sub-Saharan Africa.

De 2000 à 2012, le Malawi a étendu la thérapie antirétrovirale (ART) de <3000 à 404 905 personnes vivant avec le VIH/SIDA (virus de l'immunodéficience humaine/syndrome de l'immunodéficience acquise), aboutissant à une couverture par antirétroviraux de 40,6% parmi les personnes vivant avec le VIH. Durant cette période, la déclaration annuelle de la tuberculose (TB) a chuté de 28%, de 28 234 à 20 463. Les pourcentages de diminution annuelle des déclarations de cas de TB se répartissaient comme suit : nouveaux cas de TB (26%), rechute de TB (40%), nouvelle TB pulmonaire à frottis positif (19%), nouvelle TB pulmonaire à frottis négatif (42%), TB extra-pulmonaire (19%), TB chez un patient VIH positif (30%), TB chez un patient VIH négatif (10%). Un déclin dans la déclaration de la TB est associé à une expansion de l'ART, ce qui témoigne de sa valeur dans la lutte contre la TB dans les zones à prévalence élevée de VIH en Afrique sub-saharienne.

Entre el año 2000 y el 2012, se amplió en Malawi la escala de aplicación del tratamiento antirretrovírico (ART), de menos de 3000 a 404 905 personas con infección por el virus de la inmunodeficiencia humana (VIH) y síndrome de inmunodeficiencia adquirida, con lo cual se alcanzó una cobertura de 40,6% de las personas seropositivas. Durante este tiempo, disminuyó un 28% la tasa anual de notificación de tuberculosis (TB), de 28 234 a 20 463 casos. Se observaron las siguientes proporciones en la disminución de la notificación de casos: 26% en casos nuevos de TB, 40% en recaídas de TB, 19% en casos nuevos de TB pulmonar con baciloscopia positiva; 42% en casos nuevos de TB pulmonar con baciloscopia negativa, 19% en casos de TB extrapulmonar, 30% en casos de TB y seropositividad frente al VIH, y 10% en los casos de TB y seronegatividad frente al VIH. La observación de una disminución de la notificación de casos de TB asociada con la ampliación de escala del ART confirma la utilidad de esta estrategia en el control de la TB en las regiones con alta prevalencia de infección por el VIH en África subsahariana.

Malnutrition in young children of rural Burkina Faso: comparison of survey data from 1999 with 2009.

OBJECTIVE: For measurement of progress towards the Millennium Development Goal (MDG) 1, reliable data on nutrition indicators of specific countries are essential. Malnutrition is also the main determinant for childhood mortality, which is addressed in MDG 4. METHODS: In the health and demographic surveillance area of Kossi Province in north-western Burkina Faso, nutritional parameters were compared in two cohorts of young children of the same age range from eight villages. Surveys took place in June and December of the year 1999 and 2009. A multivariate model was used to control for confounding variables. RESULTS: For the 1999 study, data were analysed for 179 and 197 children who took part in the June and December survey respectively. In 2009, corresponding data were analysed for 460 and 409 children. Prevalence of underweight was highest in December 1999 (42.6%) and lowest in December 2009 (34.1%). After adjustment for age, sex and village, there was a slight but not always significant improvement in the z-scores of weight-for-age, weight-for-length, length-for-age, and mid-arm circumference over time. CONCLUSIONS: The findings from this study confirm the still unacceptable high prevalence of malnutrition in young children of rural sub-Saharan Africa (SSA). Progress in the reduction of malnutrition remains slow on this continent making it rather unlikely that the corresponding MDGs will be achieved. Large-scale multi-sectoral community-based interventions are urgently needed for a sustainable improvement of child health in SSA.