Challenges from Tuberculosis Diagnosis to Care in Community-Based Active Case Finding among the Urban Poor in Cambodia: A Mixed-Methods Study.

BACKGROUND: While community-based active case finding (ACF) for tuberculosis (TB) holds promise for increasing early case detection among hard-to-reach populations, limited data exist on the acceptability of active screening. We aimed to identify barriers and explore facilitators on the pathway from diagnosis to care among TB patients and health providers. METHODS: Mixed-methods study. We administered a survey questionnaire to, and performed in-depth interviews with, TB patients identified through ACF from poor urban settlements in Phnom Penh, Cambodia. Additionally, we conducted focus group discussions and in-depth interviews with community and public health providers involved in ACF, respectively. RESULTS: Acceptance of home TB screening was strong among key stakeholders due to perceived reductions in access barriers and in direct and indirect patient costs. Privacy and stigma were not an issue. To build trust and facilitate communication, the participation of community representatives alongside health workers was preferred. Most health providers saw ACF as complementary to existing TB services; however, additional workload as a result of ACF was perceived as straining operating capacity at public sector sites. Proximity to a health facility and disease severity were the strongest determinants of prompt care-seeking. The main reasons reported for delays in treatment-seeking were non-acceptance of diagnosis, high indirect costs related to lost income/productivity and transportation expenses, and anticipated side-effects from TB drugs. CONCLUSIONS: TB patients and health providers considered home-based ACF complementary to facility-based TB screening. Strong engagement with community representatives was believed critical in gaining access to high risk communities. The main barriers to prompt treatment uptake in ACF were refusal of diagnosis, high indirect costs, and anticipated treatment side-effects. A patient-centred approach and community involvement were essential in mitigating barriers to care in marginalised communities.

Rapid diagnostic tests for neurological infections in central Africa.

Infections are a leading cause of life-threatening neuropathology worldwide. In central African countries affected by endemic diseases such as human African trypanosomiasis, tuberculosis, HIV/AIDS, and schistosomiasis, delayed diagnosis and treatment often lead to avoidable death or severe sequelae. Confirmatory microbiological and parasitological tests are essential because clinical features of most neurological infections are not specific, brain imaging is seldom feasible, and treatment regimens are often prolonged or toxic. Recognition of this diagnostic bottleneck has yielded major investment in application of advances in biotechnology to clinical microbiology in the past decade. We review the neurological pathogens for which rapid diagnostic tests are most urgently needed in central Africa, detail the state of development of putative rapid diagnostic tests for each, and describe key technical and operational challenges to their development and implementation. Promising field-suitable rapid diagnostic tests exist for the diagnosis of human African trypanosomiasis and cryptococcal meningoencephalitis. For other infections-eg, syphilis and schistosomiasis-highly accurate field-validated rapid diagnostic tests are available, but their role in diagnosis of disease with neurological involvement is still unclear. For others-eg, tuberculosis-advances in research have not yet yielded validated tests for diagnosis of neurological disease.

Prevention and treatment of the immune reconstitution inflammatory syndrome.

PURPOSE OF REVIEW: The immune reconstitution inflammatory syndrome occurs in a proportion of HIV-infected patients initiated on combination antiretroviral therapy and results from dysregulated inflammatory responses driven by the recovering immune system. Infective forms may manifest as the unmasking of preexisting untreated opportunistic infections or the paradoxical clinical deterioration of appropriately treated opportunistic infections. The prevention and treatment of this condition is the focus of much research attention, which is the scope of this review. RECENT FINDINGS: Approaches to prevention are informed by studies that have reported on risk factors, particularly those that are modifiable. Two key ongoing research issues are optimal screening for opportunistic infections prior to combination antiretroviral therapy in order to prevent unmasking forms and the optimal timing of combination antiretroviral therapy in patients on treatment for an opportunistic infection, balancing the risk of paradoxical immune reconstitution inflammatory syndrome that is associated with early initiation with the risk of advancing immunosuppression associated with delaying. In most cases of immune reconstitution inflammatory syndrome combination antiretroviral therapy has been continued. A variety of additional management strategies have been used including corticosteroids, nonsteroidal anti-inflammatory drugs, drainage procedures and surgery. The advantages and disadvantages of different management strategies are discussed. SUMMARY: No controlled clinical trials regarding the prevention or treatment of immune reconstitution inflammatory syndrome have been completed. There is a need for such studies in order to guide clinicians in their approach to this condition.

Remote consultations and HIV/AIDS continuing education in low-resource settings.

BACKGROUND: Telemedicine is a way to support physicians working in resource-poor settings, providing remote consultations and continuing medical education on HIV/AIDS care. METHODS: A hybrid E-mail/web support telemedicine service was created in 2003 at the Institute of Tropical Medicine, Antwerp, Belgium, with a discussion forum hosting more than 170 healthcare professionals from 40 different countries, generally resource constrained. Interesting posts and recurring questions from this discussion forum have been elaborated as case studies or frequently asked questions, available on the website for consultation. Education and support are also provided through interactive quizzes, user-friendly guidelines, and policy documents with a particular focus on HIV/AIDS care in developing countries. RESULTS: From April 2003 to March 2005, 342 questions were sent from over 17 countries in Africa, Asia, and South America. The vast majority of these questions (93%) were patient-oriented, with only 7% being general questions. Of the patient-oriented questions, 49% were related to antiretroviral therapy, and 44% were related to the diagnosis and treatment of opportunistic infections. CONCLUSIONS: Telemedicine is a cheap and effective method of providing clinical support and continuing education to healthcare workers treating HIV-positive patients in resource-poor settings.

A new model to monitor the virological efficacy of antiretroviral treatment in resource-poor countries.

Monitoring the efficacy of antiretroviral treatment in developing countries is difficult because these countries have few laboratory facilities to test viral load and drug resistance. Those that exist are faced with a shortage of trained staff, unreliable electricity supply, and costly reagents. Not only that, but most HIV patients in resource-poor countries do not have access to such testing. We propose a new model for monitoring antiretroviral treatment in resource-limited settings that uses patients' clinical and treatment history, adherence to treatment, and laboratory indices such as haemoglobin level and total lymphocyte count to identify virological treatment failure, and offers patients future treatment options. We believe that this model can make an accurate diagnosis of treatment failure in most patients. However, operational research is needed to assess whether this strategy works in practice.

Comparison of albendazole regimen for prophylaxis of strongyloides hyperinfection in nephrotic syndrome patients on long-term steroids in Cambodia.

Nephrotic syndrome patients on long-term steroids face the risk of having heavy uncomplicated strongyloidiasis or death from its extreme form, the strongyloides hyperinfection. The risk can be minimized if we eradicate the parasite first. We compare a once daily and twice daily albendazole regimen in preventing this potentially fatal complication in 122 patients with nephrotic syndrome.

Management of Kaposi's sarcoma in resource-limited settings in the era of HAART.

The introduction of highly active antiretroviral therapy (HAART) has changed the natural history of AIDS-associated Kaposi's sarcoma (KS). Although the use of HAART remains limited in low-resource settings, there are global initiatives to make these drugs available to several millions of HIV-infected persons. While there are multiple reports of KS regression during HAART with or without chemotherapy, there is little documentation on KS management in resource-limited settings. In this paper we review current KS treatments available worldwide and discuss the implications of the increased access to antiretrovirals for KS treatment strategies in resource-limited settings.