Cluster munitions: a threat to health and human rights.

Over the course of 2009, dozens of nations signed a new convention on cluster munitions, and several nations ratified the convention. To determine how public health professionals can participate in preventing death and injury from cluster munitions, we review the history of these weapons, their effects on individuals and communities, the history of efforts to limit their use, the Convention on Cluster Munitions, and ways that health professionals can support efforts to ban their use. Cluster munitions are a threat to civilians in conflict and post-conflict settings. They render homes, farms and businesses dangerous and inaccessible, and delay resettlement after the end of a conflict. Health professionals have led efforts to limit the use and proliferation of other weapons, and global collaboration to support the Convention on Cluster Munitions would be a step towards protecting the public's health.

Mortality and immunological recovery among older adults on antiretroviral therapy at a large urban HIV clinic in Kampala, Uganda.

BACKGROUND: We describe older (>50 years) HIV-infected adults after antiretroviral therapy (ART) initiation, evaluating immunological recovery by age category, considering individual trajectories based on the pretreatment CD4. We also describe mortality on ART and its risk factors by age category including the contribution of poor immunological recovery at a large urban clinic in Kampala, Uganda. METHODS: We performed a cohort analysis of adult (>18 years) HIV-infected patients who initiated ART between January 1, 2004 and January 3, 2012. Immunological response was evaluated using mixed-effects linear regression. We described mortality using Kaplan-Meier survival methods analyzing for risk factors of mortality using multivariate Weibull survival regression stratified by age category. RESULTS: Among 9806 individuals who initiated ART, mean age was 37 years (SD: 8.8), average follow-up 5.7 years (SD: 1.7), and median baseline CD4 was 115 cells per cubic millimeter (interquartile range: 42-184). Adults younger than 50 years had on average a higher CD4 increase of 45 cells per cubic millimeter (95% confidence interval: 17 to 72; P = 0.001) compared with counterparts aged 60 years and older. Mortality was highest among older adults compared with younger counterparts. Only CD4 count <100 cells per cubic millimeter after 1 year on ART and a CD4 count less than baseline were associated with a statistically significant higher rate of death among older adults. CONCLUSIONS: Older adults had a slower immunological response, which was associated with mortality, but this mortality was not typically associated with opportunistic infections. Future steps would require more evaluation of possible causes of death among these older individuals if survival on ART is to be further improved.

Determinants of clinician knowledge on aging and HIV/AIDS: a survey of practitioners and policy makers in Kampala District, Uganda.

OBJECTIVE: The HIV/AIDS epidemic has evolved with an increasing burden in older adults. We assessed for knowledge about aging and HIV/AIDS, among clinicians in Kampala district, Uganda. METHODS: A cross-sectional survey of 301 clinicians complemented by 9 key-informant interviews between May and October 2011. Data was analyzed by multivariable logistic regression for potential determinants of clinician knowledge about HIV/AIDS in older adults, estimating their adjusted Odds Ratios (aOR) and 95% confidence intervals (95% CI) using Stata 11.2 software. RESULTS: Two-hundred and sixty-two questionnaires (87.7%) were returned. Respondents had a median age of 30 years (IQR 27-34) and 57.8% were general medical doctors. The mean knowledge score was 49% (range 8.8%-79.4%). Questions related to co-morbidities in HIV/AIDS (non-AIDS related cancers and systemic diseases) and chronic antiretroviral treatment toxicities (metabolic disorders) accounted for significantly lower scores (mean, 41.7%, 95% CI: 39.3%-44%) compared to HIV/AIDS epidemiology and prevention (mean, 65.7%, 95% CI: 63.7%-67.7%). Determinants of clinician knowledge in the multivariable analysis included (category, aOR, 95% CI): clinician age (30-39 years; 3.28∶1.65-9.75), number of persons with HIV/AIDS seen in the past year (less than 50; 0.34∶0.14-0.86) and clinical profession (clinical nurse practitioner; 0.31∶0.11-0.83). Having diploma level education had a marginal association with lower knowledge about HIV and aging (p = 0.09). CONCLUSION: Our study identified gaps and determinants of knowledge about HIV/AIDS in older adults among clinicians in Kampala district, Uganda. Clinicians in low and middle income countries could benefit from targeted training in chronic care for older adults with HIV/AIDS and long-term complications of antiretroviral treatment.

Clinical differences between younger and older adults with HIV/AIDS starting antiretroviral therapy in Uganda and Zimbabwe: a secondary analysis of the DART trial.

OBJECTIVE: Clinical and immunological data about HIV in older adults from low and middle income countries is scarce. We aimed to describe differences between younger and older adults with HIV starting antiretroviral therapy in two low-income African countries. SETTING: HIV clinics in Uganda and Zimbabwe. DESIGN: Secondary exploratory cross-sectional analysis of the DART randomized controlled trial. OUTCOME MEASURES: Clinical and laboratory characteristics were compared between adults aged 18-49 years (younger) and ≥ 50 years (older), using two exploratory multivariable logistic regression models, one with HIV viral load (measured in a subset pre-ART) and one without. RESULTS: A total of 3316 eligible participants enrolled in DART were available for analysis; 219 (7%) were ≥ 50 years and 1160 (35%) were male. Across the two adjusted regression models, older adults had significantly higher systolic blood pressure, lower creatinine clearance and were consistently less likely to be females compared to younger adults with HIV. Paradoxically, the models separately suggested that older adults had statistically significant (but not clinically important) higher CD4+ cell counts and higher plasma HIV-1 viral copies at initiation. Crude associations between older age and higher baseline hemoglobin, body mass index, diastolic blood pressure and lower WHO clinical stage were not sustained in the adjusted analysis. CONCLUSIONS: Our study found clinical and immunological differences between younger and older adults, in a cohort of Africans starting antiretroviral therapy. Further investigations should explore how these differences could be used to ensure equity in service delivery and affect outcomes of antiretroviral therapy.

Hypersensitivity testing for Aspergillus fumigatus IgE is significantly more sensitive than testing for Aspergillus niger IgE.

We sought to determine if sufficient redundancy exists between specific IgE testing for Aspergillus fumigatus and Aspergillus niger to eliminate one of the assays in determining Aspergillus hypersensitivity. We reviewed regional laboratory results comparing A fumigatus-specific IgE with A niger-specific IgE using the Pharmacia UniCAP system (Pharmacia, Kalamazoo, MI). By using the Fisher exact test as an index of concordance among paired results, we showed a significant difference between 109 paired samples for the presence of specific IgE to A fumigatus and A niger (P < .0001). Of these specimens, 94 were negative for IgE to both species, 10 were positive for A fumigatus and negative for A niger; no specimen was positive for A niger and negative for A fumigatus. We conclude that A fumigatus-specific IgE is sufficient to detect Aspergillus hypersensitivity. The assay for A niger-specific IgE is redundant, less sensitive, and unnecessary if the assay for specific IgE for A fumigatus is performed.

A pilot study of the neuropsychological benefits of computerized cognitive rehabilitation in Ugandan children with HIV.

OBJECTIVE: Because antiretroviral treatment (ART) fails to improve neurocognitive impairment in children with HIV, we completed a pilot study evaluating the feasibility and cognitive benefit of computerized cognitive rehabilitation therapy (CCRT) in Ugandan children with HIV. METHOD: Sixty Ugandan children with HIV (23 on ART) were randomly assigned to 10 sessions of Captain's Log CCRT (Sandford, 2007) training configured for attention and memory skills or no intervention. Kaufman Assessment Battery for Children (2nd ed., KABC-2; Kaufman & Kaufman, 2004) performance at baseline indicated pervasive neurocognitive impairment. Cognitive ability was assessed before and after training using the Cogstate computerized neuropsychological test (Darby, Maruff, Collie, & McStephen, 2002). Viral load along with CD4 and CD8 absolute and activation levels also were measured posttest. RESULTS: CCRT was well received with a 95% adherence rate to scheduled training sessions. CCRT intervention children showed greater improvement on a Cogstate card detection task of simple attention (p = .02), and speed of correct moves on a Groton Maze Learning Task (p < .001). These analyses were completed using an analysis of covariance model that adjusted Cogstate performance for the child's age, standardized weight for age, gender, socioeconomic status, school grade level, and baseline KABC-2 performance. ART treatment was not related to Cogstate performance or improvement as a result of CCRT. CD4 and CD8 activation levels were correlated with Cogstate improvement specifically for the CCRT group. CONCLUSIONS: CCRT was feasible with our study population and improved maze learning and attention on a detection task. This supports previous findings by our group with cerebral malaria survivors (Bangirana, Giordani, et al., 2009).