Evaluation of the uptake of tuberculosis preventative therapy for people living with HIV in Namibia: a multiple methods analysis.

BACKGROUND: In 2016, Namibia had ~ 230,000 people living with HIV (PLHIV) and 9154 new tuberculosis (TB) cases, including 3410 (38%) co-infected cases. TB preventative therapy (TPT), consisting of intensive case finding and isoniazid preventative therapy, is critical to reducing TB disease and mortality. METHODS: Between November 2014 and February 2015, data was abstracted from charts of PLHIV enrolled in HIV treatment. Fifty-five facilities were purposively selected based on patient volume, type and location. Charts were randomly sampled. The primary outcome was to estimate baseline TPT in PLHIV, using nationally weighted proportions. Qualitative surveys were conducted and summarized to evaluate TPT practices and quantify challenges encountered by health care workers (HCW). RESULTS: Among 861 PLHIV sampled, 96% were eligible for TPT services, of which 87.1% were screened for TB at least once. For PLHIV eligible for preventative therapy (646/810; 82.6%), 45.4% (294/646) initiated therapy and 45.7% (139/294) of those completed therapy. The proportion of eligible PLHIV completing TB screening, initiating preventative therapy and then completing preventative therapy was 20.7%. Qualitative surveys with 271 HCW identified barriers to TPT implementation including: lack of training (61.3% reported receiving training on TPT); misunderstandings about timing of TPT initiation (46.7% correctly reported TPT should be started with antiretroviral therapy); and variable screening practices and responsibilities (66.1% of HCWs screened for TB at every encounter). Though barriers were evident, 72.2% HCWs surveyed described their clinical performance as very good, often placing responsibility of difficulties on patients and downplaying challenges like staff shortages and medication stock outs. CONCLUSIONS: In this study, only 1 in 5 eligible PLHIV completed the TPT cascade in Namibia. Lack of training, irregularities with TB screening and timing of TPT, unclear prescribing and recording responsibilities, and a clinical misperception may have contributed to suboptimal programmatic implementation. Addressing these challenges will be critical with continued TPT scale-up.

Aerobic training in older adults with type 2 diabetes and vasodepressive carotid sinus hypersensitivity.

BACKGROUND AND AIMS: Vasodepressive carotid sinus hypersensitivity (V-CSH) is a common but incurable etiology for fainting in older adults with diabetes (OADM), and is diagnosed by carotid sinus massage (CSM). Aerobic exercise has been shown to be an effective therapy for other neuroautonomic etiologies of syncope (such as orthostatic hypotension), but the effectiveness of aerobic training in V-CSH remains unknown. We examined whether aerobic training could attenuate the vasodepressive response to CSM in OADM (older adults with type 2 diabetes) subjects complicated by V-CSH. METHODS: Forty OADM subjects (mean age 72.2 ± 0.7) complicated by V-CSH were recruited. Subjects were randomized to each of two groups: an aerobic group (AT, n = 20, 3 months vigorous aerobic exercise), and a nonaerobic (NA, n = 20, no aerobic exercise) group. Exercise sessions were supervised by a certified exercise trainer three times per week. The vasodepressive response [defined as the decrease in systolic blood pressure (SBP) during CSM] was measured before and after the training intervention using a Finometer. RESULTS: The intervention had no impact on the number of subjects that met the criteria for V-CSM in either the AT or NA groups, regardless of the criteria used (-10, -20, -30, -40 and -50 mmHg). There was no training effect on the vasodepressive response in either the AT or NA group (P = 0.214, 2-way analysis of variance, -30 mmHg definition for V-CSH). CONCLUSIONS: Aerobic training has no effect on the SBP response to CSM in OADM subjects with V-CSH. Unlike in other neuroautonomic etiologies for fainting, aerobic exercise is not effective as a treatment for V-CSH, at least in the OADM population.

Short-term aerobic exercise reduces nitroglycerin-induced orthostatic intolerance in older adults with type 2 diabetes.

AIMS/HYPOTHESIS: Older adults are at a high risk for syncope due to orthostatic intolerance (OI), and this risk increases with comorbid type 2 diabetes and vasoactive medications. Despite many benefits, previous investigations have shown worsening OI with aerobic training. We examined whether aerobic exercise reduced OI in older adults with type 2 diabetes who were given a short-acting vasoactive agent (nitroglycerin). METHODS: Forty older adults (25 males and 15 females, mean age 71.4 ± 0.7 years, ranging in age from 65 to 83 years) with type 2 diabetes were recruited. Subjects were randomized to each of 2 groups: an aerobic group (3 months of vigorous aerobic exercise) and a nonaerobic (no aerobic exercise) group. Exercise sessions were supervised by a certified exercise trainer 3 times per week. After being given 400 µg of sublingual nitroglycerin, each subject was placed in a 70° head-up tilt for 30 minutes. RESULTS: When the 2 groups were compared using a Cox proportional hazards model, tilt table tolerance was significantly better in the aerobic group as compared to in the nonaerobic group (χ(2)(MC) = 7.271, P = 0.007). CONCLUSIONS: Our findings indicate that a relatively short aerobic exercise intervention can improve postnitroglycerin orthostatic tolerance in older adults with type 2 diabetes.

Aerobic training restores arterial baroreflex sensitivity in older adults with type 2 diabetes, hypertension, and hypercholesterolemia.

OBJECTIVE: Lowered baroreflex sensitivity (BRS) predicts mortality and occurs with increasing age and diabetes. We examined whether aerobic exercise could restore arterial BRS in adults at high cardiovascular risk (diabetes, geriatric age group, hypercholesterolemia, and hypertension). DESIGN: Randomized, controlled, single-blind study. SETTING: VITALiTY (Vancouver Initiative to Add Life to Years) Research Laboratory. PARTICIPANTS: Thirty-nine older adults (mean age, 71.5 +/- 0.7 years) with diet-controlled or oral hypoglycemic-controlled type 2 diabetes, hypertension, and hypercholesterolemia. INTERVENTIONS: Subjects were recruited to each of 2 groups: an aerobic group (3 months of vigorous aerobic exercise as defined by 80% to 85% of maximal heart rate), and a nonaerobic (no aerobic exercise) group. Exercise sessions were supervised by a certified exercise trainer 3 times per week. MAIN OUTCOME MEASURES: : Baroreflex function was assessed using the spontaneous baroreflex method. Main outcome measures included BRS, BRS(up), BRS(down), and [latin capital V with dot above]o(2)max. RESULTS: The aerobic group demonstrated an increase in BRS that was not demonstrated in the nonaerobic group (+60.9 +/- 23.5 vs +2.2 +/- 7.9%; P = 0.010). CONCLUSIONS: Our findings indicate that a relatively short aerobic exercise intervention can reverse functional impairments of the arterial baroreflex function in older adults at high cardiovascular risk.

Arterial baroreflex function in older adults with neurocardiogenic syncope.

PURPOSE: Neurocardiogenic syncope (formerly vasovagal) accounts for large numbers of falls in older adults and the mechanisms are poorly understood. This study examined the differences in baseline arterial baroreflex function in older adults with and without a neruocardiovascular response to orthostatic stress. METHODS: Subjects were divided into two groups based on the presence (TT+ group) or absence (TT- group) of a neurocardiovascular response to upright tilting (70 degree head-up tilt for 10 minutes after 400 micrograms of sublingual nitroglycerin). A neurocardiovascular response was defined as presyncopal symptoms (lightheadedness) in association with at least a 30 mm Hg decrease in blood pressure. Before being divided into groups, baroreflex function was assessed using the spontaneous baroreflex method (baroreflex sensitivity, BRS). This method involves the analysis of "spontaneous" swings in blood pressure and heart rate that are mediated by the arterial baroreflexes. RESULTS: 42 older adults (mean age 70.3+/-0.7 yr) were recruited, of which 18 were in the TT+ and 24 were in the TT- group. At baseline, the TT+ group demonstrated increased arterial baroreflex sensitivity in response to negative blood pressure sequences only (BRSdown, 11.2+/-1.9 vs. 7.3+/-1.0 ms/mm Hg, P=0.011). During tilt, the TT+ group demonstrated a much larger decrease in overall arterial baroreflex sensitivity than the TT- group (-6.8+/-1.2 vs. -3.2+/-0.9 ms/mm Hg, P=0.012). There was a negative correlation between BRSdown and length of tilt table test (r=-0.329, P=0.041) in the TT+ subjects. CONCLUSION: Older adults with neurocardiogenic syncope have exaggerated arterial baroreflex sensitivity at baseline.

The life and death of a street boy in East Africa: everyday violence in the time of AIDS.

This article focuses on the life history of a single street boy in northwestern Tanzania, whom I name Juma. I suggest that Juma's experiences and the life trajectory of himself and of significant individuals around him (particularly his mother) were structured by everyday violence. I describe everyday violence in terms of a conjuncture between macrostructural forces in East Africa (including a history of failed development schemes and the contemporary political economy of neoliberalism) and the lived experience of individuals as they negotiate local, contextual factors (including land-tenure practices, the power dynamics between immediate and extended kin, life on the streets, and constructions of gender and sexuality). I suggest that AIDS and its many impacts on Juma's life course can only be understood in a broader context of everyday violence. From this basis, I draw several general conclusions regarding AIDS prevention and intervention strategies.

The oral glucose tolerance test induces myocardial ischemia in healthy older adults.

PURPOSE: Postprandial myocardial ischemia has been observed in frail older adults with postprandial hypotension and in patients with severe coronary artery disease, especially after high doses of carbohydrates. The impact of oral glucose on myocardial oxygen supply and demand in healthy older adults without postprandial hypotension or postprandial angina remains unexamined. We hypothesized that oral glucose would result in decreased myocardial oxygen supply relative to demand in a healthy older subject pool free of postprandial hypotension, reversible coronary risk factors and postprandial angina. METHODS: 19 older adults (mean age 71.9+/-1.1 yr) were screened for reversible coronary risk factors. Subjects were given a standardized oral glucose load (75 g) or a sham isovolumetric unsweetened drink during two separate sessions. Indirect measures of oxygen supply (Diastolic Pressure Time Index, DPTI) and demand (Rate Pressure Product, RPP; Systolic Pressure Time Index, SPTI) were obtained from aortic arterial blood pressure waveforms. The Subendocardial Viability Ratio (SEVR, DPTI/SPTI) and DPTI/RPP were also calculated. RESULTS: Oral glucose resulted in decreases in both SEVR (P=0.016) and DPTI/RPP (P=0.028) in the glucose session, indicating a decrease in the relative myocardial oxygen supply to demand. This was due solely to a decrease in myocardial oxygen supply while measures of myocardial oxygen demand did not change significantly. CONCLUSIONS: Oral glucose decreases myocardial oxygen supply in older adults free of severe coronary artery disease and without postprandial hypotension. This represents a previously unrecognized complication of oral glucose tolerance tests in healthy older adults.

Kunyenga, "real sex," and survival: assessing the risk of HIV infection among urban street boys in Tanzania.

This article examines possible avenues of HIV infection among urban street boys in Tanzania. In doing so, it questions the ways that AIDS researchers have defined and approached the phenomenon of "survival sex" in East and Central Africa. The article specifically examines the boys' sexual networks, sexual practices, and attitudes regarding their own sexual behavior, including their perceived risk of HIV/AIDS infection. Seventy-five street boys aged eight to 20 from the city of Mwanza were interviewed. Results suggest that almost all street boys are involved in a sexual network in which homosexual and heterosexual behavior occurs. Homosexual practices are rooted in a complex set of behaviors and ideologies known as kunyenga, which is a situated aspect of life on the streets and helps maintain the boys' strong dependence on one another. A key aspect of the boys' sexual careers involves a decrease in kunyenga activity as they approach the age of 18 and an increase in heterosexual encounters after the age of 11. There appears to be a critical period between these ages in which heterosexual and kunyenga activities overlap. It is suggested that boys between these ages represent a potential bridge for HIV/AIDS infection between the general population and the relatively enclosed sexual network of street boys.

Experiencing "change" from within: situating the transition to primary health care in a remote Australian context.

The transition to primary health care (PHC) is often described in an idealized manner, which either ignores or obscures the experiences associated with its implementation at the local level. By adopting an anthropological perspective, this article highlights some of these experiences and the context within which they occur for one health care organisation in remote Western Australia. It specifically focuses on problems associated with economic rationalism, managerialism, and the inherently fragmented character of health service organisations. Such issues must be allowed to inform idealized PHC models in order to make them more applicable and attuned to local needs and realities.

A review of community consultation in the development of a multi purpose service in rural and remote Australia.

This paper examines the role of community consultation and participation in the process of establishing a Multi Purpose Service (MPS) program in two towns in Western Australia. Information was gathered through written documents and semi-structured interviews with individuals who were integral to the process. Consumer involvement in health care is increasing, and while claims of being community driven underpinned the MPS program, our findings suggest otherwise. Conflicts of interest, a lack of representation, and misunderstandings about the meaning of community consultation were present throughout the process of implementation. Moreover, official reports either ignore or downplay these events. We conclude that more attention must be paid to the role of the community in the health reform agenda generally and the MPS program specifically.

Sedentary behavior and sleep efficiency in active community-dwelling older adults.

OBJECTIVES: Previous studies have demonstrated that aerobic exercise interventions have a positive impact on sleep efficiency in older adults. However, little work has been done on the impact of sedentary behavior (sitting, watching television, etc.) on sleep efficiency. METHODS: 54 Community-dwelling men and women >65 years of age living in Whistler, British Columbia (mean 71.5 years) were enrolled in this cross-sectional observational study. Measures of sleep efficiency as well as average waking sedentary (ST), light (LT), and moderate (MT) activity were recorded with Sensewear accelerometers worn continuously for 7 days. RESULTS: From the univariate regression analysis, there was no association between sleep efficiency and the predictors LT and MT. There was a small negative association between ST and sleep efficiency that remained significant in our multivariate regression model containing alcohol consumption, age and gender as covariates. (standardized ß correlation coefficient -0.322, p=0.019). Although significant, this effect was small (an increase in sedentary time of 3 hours per day was associated with an approximately 5% reduction in sleep efficiency). CONCLUSIONS: This study found a small significant association between the time spent sedentary and sleep efficiency, despite high levels of activity in this older adult group.

Arterial stiffness and the response to carotid sinus massage in older adults.

BACKGROUND AND AIMS: Carotid sinus hypersensitivity (CSH) is a common cause of fainting and falls in the older adult population and is diagnosed by carotid sinus massage (CSM). Previous work has suggested that age-related stiffening of blood vessels reduces afferent input from the carotid sinus leading to central upregulation of the overall arterial baroreflex response. We examined the differences in arterial stiffness and baroreflex function in older adults at high cardiovascular risk (advanced age, Type 2 diabetes, hypertension and hyperlipidemia) with and without CSH. METHODS: Forty-three older adults (mean age 71.4+/-0.7) with Type 2 diabetes, hyperlipidemia and hypertension were recruited. After resting supine for 45 minutes prior to the start of data collection, each subject had arterial stiffness measured by pulse wave velocity (PWV, Complior SD), followed by spontaneous baroreflex measures (Baroreflex sensitivity, BRS) and CSM. RESULTS: Of the 43 subjects tested, 10 subjects met the criteria for CSH (8 pure vasodepressor and 2 mixed CSH). CSH subjects had higher measures of arterial stiffness when compared to normal subjects for both radial PWV (11.5+/-0.6 vs 9.6+/-0.4 m/s, p=0.043) and femoral PWV (13.4+/-0.9 vs 11.0+/-0.5 m/s, p=0.036). The CSH group demonstrated significantly lower BRS as compared to the normal group (BRS, 6.73+/-0.58 vs 10.41+/-0.85 ms/mmHg, p=0.038). These results were unchanged when the analysis was repeated with only the VD subjects. CONCLUSIONS: Older adults with CSH have higher arterial stiffness and reduced arterial baroreflex sensitivity. There was no evidence to support upregulation of the arterial baroreflex in patients with CSH.

Short-term aerobic exercise reduces arterial stiffness in older adults with type 2 diabetes, hypertension, and hypercholesterolemia.

OBJECTIVE The relationship between increased arterial stiffness and cardiovascular mortality is well established in type 2 diabetes. We examined whether aerobic exercise could reduce arterial stiffness in older adults with type 2 diabetes complicated by comorbid hypertension and hyperlipidemia. RESEARCH DESIGN AND METHODS A total of 36 older adults (mean age 71.4 +/- 0.7 years) with diet-controlled or oral hypoglycemic-controlled type 2 diabetes, hypertension, and hypercholesterolemia were recruited. Subjects were randomly assigned to one of two groups: an aerobic group (3 months vigorous aerobic exercise) and a nonaerobic group (no aerobic exercise). Exercise sessions were supervised by a certified exercise trainer three times per week, and a combination of cycle ergometers and treadmills was used. Arterial stiffness was measured using the Complior device. RESULTS When the two groups were compared, aerobic training resulted in a decrease in measures of both radial (-20.7 +/- 6.3 vs. +8.5 +/- 6.6%, P = 0.005) and femoral (-13.9 +/- 6.7 vs. +4.4 +/- 3.3%, P = 0.015) pulse-wave velocity despite the fact that aerobic fitness as assessed by Vo(2max) did not demonstrate an improvement with training (P = 0.026). CONCLUSIONS Our findings indicate that a relatively short aerobic exercise intervention in older adults can reduce multifactorial arterial stiffness (type 2 diabetes, aging, hypertension, and hypercholesterolemia).

Euglycemic hyperinsulinemia alters the response to orthostatic stress in older adults with type 2 diabetes.

OBJECTIVE: Insulin has opposing influences on blood pressure by simultaneously increasing adrenergic activity and vasodilatating peripheral blood vessels. In this study, we sought to determine whether hyperinsulinemia affects tilt table responses in older adults with type 2 diabetes not complicated by orthostatic hypotension. RESEARCH DESIGN AND METHODS: Twenty-two older adults (mean age 71.7 +/- 1.1) with diet-controlled or oral hypoglycemic drug-controlled type 2 diabetes were recruited. All subjects with orthostatic hypotension, diabetic nephropathy, and sensory neuropathy were excluded. Subjects underwent euglycemic-hyperinsulinemic clamp and placebo "sham clamp" sessions. Sequential euglycemic-hyperinsulinemic clamps were performed for 2 h at 40 mU x m(-2) x min(-1) (low dose) and 2 h at 80 mU x m(-2) x min(-1) (high dose), and each was followed by a head-up tilt table test at 70 degrees C for 10 min. RESULTS: There were no incidents of presyncope during the sham clamp, whereas there were four presyncopal events during both the low-dose and high-dose tilts. Although the low-dose clamp showed no difference in the response between sessions (two-way ANOVA), subjects demonstrated a significantly larger decrease in mean arterial pressure (P = 0.005) and diastolic blood pressure (P = 0.08) during the high-dose tilt. Doppler measures of middle cerebral artery velocity were no different between the two sessions at either dose. CONCLUSIONS: The vasodilatory response to insulin can unmask orthostatic intolerance in older adults with type 2 diabetes, resulting in presyncopal symptoms. This could contribute to orthostatic hypotension in combination with other factors such as hyperthermia, hypovolemia, and adverse effects from medications.

Oral glucose tolerance test reduces arterial baroreflex sensitivity in older adults.

Although postprandial decreases in blood pressure are a common cause of syncope in the older adult population, the postprandial effects of the oral glucose tolerance test on blood pressure and the arterial baroreflex remain poorly characterized in older adults. Therefore, arterial blood pressure and the arterial baroreflex were studied in 19 healthy older adults (mean age 71.7 +/- 1.1 years) who were given a standardized oral glucose load (75 g) or an isovolumetric sham drink during 2 separate sessions. All measures were taken for 120 min after treatment. Baroreflex function was assessed by using the spontaneous baroreflex method (baroreflex sensitivity, BRS). Subjects demonstrated a decrease in BRS after oral glucose that was not seen in the placebo session (two-way analysis of variance, p = 0.04). There was no significant change in systolic, mean, or diastolic blood pressure; together with a drop in BRS, this resulted in a significant tachycardia post glucose (two-way analysis of variance, p < 0.001). We conclude that healthy older adults can successfully maintain blood pressure during an oral glucose tolerance test despite a decrease in arterial BRS. Decreased BRS resulted in a tachycardic response to glucose.

Collaboration and referral practices of general practitioners and community mental health workers in rural and remote Australia.

OBJECTIVE: To assess an important part of Australia's National Mental Health Strategy by examining the collaboration and referral practices between general practitioners and community mental health workers in rural and remote areas. DESIGN: Semistructured interviews. SETTING: Rural and remote health service region in Australia. PARTICIPANTS: In total, 31 general practitioners and 14 mental health workers. RESULTS: Meaningful collaboration and referral practices between general practitioners and mental health workers are prevented by contradictory and ambiguous definitions involving professional roles and mental health. A pattern of negative collaboration was further magnified by the rural and remote context. CONCLUSION: The implementation of Australia's National Mental Health Strategy faces serious problems in rural and remote area due to the negative collaboration and referral practices between general practitioners and mental health workers.