Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study.

BACKGROUND: COVID-19 has the potential to cause substantial disruptions to health services, due to cases overburdening the health system or response measures limiting usual programmatic activities. We aimed to quantify the extent to which disruptions to services for HIV, tuberculosis, and malaria in low-income and middle-income countries with high burdens of these diseases could lead to additional loss of life over the next 5 years. METHODS: Assuming a basic reproduction number of 3·0, we constructed four scenarios for possible responses to the COVID-19 pandemic: no action, mitigation for 6 months, suppression for 2 months, or suppression for 1 year. We used established transmission models of HIV, tuberculosis, and malaria to estimate the additional impact on health that could be caused in selected settings, either due to COVID-19 interventions limiting activities, or due to the high demand on the health system due to the COVID-19 pandemic. FINDINGS: In high-burden settings, deaths due to HIV, tuberculosis, and malaria over 5 years could increase by up to 10%, 20%, and 36%, respectively, compared with if there was no COVID-19 pandemic. The greatest impact on HIV was estimated to be from interruption to antiretroviral therapy, which could occur during a period of high health system demand. For tuberculosis, the greatest impact would be from reductions in timely diagnosis and treatment of new cases, which could result from any prolonged period of COVID-19 suppression interventions. The greatest impact on malaria burden could be as a result of interruption of planned net campaigns. These disruptions could lead to a loss of life-years over 5 years that is of the same order of magnitude as the direct impact from COVID-19 in places with a high burden of malaria and large HIV and tuberculosis epidemics. INTERPRETATION: Maintaining the most critical prevention activities and health-care services for HIV, tuberculosis, and malaria could substantially reduce the overall impact of the COVID-19 pandemic. FUNDING: Bill & Melinda Gates Foundation, Wellcome Trust, UK Department for International Development, and Medical Research Council.

Destitution, treatment adherence and survival of children with Burkitt lymphoma in a twinning programme in Northwest Cameroon.

BACKGROUND: Burkitt lymphoma (BL) is a curable childhood cancer. Treatment adherence is crucial for a good outcome, but is potentially problematic in low- and middle-income countries owing to parental financial constraints. AIMS: To investigate the association of destitution with treatment adherence and its effect on the survival of patients with BL. METHODS: Patients received free medical treatment from a twinning programme at two Cameroon Baptist hospitals. A destitution assessment questionnaire, based on socioeconomic status, was completed at diagnosis. Medical records were reviewed for treatment adherence and survival. Chi-squared and Fisher's exact tests were used to compare groups. Kaplan-Meier plots were used to calculate overall survival, and log-rank chi-squared tests when comparing survival rates between patient subgroups. Significance was measured at P < .05. RESULTS: The 225 children with BL had a mean age of 8.2 years (median 8.0) and the overall survival was 52%. The mean family destitution score was 56% on a linear scale. Few (8%) patients delayed treatment appointments. A quarter (25%) experienced more than a 1-week follow-up delay and 9.8% absconded within 1 year. The destitution score was not significantly associated with delay of treatment, but with delay in follow-up (P < .001). Guardian relationship (single mother) and patient's age were significantly associated with overall survival (P = .025). CONCLUSIONS: Though linked to poor follow-up, destitution was not significantly associated with absconding patients, poor outcome or poor adherence to treatment, probably due to comprehensive financial support from the international twinning programme. However, additional support for single mothers should be considered.

Paediatric ART Adherence in South Africa: A Comprehensive Analysis.

Adherence to antiretroviral therapy (ART) remains a challenge for HIV-infected children. In this cross-sectional study, we used structured interview-administered questionnaires and medical records to measure adherence levels and factors associated with adherence and viral suppression. We included 195 South African children aged 2.1-12.9 on ART. Adherence levels ranged between 20.5% (pill count) and 89.1% (self-report). Boys were less adherent according to self-report, girls were less adherent according to pill count. Caregivers ensured medication was taken when the condition directly affected daily life. Well-functioning families and families with high SES provide a context supportive of adherence. Non-disclosure and difficulties administering medication negatively affected adherence and viral suppression. This study shows challenging levels of adherence impacting directly on viral suppression in a South African paediatric HIV program. Gender roles, non-disclosure and difficulty administering medication may undermine adherence and should be taken into account for clinical guidelines, policy design and inform strategies.

State of affairs of tuberculosis in prison facilities: a systematic review of screening practices and recommendations for best TB control.

BACKGROUND: Prisoners are at high risk of developing tuberculosis (TB), causing morbidity and mortality. Prison facilities encounter many challenges in TB screening procedures and TB control. This review explores screening practices for detection of TB and describes limitations of TB control in prison facilities worldwide. METHODS: A systematic search of online databases (e.g., PubMed and Embase) and conference abstracts was carried out. Research papers describing screening and diagnostic practices among prisoners were included. A total of 52 articles met the inclusion criteria. A meta-analysis of TB prevalence in prison facilities by screening and diagnostic tools was performed. RESULTS: The most common screening tool was symptom questionnaires (63·5%), mostly reporting presence of cough. Microscopy of sputum with Ziehl-Neelsen staining and solid culture were the most frequently combined diagnostic methods (21·2%). Chest X-ray and tuberculin skin tests were used by 73·1% and 50%, respectively, as either a screening and/or diagnostic tool. Median TB prevalence among prisoners of all included studies was 1,913 cases of TB per 100,000 prisoners (interquartile range [IQR]: 332-3,517). The overall annual median TB incidence was 7·0 cases per 1000 person-years (IQR: 2·7-30·0). Major limitations for successful TB control were inaccuracy of diagnostic algorithms and the lack of adequate laboratory facilities reported by 61·5% of studies. The most frequent recommendation for improving TB control and case detection was to increase screening frequency (73·1%). DISCUSSION: TB screening algorithms differ by income area and should be adapted to local contexts. In order to control TB, prison facilities must improve laboratory capacity and frequent use of effective screening and diagnostic tools. Sustainable political will and funding are critical to achieve this.

Pressure cooker ownership and food security in Aurangabad, India.

OBJECTIVE: To explore associations between household food security and home gardening, use of soya and pressure cooker ownership in low-income households affected by HIV/AIDS in Aurangabad, India. DESIGN: Cross-sectional pilot study which assessed household food security using the validated US Department of Agriculture's food security core-module questionnaire. Questions were added to explore household environment, education, occupation, home gardening, use of soya and pressure cooker ownership. Households with very low v. low food security were compared using logistic regression analysis, controlling for confounding by socio-economic status. SETTING: Aurangabad is an urban setting situated in a primarily agricultural dependent area. The study was carried out in 2008, at the peak of the global food crisis. SUBJECTS: Adult caregivers of children affiliated with the Network of People Living with HIV/AIDS in Aurangabad. RESULTS: All except for one of 133 households were identified as food insecure (99.2 %). Of these households, 35.6 % had to cut size or skip a meal in the past 30 d. Households that cut meal size due to cooking fuel shortages were more likely to have very low food security (OR = 4.67; 95 % CI 1.62, 13.44) compared with households having no cooking fuel shortages. Owning a pressure cooker was shown to be protective against very low food security after controlling for confounding by socio-economic status (OR = 0.27; 95 % CI 0.11, 0.64). CONCLUSIONS: Only pressure cooker ownership showed a protective association with low household food security. Pressure cookers save household fuel costs. Therefore, future interventions should explore pressure cookers as a sustainable means of improving household food security.

Tuberculous meningitis: barriers to adherence in home treatment of children and caretaker perceptions.

INTRODUCTION: In-hospital treatment of children with tuberculous meningitis (TBM) is not a feasible option in many resource-poor countries. Home-based treatment has shown to be a viable alternative. Adherence is an important factor determining success of treatment. OBJECTIVE: Identify possible barriers to adherence of home-based treatment and caretaker perception of the disease. METHOD: A qualitative study consisting of 11 in-depth semi-structured interviews was performed based on principles of the health belief model. RESULTS: Barriers of adherence identified include poor understanding of the disease and transmission route, difficulty with medication administration and side effects, lack of access to the health-care facility, long waiting times and hidden costs of transportation. Caretakers showed good appreciation of the adverse effects of noncompliance and benefits obtained from taking treatment in the home environment. CONCLUSION: Improved doctor-patient communication, information brochures, structural changes to hospital settings, provision of financial and peer support all contribute to optimal TBM home-based treatment.