What clinic closure reveals about care for drug-resistant TB: a qualitative study.

BACKGROUND: There have been calls for "person-centered" approaches to drug-resistant tuberculosis (DR-TB) care. In 2020, Charles James Hospital in South Africa, which incorporated person-centered care, was closed. Patients were referred mid-course to a centralized, tertiary hospital, providing an opportunity to examine person-centered DR-TB and HIV care from the perspective of patients who lost access to it. METHODS: The impact of transfer was explored through qualitative interviews performed using standard methods. Analysis involved grounded theory; interviews were assessed for theme and content. RESULTS: After switching to the centralized site, patients reported being unsatisfied with losing access to a single clinic and pharmacy where DR-TB, HIV and chronic disease care were integrated. Patients also reported a loss of care continuity; at the decentralized site there was a single, familiar clinician whereas the centralized site had multiple, changing clinicians and less satisfactory communication. Additionally, patients reported more disease-related stigma and less respectful treatment, noting the loss of a "special place" for DR-TB treatment. CONCLUSION: By focusing on a DR-TB clinic closure, we uncovered aspects of person-centered care that were critical to people living with DR-TB and HIV. These perspectives can inform how care for DR-TB is operationalized to optimize treatment retention and effectiveness.

Quantitative Proteomic Analysis Reveals Yeast Cell Wall Products Influence the Serum Proteome Composition of Broiler Chickens.

With an ever-growing market and continual financial pressures associated with the prohibition of antibiotic growth promoters, the poultry industry has had to rapidly develop non-antibiotic alternatives to increase production yields. A possible alternative is yeast and its derivatives, such as the yeast cell wall (YCW), which have been proposed to confer selected beneficial effects on the host animal. Here, the effect of YCW supplementation on the broiler chicken was investigated using a quantitative proteomic strategy, whereby serum was obtained from three groups of broilers fed with distinct YCW-based Gut Health Products (GHP) or a control basal diet. Development of a novel reagent enabled application of ProteoMiner™ technology for sample preparation and subsequent comparative quantitative proteomic analysis revealed proteins which showed a significant change in abundance (n = 167 individual proteins; p < 0.05); as well as proteins which were uniquely identified (n = 52) in, or absent (n = 37) from, GHP-fed treatment groups versus controls. An average of 7.1% of proteins showed changes in abundance with GHP supplementation. Several effects of these GHPs including immunostimulation (via elevated complement protein detection), potential alterations in the oxidative status of the animal (e.g., glutathione peroxidase and catalase), stimulation of metabolic processes (e.g., differential abundance of glyceraldehyde-3-phosphate dehydrogenase), as well as evidence of a possible hepatoprotective effect (attenuated levels of serum α-glutathione s-transferase) by one GHP feed supplement, were observed. It is proposed that specific protein detection may be indicative of GHP efficacy to stimulate broiler immune status, i.e., may be biomarkers of GHP efficacy. In summary, this work has developed a novel technology for the preparation of high dynamic range proteomic samples for LC-MS/MS analysis, is part of the growing area of livestock proteomics and, importantly, provides evidential support for beneficial effects that GHP supplementation has on the broiler chicken.

Prevention of common healthcare-associated infections in humanitarian hospitals.

PURPOSE OF REVIEW: Humanitarian medical organizations focus on vulnerable patients with increased risk for healthcare-associated infections (HAIs) and are obligated to minimize them in inpatient departments (IPDs). However, in doing so humanitarian groups face considerable obstacles. This report will focus on approaches to reducing common HAIs that the authors have found to be helpful in humanitarian settings. RECENT FINDINGS: HAIs are common in humanitarian contexts but there are few interventions or guidelines adapted for use in poor and conflict-affected settings to improve prevention and guide surveillance. Based on existing recommendations and studies, it appears prudent that all humanitarian IPDs introduce a basic infection prevention infrastructure, assure high adherence to hand hygiene with wide accessibility to alcohol-based hand rub, and develop pragmatic surveillance based on clinically evident nosocomial infection. Although microbiology remains out of reach for most humanitarian hospitals, rapid tests offer the possibility of improving the diagnosis of HAIs in humanitarian hospitals in the decade ahead. SUMMARY: There is a dearth of new studies that can direct efforts to prevent HAIs in IPDs in poor and conflict-affected areas and there is a need for practical, field-adapted guidelines from professional societies, and international bodies to guide infection prevention efforts in humanitarian environments.

Invasive Infection and Outcomes in a Humanitarian Surgical Burn Program in Haiti.

BACKGROUND: Compare to high-income settings, survival in burn units in low-income settings is lower with invasive infections one leading cause of death. Médecins Sans Frontières is involved in the treatment of large burns in adults and children in Haiti. METHODS: In 2014, we performed a review of 228 patients admitted consecutively with burn injury during a 6-month period to determine patient outcomes and infectious complications. Microbiology was available through a linkage with a Haitian organization. Regression analysis was performed to determine covariates associated with bloodstream infection and mortality. RESULTS: 102 (45 %) patients were male, the median age was 8 years (IQR, 2-28), and the majority of patients (60 %) were admitted to the unit within 6 h of injury. There were 20 patients (9 %) with culture-proven bacteremia. Among organisms in blood, common isolates were Staphylococcus aureus (42 %), Pseudomonas aeruginosa (23 %), and Acinetobacter baumannii (15 %). Among patients with burns involving <40 % total body area, 4 (2 %) of 192 died and 20 (65 %) of 31 with ≥40 % body surface area involvement died. Factors associated with mortality included involvement of ≥40 % of body surface, depth, and flame as the mechanism. Multidrug-resistant infections were common; 18 % of S. aureus isolates were methicillin resistant, and 83 % of P. aeruginosa isolates were imipenem resistant. CONCLUSIONS: A low mortality rate was observed in a humanitarian burn surgery project in patients with burns involving <40 % of total body surface. Invasive infection was common and alarming rates of antibiotic resistance were observed, including infections not treatable with antibiotics available locally.

Yeast mannan rich fraction positively influences microbiome uniformity, productivity associated taxa, and lay performance.

BACKGROUND: Alternatives to antibiotic as growth promoters in agriculture, such as supplemental prebiotics, are required to maintain healthy and high performing animals without directly contributing to antimicrobial resistance bioburden. While the gut microbiota of broiler hens has been well established and successfully correlated to performance, to our knowledge, a study has yet to be completed on the effect of prebiotic supplementation on correlating the mature laying hen productivity and microbiota. This study focused on establishing the impact of a yeast derived prebiotic, mannan rich fraction (MRF), on the cecal microbiota of late laying hens. This study benefitted from large sample sizes so intra- and intergroup variation effects could be statistically accounted for. RESULTS: Taxonomic richness was significantly greater at all taxonomic ranks and taxonomic evenness was significantly lower for all taxonomic ranks in MRF-supplemented birds (P < 0.005). Use of principal coordinate analyses and principal component analyses found significant variation between treatment groups. When assessed for compositional uniformity (an indicator of flock health), microbiota in MRF-supplemented birds was more uniform than control birds at the species level. From a food safety and animal welfare perspective, Campylobacter jejuni was significantly lower in abundance in MRF-supplemented birds. In this study, species associated with high weight gain (an anticorrelator of performance in laying hens) were significantly lower in abundance in laying hens while health-correlated butyrate and propionate producing species were significantly greater in abundance in MRF-supplemented birds. CONCLUSIONS: The use of prebiotics may be a key factor in controlling the microbiota balance limiting agri-food chain pathogen persistence and in promoting uniformity. In previous studies, increased α- and ß-diversity indices were determinants of pathogen mitigation and performance. MRF-supplemented birds in this study established greater α- and ß-diversity indices in post-peak laying hens, greater compositional uniformity across samples, a lower pathogenic bioburden and a greater abundance of correlators of performance.

Dolutegravir Resistance in African Programmatic Settings Among Patients With Failure of Dolutegravir-based ART.

Dolutegravir resistance is emerging in routine clinical contexts in southern Africa, primarily in patients with prior treatment experience failing dolutegravir-based antiretroviral therapy (ART). This potential issue was raised by The Nucleosides and Darunavir/Dolutegravir in Africa trial that compared dolutegravir and boosted protease inhibitor-based therapy as second-line ART, in which new dolutegravir resistance was observed at failure. However, recent data suggest that also at risk are patients who were transitioned to dolutegravir from non-nucleoside reverse transcriptase inhibitor-based ART while viremic. Identifying patients experiencing failure of dolutegravir with resistance will be difficult given current gaps in viral load monitoring and limited capacity for genotypic resistance testing. As a result, in the short term, most patients affected will go unrecognized, with particularly important implications for patients affected who have advanced HIV or who are pregnant/breastfeeding. Prospective research is needed to understand the scope of the problem, identify additional risk factors, and determine best management. In the short term, for most patients with dolutegravir resistance and prior non-nucleoside reverse transcriptase inhibitor exposure, the best option will be a timely switch to a regimen anchored by a boosted protease inhibitor, with a high genetic barrier to resistance.

The burden of hospital-acquired infections (HAI) in sub-Saharan Africa: a systematic review and meta-analysis.

Background: Hospital-acquired infections (HAI) are a leading cause of morbidity and mortality globally. These infections are diverse, but the majority are lower respiratory tract infection (LRTI), surgical site infection (SSI), bloodstream infection (BSI), and urinary tract infection (UTI). For most sub-Saharan African countries, studies revealing the burden and impact of HAI are scarce, and few systematic reviews and meta-analysis have been attempted. We sought to fill this gap by reporting recent trends in HAI in sub-Saharan Africa (SSA) with attention to key patient populations, geographic variation, and associated mortality. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a literature search of six electronic databases (Web of Science, Pubmed, APA PsycInfo, CINAHL, Embase, and the Cochrane Library) to identify studies assessing the prevalence of HAI in SSA countries. Studies published between 01 January 2014 and 31 December 2023 were included. We applied no language or publication restrictions. Record screening and data extractions were independently conducted by teams of two or more reviewers. Using the R software (version 4.3.1) meta and metafor packages, we calculated the pooled prevalence estimates from random-effect meta-analysis, and further explored sources of heterogeneity through subgroup analyses and meta-regression. This study is registered with PROSPERO, CRD42023433271. Findings: Forty-one relevant studies were identified for analysis, consisting of 15 from West Africa (n = 2107), 12 from Southern Africa (n = 2963), 11 from East Africa (n = 2142), and 3 from Central Africa (n = 124). A total of 59.4% of the patient population were associated with paediatric admissions. The pooled prevalence of HAI was estimated at 12.9% (95% CI: 8.9-17.4; n = 7336; number of included estimates [k] = 41, p < 0.001). By subregions, the pooled current prevalence of HAI in the West Africa, Southern Africa, East Africa and Central Africa were estimated at 15.5% (95% CI: 8.3-24.4; n = 2107; k = 15), 6.5% (95% CI: 3.3-10.7; n = 2963; k = 12), 19.7% (95% CI: 10.8-30.5; n = 2142; k = 11) and 10.3% (95% CI: 1.1-27.0; n = 124; k = 3) of the patient populations respectively. We estimated mortality resulting from HAI in SSA at 22.2% (95% CI: 14.2-31.4; n = 1118; k = 9). Interpretation: Our estimates reveal a high burden of HAI in SSA with significant heterogeneity between regions. Variations in HAI distribution highlight the need for infection prevention and surveillance strategies specifically tailored to enhance prevention and management with special focus on West and East Africa, as part of the broader global control effort. Funding: No funding was received for this study.

ATR-FTIR spectroscopy as a method for the determination of mineral chelation in high concentration manganese and zinc proteinates used as animal feed additives.

Attenuated total reflectance Fourier transform infrared (ATR-FTIR) spectroscopy is an essential tool for the determination of mineral chelation in proteinates used as animal feed additives. With advances in feed formulations and stringent regulatory requirements to confirm the degree of chelation in animal feed supplements, the aim of this work was to further refine the method and demonstrate its applicability to newly formulated, higher concentration (20% (w/w)) manganese and zinc proteinates of industrial relevance. Calibration and prediction models were created using multivariate analysis with R2 > 0.99 for both mineral proteinates tested. Root mean square error of calibration (RMSEC) values were found to be 1.7% and 2.1% respectively for the manganese and zinc products. The refined method produced reliable data for various applications with excellent specificity, selectivity, and reproducibility. Consequently, the proposed refinements are expected to be of interest from a regulatory perspective and for those in the feed industry for conclusively determining the percentage chelation of minerals in high concentration proteinate products.

Decentralized, Integrated Treatment of RR/MDR-TB and HIV Using a Bedaquiline-Based, Short-Course Regimen Is Effective and Associated With Improved HIV Disease Control.

BACKGROUND: In decentralized sites, with fewer resources and a high prevalence of advanced HIV, the effectiveness of the new short-course, bedaquiline-based regimen for rifampicin-resistant and multidrug-resistant tuberculosis (RR/MDR-TB) is not well-described. SETTING: Adults with pulmonary RR/MDR-TB initiating the short-course regimen in KwaZulu-Natal, South Africa were prospectively enrolled at a decentralized program that integrated person-centered TB care. METHODS: In addition to standard of care monitoring, study visits occurred at enrollment and months 1, 2, 4, 6, and 9. Favorable RR/MDR-TB outcome was defined as cure or treatment completion without loss to follow-up, death, or failure by treatment. In patients with HIV, we assessed antiretroviral therapy (ART) uptake, virologic and immunologic outcomes. RESULTS: Among 57 patients, HIV was present in 73.7% (95% CI: 60.3-84.5), with a median CD4 count of 170 cells/mm 3 (intraquartile range 49-314). A favorable RR/MDR-TB outcome was achieved in 78.9% (CI: 67.1-87.9). Three deaths occurred, all in the setting of baseline advanced HIV and elevated viral load. Overall, 21.1% (95% CI: 12.1-32.9) experienced a severe or life-threatening adverse event, the most common of which was anemia. Among patients with HIV, enrollment resulted in increased ART uptake by 24% (95% CI: 12.1%-39.4%), a significant improvement from baseline ( P = 0.004); virologic suppression during concomitant treatment was observed in 71.4% (n = 30, 95% CI: 55.4-84.3). CONCLUSION: Decentralized, person-centered care for RR/MDR-TB in patients with HIV using the short-course, bedaquiline-based regimen is effective and safe. In patients with HIV, enrollment led to improved ART use and reassuring virologic outcomes.

Safety of Single High-Dose Liposomal Amphotericin B for Induction Treatment of Cryptococcal Meningitis and Histoplasmosis in People With HIV: A Systematic Review and Meta-analysis.

Background: Evidence for efficacy of single, high-dose liposomal amphotericin B (LAmB) in HIV-associated cryptococcal meningitis and histoplasmosis is growing. No systematic review has examined the safety of this regimen across multiple studies. Methods: We systematically searched Medline, Scopus, and the Cochrane Library from inception to April 2023 for studies reporting grade 3 and 4 adverse events (AEs) with single high-dose LAmB vs traditional amphotericin regimens for HIV-associated fungal infections. Results: Three trials (n = 946) were included. Compared with traditional regimens, single high-dose LAmB was associated with equivalent risk of grade 3 and 4 AEs (risk ratio [RR], 0.75; 95% CI, 0.53-1.06) and lower overall risk of grade 4 AEs (RR, 0.68; 95% CI, 0.55-0.86), grade 4 renal (RR, 0.43; 95% CI, 0.20-0.94) and grade 4 hematological AEs (RR, 0.46; 95% CI, 0.32-0.65). Conclusions: Single, high-dose LAmB is associated with a lower risk of life-threatening AEs compared with other World Health Organization-endorsed amphotericin B-based regimens in invasive HIV-related fungal infection.

Relative Bioavailability of Trace Minerals in Production Animal Nutrition: A Review.

The importance of dietary supplementation of animal feeds with trace minerals is irrefutable, with various forms of both organic and inorganic products commercially available. With advances in research techniques, and data obtained from both in-vitro and in-vivo studies in recent years, differences between inorganic and organic trace minerals have become more apparent. Furthermore, differences between specific organic mineral types can now be identified. Adhering to PRISMA guidelines for systematic reviews, we carried out an extensive literature search on previously published studies detailing performance responses to trace minerals, in addition to their corresponding relative bioavailability values. This review covers four of the main trace minerals included in feed: copper, iron, manganese and zinc, and encompasses the different types of organic and inorganic products commercially available. Their impact from environmental, economic, and nutritional perspectives are discussed, along with the biological availability of various mineral forms in production animals. Species-specific sections cover ruminants, poultry, and swine. Extensive relative bioavailability tables cover values for all trace mineral products commercially available, including those not previously reviewed in earlier studies, thereby providing a comprehensive industry reference guide. Additionally, we examine reasons for variance in reported relative bioavailability values, with an emphasis on accounting for data misinterpretation.

A surprising complication of breast augmentation surgery.

Infections caused by opportunistic fungal organisms such as Scedosporium spp. have been increasingly recognized over the last few decades. Most affected patients are immunocompromised or critically ill, but Scedosporium spp. infections have also been described in immunocompetent patients, such as localized disease from direct inoculation or in near-drowning events. We describe a case of a patient with no known underlying immune impairment who experienced significant infection with Scedosporium apiospermum at both sites of breast augmentation. Once identified, the choice of therapeutics can be challenging given the intrinsic resistance and variable activity of different antifungal agents; however, other factors also impact the outcome of this infection such as the host immune status. Thus, both the recognition and treatment of Scedosporium infections can be challenging.

Effect of Mannan-rich fraction supplementation on commercial broiler intestinum tenue and cecum microbiota.

BACKGROUND: The broiler gastrointestinal microbiome is a potent flock performance modulator yet may also serve as a reservoir for pathogen entry into the food chain. The goal of this project was to characterise the effect of mannan rich fraction (MRF) supplementation on microbiome diversity and composition of the intestinum tenue and cecum of commercial broilers. This study also aimed to address some of the intrinsic biases that exist in microbiome studies which arise due to the extensive disparity in 16S rRNA gene copy numbers between bacterial species and due to large intersample variation. RESULTS: We observed a divergent yet rich microbiome structure between different anatomical sites and observed the explicit effect MRF supplementation had on community structure, diversity, and pathogen modulation. Birds supplemented with MRF displayed significantly higher species richness in the cecum and significantly different bacterial community composition in each gastrointestinal (GI) tract section. Supplemented birds had lower levels of the zoonotic pathogens Escherichia coli and Clostridioides difficile across all three intestinum tenue sites highlighting the potential of MRF supplementation in maintaining food chain integrity. Higher levels of probiotic genera (eg. Lactobacillus and Blautia) were also noted in the MRF supplemented birds. Following MRF supplementation, the cecum displayed higher relative abundances of both short chain fatty acid (SFCA) synthesising bacteria and SCFA concentrations. CONCLUSIONS: Mannan rich fraction addition has been observed to reduce the bioburden of pathogens in broilers and to promote greater intestinal tract microbial biodiversity. This study is the first, to our knowledge, to investigate the effect of mannan-rich fraction supplementation on the microbiome associated with different GI tract anatomical geographies. In addition to this novelty, this study also exploited machine learning and biostatistical techniques to correct the intrinsic biases associated with microbiome community studies to enable a more robust understanding of community structure.

Detection of HIV Virologic Failure and Switch to Second-Line Therapy: A Systematic Review and Meta-analysis of Data From Sub-Saharan Africa.

Background: The late recognition of virologic failure (VF) places persons with HIV in Sub-Saharan Africa at risk for HIV transmission, disease progression, and death. We conducted a systematic review and meta-analysis to determine if the recognition and response to VF in the region has improved. Methods: We searched for studies reporting CD4 count at confirmed VF or at switch to second-line antiretroviral therapy (ART). Using a random-effects metaregression model, we analyzed temporal trends in CD4 count at VF-or at second-line ART switch-over time. We also explored temporal trends in delay between VF and switch to second-line ART. Results: We identified 26 studies enrolling patients with VF and 10 enrolling patients at second-line ART switch. For studies that enrolled patients at VF, pooled mean CD4 cell count at failure was 187 cells/mm3 (95% CI, 111 to 263). There was no significant change in CD4 count at confirmed failure over time (+4 cells/year; 95% CI, -7 to 15). Among studies that enrolled patients at second-line switch, the pooled mean CD4 count was 108 cells/mm3 (95% CI, 63 to 154). CD4 count at switch increased slightly over time (+10 CD4 cells/year; 95% CI, 2 to 19). During the same period, the mean delay between confirmation of VF and switch was 530 days, with no significant decline over time (-14 days/year; 95% CI, -58 to 52). Conclusions: VF in Africa remains an event recognized late in HIV infection, a problem compounded by ongoing delays between VF and second-line switch.

Shooting hoops: globetrotting plasmids spreading more than just antimicrobial resistance genes across One Health.

Our study provides novel insights into the global nature of antimicrobial resistance (AMR) plasmids across the food chain. We provide compelling evidence of the globetrotting nature of AMR plasmids and the need for surveillance to sequence plasmids with a template of analyses for others to expand these data. The AMR plasmids analysed were detected in 63 countries and in samples from humans, animals and the environment. They contained a combination of known and novel AMR genes, metal resistance genes, virulence factors, phage and replicon types.

Multidrug-resistant chronic osteomyelitis complicating war injury in Iraqi civilians.

BACKGROUND: War-related orthopedic injury is frequently complicated by environmental contamination and delays in management, placing victims at increased risk for long-term infectious complications. We describe, among Iraqi civilians with war-related chronic osteomyelitis, the bacteriology of infection at the time of admission. METHODS: In the Médecins Sans Frontières Reconstructive Surgery Project in Amman, Jordan, we retrospectively reviewed baseline demographics and results of initial intraoperative surgical cultures among Iraqi civilians with suspected osteomyelitis. RESULTS: One hundred thirty-seven patients (90% male; median age, 35 years [interquartile range {IQR}, 28-46]; median time since initial injury, 19 months [IQR, 10-35]) were admitted with suspected chronic osteomyelitis after war-related injury. One hundred seven patients had a positive intraoperative culture. Before arrival, patients had undergone a median of 4 (IQR, 2-6) surgical procedures in Iraq. Fifty-nine (55%) of 107 patients with confirmed osteomyelitis had a multidrug-resistant (MDR) organism isolated at admission: cefepime-resistant Enterobacteriaceae (n = 40), methicillin-resistant Staphylococcus aureus (n = 16), and MDR Acinetobacter baumannii (n = 3). An association of borderline significance existed between a history of more than two prior surgical procedures in Iraq and an MDR isolate at program entry (multivariate: odds ratio, 5.3; 95% confidence interval, 0.9-30.6; p = 0.064). CONCLUSION: Health care actors, including Iraqi health facilities and humanitarian medical organizations, must be aware of the link between chronic war injury and antimicrobial drug resistance in this region and should be prepared for the management challenges involved with the treatment of chronic drug-resistant osteomyelitis.

Influence of the Chelation Process on the Stability of Organic Trace Mineral Supplements Used in Animal Nutrition.

The effect of the chelation process on the pH-dependent stability of organic trace minerals (OTMs) used as mineral supplements in animal nutrition was assessed using analytical techniques such as potentiometry, Fourier Transform Infrared Spectroscopy (FTIRS) and amino acid profiling. The aim was to understand the influence and relative importance of the manufacturing conditions on mineral chelation and the subsequent pH stability of OTMs. A selection of OTMs were assessed over a wide pH range to account for the typical environmental changes encountered in the gastrointestinal (GI) tract. In the case of proteinate type products, the potentiometric assessment of free mineral concentration indicated that the hydrolysis procedure used to generate the chelating peptides was the major influencer of the pH stability of the products. Many products are available under the umbrella term "OTMs", including amino acid complexes, amino acid chelates, polysaccharide complexes and proteinates. Significant differences in the pH-dependent stability of a range of commercially available OTMs were observed.

Analysis of wide-domain transcriptional regulation in solid-state cultures of Aspergillus oryzae.

Many filamentous fungi secrete considerable quantities of enzymes including protease, cellulase and xylanase, which are of major industrial importance. Over the past few decades, many of these fungal enzymes have been isolated and their relevant genes characterised. Solid-state fermentation (SSF), an ancient technique described as a fermentation process performed on non-soluble material whereby the material acts as a physical support and as a source of nutrients, is widely employed in the production of industrially important enzymes. Control mechanisms governing gene expression in SSF however, have been rarely studied. The influence of carbon and nitrogen sources on the production and transcriptional regulation of hydrolase enzymes secreted by an Aspergillus strain was investigated with the hope of expanding on the relatively small amount of knowledge regarding cellular control of gene expression. This study involved screening a collection of fungal strains for protease, cellulase and xylanase production under SSF conditions. From this, one fungal strain was then chosen for further analysis. Factors affecting the secretion of the hydrolase enzymes were optimised, and following this, the influence of nutritional supplementation on the production and transcriptional regulation of the enzymes was investigated. Real-time PCR techniques were used to assess the relative expression levels of genes encoding hydrolase activities and of the genes encoding regulatory elements such as AreA, PacC and CreA in an effort to identify possible transcriptional regulation mechanisms. The complexity of gene regulation under SSF conditions became apparent during the study, as other factors such as post-transcriptional regulation appeared to play a far greater role than previously imagined.

Increased Mortality With Delayed and Missed Switch to Second-Line Antiretroviral Therapy in South Africa.

BACKGROUND: After failure of first-line antiretroviral therapy (ART) in the public sector, delayed or missed second-line ART switch is linked with poor outcomes in patients with advanced HIV. SETTING: We investigated delayed or missed second-line ART switch after confirmed virologic failure in the largest private sector HIV cohort in Africa. METHODS: We included HIV-infected adults with confirmed virologic failure after 6 months of nonnucleoside reverse-transcriptase inhibitor-based ART. We estimated the effect of timing of switch on the hazard of death using inverse probability of treatment weighting of marginal structural models. We adjusted for time-dependent confounding of CD4 count, viral load, and visit frequency. RESULTS: Five thousand seven hundred forty-eight patients (53% female) with confirmed virologic failure met inclusion criteria; the median age was 40 [interquartile range (IQR): 35-47], advanced HIV was present in 48% and the prior duration of nonnucleoside reverse-transcriptase inhibitor-based ART was 1083 days (IQR: 665-1770). Median time to confirmation of virologic failure and to second-line switch was 196 (IQR: 136-316) and 220 days (IQR: 65-542), respectively. Switching to second-line ART after confirmed failure compared with remaining on first-line ART reduced risk of subsequent death [adjusted hazard ratio: 0.47 (95% confidence interval: 0.36 to 0.63)]. Compared with patients who experienced delayed switch, those switched immediately had a lower risk of death, regardless of CD4 cell count. CONCLUSIONS: Delayed or missed switch to second-line ART after confirmed first-line ART failure is common in the South African private sector and associated with mortality. Novel interventions to minimize switch delay should be tested and not limited to those with advanced disease at treatment failure.

Time to embrace access programmes for medicines: lessons from the South African flucytosine access programme.

BACKGROUND: Cryptococcal meningitis (CM) is estimated to cause 181 000 deaths annually, with the majority occurring in Sub-Saharan Africa. Flucytosine is recommended by the World Health Organization as part of the treatment for CM. Widespread use of flucytosine could reduce mortality in hospital by as much as 40% compared to the standard of care, yet due to market failure, quality-assured flucytosine remains unregistered and largely inaccessible throughout Africa. METHODS: The recently established South African flucytosine clinical access programme is an attempt to address the market failure that led to a lack of public sector access to flucytosine for CM, by making the medicine freely available to tertiary hospitals in South Africa. RESULTS: Between November 2018 and September 2019, 327 CM patients received flucytosine through this programme, with efforts to support sustainable national scale-up presently ongoing. We describe why this programme was needed, its catalytic potential, what is still required to ensure widespread access to flucytosine, and observations from this experience that may have wider relevance. CONCLUSIONS: The South African flucytosine access programme illustrates how access programmes may be one part of the solution to addressing the vicious cycle of perceived low demand, limiting manufacturer interest in specific product markets.