Designing and implementing equity-based pandemic preparedness and response learning modules: lessons from a multi-country short-course

BACKGROUND

The COVID-19 pandemic has had disproportionate impacts across race, social class, and geography. Insufficient attention has been paid to addressing the massive inequities worsened by COVID-19. In July 2020, Partners In Health (PIH) and the University of Global Health Equity (UGHE) delivered a four-module short course, 'An Equity Approach to Pandemic Preparedness and Response: Emerging Insights from COVID-19 Global Response Leaders.'

OBJECTIVE

We describe the design and use of a case-based, short-course education model to transfer knowledge and skills in equity approaches to pandemic preparedness and response.

METHODS

This course used case studies of Massachusetts and Navajo Nation in the US, and Rwanda to highlight examples of equity-centered pandemic response. Course participants completed a post-session assessment survey after each of the four modules. A mixed-method analysis was conducted to elucidate knowledge acquisition on key topics and assess participants' experience and satisfaction with the course.

RESULTS

Forty-four percent of participants identified, 'Immediate need for skills and information to address COVID-19' as their primary reason for attending the course. Participants reported that they are very likely (4.75 out of 5) to use the information, tools, or skills from the course in their work. The average score for content-related questions answered correctly was 82-88% for each session. Participants (~70-90%) said their understanding was Excellent or Very Good for each session. Participants expressed a deepened understanding of the importance of prioritizing vulnerable communities and built global solidarity.

CONCLUSION

The training contributed to a new level of understanding of the social determinants of health and equity issues surrounding pandemic preparedness and response. This course elucidated the intersection of racism and wealth inequality; the role of the social determinants of health in pandemic preparedness and response; and the impacts of neocolonialism on pandemic response in low- and middle-income countries.

Uterine fibroid: a socially malignant illness in Haiti

This qualitative study documented the effects of uterine fibroids on the suffering of women in Haiti. It makes a unique contribution by re-socializing this disease, by making visible the social inequalities and what is at stake for the women, for their families, and for healthcare delivery. Uterine fibroid is a benign tumor of the uterus, common in gynecology, but profoundly malignant in how it affects women's lives. Little has been reported on their lived experiences. Haiti has historical, social, and economic factors that hinder the search for treatment. The study explores how and why patients seek surgical care for uterine fibroids at Mirebalais University Hospital. Seventeen in-depth interviews with patients and seven accompanying family members were conducted and recorded in Creole and translated into English, along with participant observations in two patients' homes. Content and narrative analysis were done iteratively, and the processual ethnographic method was used to relate our findings to Haitian history, to the context of the study, and to future implications. The women's experience of accompaniment, their suffering in their pèlerinage (care-seeking journey), and the troubling social impact of uterine fibroids make it a socially malignant illness. The study shows that it is critical to address the suffering of women afflicted with uterine fibroids by strengthening the Haitian health system, improving economic advantages, and establishing ways for them to gain access to social goods and participate in community activities.

Increased Frequency of Inter-Subtype HIV-1 Recombinants Identified by Near Full-Length Virus Sequencing in Rwandan Acute Transmission Cohorts

Most studies of HIV-1 transmission have focused on subtypes B and C. In this study, we determined the genomic sequences of the transmitted founder (TF) viruses from acutely infected individuals enrolled between 2005 and 2011 into IAVI protocol C in Rwanda and have compared these isolates to viruses from more recent (2016–2019) acute/early infections in three at risk populations – MSM, high risk women (HRW), and discordant couples (DC). For the Protocol C samples, we utilized near full-length single genome (NFLG) amplification to generate 288 HIV-1 amplicons from 26 acutely infected seroconverters (SC), while for the 21 recent seroconverter samples (13 from HRW, two from DC, and six from MSM), we PCR amplified overlapping half-genomes. Using PacBio SMRT technology combined with the MDPseq workflow, we performed multiplex sequencing to obtain high accuracy sequences for each amplicon. Phylogenetic analyses indicated that the majority of recent transmitted viruses from DC and HRW clustered within those of the earlier Protocol C cohort. However, five of six sequences from the MSM cohort branched together and were greater than 97% identical. Recombination analyses revealed a high frequency (6/26; 23%) of unique inter-subtype recombination in Protocol C with 19% AC and 4% CD recombinant viruses, which contrasted with only 6.5% of recombinants defined by sequencing of the pol gene previously. The frequency of recombinants was significantly higher (12/21; 57%) in the more recent isolates, although, the five related viruses from the MSM cohort had identical recombination break points. While major drug resistance mutations were absent from Protocol C viruses, 4/21 of recent isolates exhibited transmitted nevirapine resistance. These results demonstrate the ongoing evolution and increased prevalence of recombinant and drug resistant transmitted viruses in Rwanda and highlight the importance of defining NFLG sequences to fully understand the nature of TF viruses and in particular the prevalence of unique recombinant forms (URFs) in transmission cohorts.

Harvard Medical School Department of Global Health and Social Medicine COVID-19 seminar series: COVID and surgical, anesthetic and obstetric care

On May 21, 2020, the Harvard Program in Global Surgery and Social Change (PGSSC) hosted a webinar as part of the Harvard Medical School Department of Global Health and Social Medicine’s COVID-19 webinar series. The goal of PGSSC’s virtual webinar was to share the experiences of surgical, anesthesia, and obstetric (SAO) providers on the frontlines of the COVID pandemic, from both high-income countries (HICs), such as the United States and the United Kingdom, as well as low- and middle-income countries (LMICs). Providers shared not only their experiences delivering SAO care during this global pandemic, but also solutions and innovations they and their colleagues developed to address these new challenges. Additionally, the seminar explored the relationship between surgery and health system strengthening and pandemic preparedness, and outlined the way forward, including a roadmap for prioritization and investment in surgical system strengthening. Throughout the discussion, other themes emerged as well, such as the definition of elective surgery and its implications during a persistent global pandemic, the safe and ethical reintroduction of surgical services, and the social inequities exposed by the stress placed on health systems by COVID-19. These proceedings document the perspectives shared by participants through their invited lectures as well as through the panel discussion at the end of the seminar.

'It is this which is normal' A qualitative study on girl child marriage and health in conakry, Guinea

Guinea has the eighth highest rate of girl child marriage, as 1 in 2 girls marry before age 18. The aim of this study was to qualitatively explore how women married as children in Conakry, Guinea see their marriage as related to their health and their children's health. This study draws from grounded theory. The primary data sources were in-depth interviews collected from August 2016 to January 2017; during that time, we also conducted brief ethnographic interviews, observation, and participant observation. Purposive sampling was used to identify 19 participants who first married before age 18. We used open coding for data analysis. At the first level of coding, key categories were identified. At the second level of coding, categories were grouped. We secured ethical board approval for all study procedures. Through this study, a new picture emerges about health experiences within girl child marriage. We found that most women perceived health disadvantages of their early marriages (n = 16), captured through themes of poor sexual and reproductive health, intimate partner violence and long-term consequences, poor mental health and psychosocial well-being, and other physical health conditions. Most women also perceived health advantages of their early marriages (n = 15), captured through themes of having children, "good health for me and my children," access to health care, delaying first pregnancy and birth spacing, and positive mental health and psychosocial well-being. Sixty-three percent of participants articulated both disadvantages and advantages of their early marriages as related to health outcomes. These findings could be considered in many marital experiences in several contexts, yet women's reflections point toward the importance of the timing of their early marriages in their experiences. Change in preventing this practice and addressing its full set of consequences will not happen effectively without incorporating the voices and experiences of women affected.

Global Health in the Age of COVID-19: Responsive Health Systems Through a Right to Health Fund

We propose that a Right to Health Capacity Fund (R2HCF) be created as a central institution of a reimagined global health architecture developed in the aftermath of the COVID-19 pandemic. Such a fund would help ensure the strong health systems required to prevent disease outbreaks from becoming devastating global pandemics, while ensuring genuinely universal health coverage that would encompass even the most marginalized populations. The R2HCF's mission would be to promote inclusive participation, equality, and accountability for advancing the right to health. The fund would focus its resources on civil society organizations, supporting their advocacy and strengthening mechanisms for accountability and participation. We propose an initial annual target of US$500 million for the fund, adjusted based on needs assessments. Such a financing level would be both achievable and transformative, given the limited right to health funding presently and the demonstrated potential of right to health initiatives to strengthen health systems and meet the health needs of marginalized populations-and enable these populations to be treated with dignity. We call for a civil society-led multi-stakeholder process to further conceptualize, and then launch, an R2HCF, helping create a world where, whether during a health emergency or in ordinary times, no one is left behind.

Transmissibility and potential for disease progression of drug resistant Mycobacterium tuberculosis: prospective cohort study

OBJECTIVE

To measure the association between phenotypic drug resistance and the risk of tuberculosis infection and disease among household contacts of patients with pulmonary tuberculosis.

SETTING

106 district health centers in Lima, Peru between September 2009 and September 2012.

DESIGN

Prospective cohort study.

PARTICIPANTS

10 160 household contacts of 3339 index patients with tuberculosis were classified on the basis of the drug resistance profile of the patient: 6189 were exposed to drug susceptible strains of Mycobacterium tuberculosis, 1659 to strains resistant to isoniazid or rifampicin, and 1541 to strains that were multidrug resistant (resistant to isoniazid and rifampicin).

MAIN OUTCOME MEASURES

Tuberculosis infection (positive tuberculin skin test) and the incidence of active disease (diagnosed by positive sputum smear or chest radiograph) after 12 months of follow-up.

RESULTS

Household contacts exposed to patients with multidrug resistant tuberculosis had an 8% (95% confidence interval 4% to 13%) higher risk of infection by the end of follow-up compared with household contacts of patients with drug sensitive tuberculosis. The relative hazard of incident tuberculosis disease did not differ among household contacts exposed to multidrug resistant tuberculosis and those exposed to drug sensitive tuberculosis (adjusted hazard ratio 1.28, 95% confidence interval 0.9 to 1.83).

CONCLUSION

Household contacts of patients with multidrug resistant tuberculosis were at higher risk of tuberculosis infection than contacts exposed to drug sensitive tuberculosis. The risk of developing tuberculosis disease did not differ among contacts in both groups. The evidence invites guideline producers to take action by targeting drug resistant and drug sensitive tuberculosis, such as early detection and effective treatment of infection and disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00676754.

Indirect rule redux: the political economy of diamond mining and its relation to the Ebola outbreak in Kono District, Sierra Leone

This article explores the relationship between the 2014-2016 Ebola outbreak and the political economy of diamond mining in Kono District, Sierra Leone. The authors argue that foreign companies have recycled colonial strategies of indirect rule to facilitate the illicit flow of resources out of Sierra Leone. Drawing on field research conducted during the outbreak and in its aftermath, they show how this 'indirect rule redux' undermines democratic governance and the development of revenue-generation institutions. Finally, they consider the linkages between indirect rule and the Ebola outbreak, vis-à-vis the consequences of the region's intentionally underdeveloped health care infrastructure and the scaffolding of outbreak containment onto the paramount chieftaincy system.

Girl child marriage, socioeconomic status, and undernutrition: evidence from 35 countries in Sub-Saharan Africa

BACKGROUND

Girl child marriage, a formal union of a female before age 18, and undernutrition remain common in Sub-Saharan Africa. The aim of this study is to establish the extent to which girl child marriage contributes to socioeconomic status and underweight, a measure of undernutrition, among adult women.

METHODS

We used data from 103 Demographic and Health Surveys (DHS), representing 35 African countries from 1991 to 2014. Girl child marriage was coded both as a binary variable (before 18 years) and categorical variable (before 14, 14 to 15 years, 16 to 17 years). The primary outcome was underweight (body mass index less than 18·5). Secondary outcomes were early and multiple childbearing, secondary education completion, and wealth index. Logistic regression models were used to estimate associations.

RESULTS

Fifty-five percent of women married before age 18. Girl child marriage was associated with reduced risk of being underweight both in models adjusted for basic confounders (risk difference = - 0.020, 95% CI [- 0.026, - 0.014], p < 0.01) and in models adjusted for childbearing, women's relative status, and socioeconomic outcomes (risk difference = - 0.018, 95% CI [- 0.024, - 0.011], p < 0.01). Conditional on completing primary education and community fixed-effects, women married before 18 years had an increased risk of early motherhood (risk difference = 0.38, 95% CI [0.38, 0.38], p < 0.01) and of being in the poorest quintile (risk difference = 0.024, 95% CI [0.012, 0.036], p < 0.01), and were 27 percentage points less likely to complete secondary education (risk difference = - 0.27, 95% CI [- 0.28, - 0.26)], p < 001), compared to women married as adults.

CONCLUSIONS

Though associated with substantially reduced socioeconomic status, girl child marriage appears to be associated with slightly reduced risk of being underweight in the population studied. Further research is needed to understand the determinants of undernutrition in this context as well as the broader relationship between socioeconomic status and nutritional outcomes.

In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage

Despite overwhelming burdens of disease, health care access in most developing countries is extremely low. As governments work toward achieving universal health coverage, evidence on appropriate interventions to expand access in rural populations is critical for informing policies. Using a combination of population and health system data, we evaluated the impact of two pilot fee exemption interventions in a rural area of Madagascar. We found that fewer than one-third of people in need of health care accessed treatment when point-of-service fees were in place. However, when fee exemptions were introduced for targeted medicines and services, the use of health care increased by 65 percent for all patients, 52 percent for children under age five, and over 25 percent for maternity consultations. These effects were sustained at an average direct cost of US$0.60 per patient. The pilot interventions can become a key element of universal health care in Madagascar with the support of external donors.

Implementing One Health as an integrated approach to health in Rwanda

It is increasingly clear that resolution of complex global health problems requires interdisciplinary, intersectoral expertise and cooperation from governmental, non-governmental and educational agencies. ‘One Health’ refers to the collaboration of multiple disciplines and sectors working locally, nationally and globally to attain optimal health for people, animals and the environment. One Health offers the opportunity to acknowledge shared interests, set common goals, and drive toward team work to benefit the overall health of a nation. As in most countries, the health of Rwanda's people and economy are highly dependent on the health of the environment. Recently, Rwanda has developed a One Health strategic plan to meet its human, animal and environmental health challenges. This approach drives innovations that are important to solve both acute and chronic health problems and offers synergy across systems, resulting in improved communication, evidence-based solutions, development of a new generation of systems-thinkers, improved surveillance, decreased lag time in response, and improved health and economic savings. Several factors have enabled the One Health movement in Rwanda including an elaborate network of community health workers, existing rapid response teams, international academic partnerships willing to look more broadly than at a single disease or population, and relative equity between female and male health professionals. Barriers to implementing this strategy include competition over budget, poor communication, and the need for improved technology. Given the interconnectedness of our global community, it may be time for countries and their neighbours to follow Rwanda's lead and consider incorporating One Health principles into their national strategic health plans.

Balance between transmitted HLA preadapted and nonassociated polymorphisms is a major determinant of HIV-1 disease progression

In a cohort of Zambian heterosexual transmission pairs, the authors show that HIV-1–transmitted variants already exhibit a significant degree of preadaptation to the new host's HLA alleles, which, modulated by polymorphisms that decrease viral fitness, determines early set-point VL and the rate of disease progression in the newly infected individual.

HIV-1 adapts to a new host through mutations that facilitate immune escape. Here, we evaluate the impact on viral control and disease progression of transmitted polymorphisms that were either preadapted to or nonassociated with the new host’s HLA. In a cohort of 169 Zambian heterosexual transmission pairs, we found that almost one-third of possible HLA-linked target sites in the transmitted virus Gag protein are already adapted, and that this transmitted preadaptation significantly reduced early immune recognition of epitopes. Transmitted preadapted and nonassociated polymorphisms showed opposing effects on set-point VL and the balance between the two was significantly associated with higher set-point VLs in a multivariable model including other risk factors. Transmitted preadaptation was also significantly associated with faster CD4 decline (<350 cells/µl) and this association was stronger after accounting for nonassociated polymorphisms, which were linked with slower CD4 decline. Overall, the relative ratio of the two classes of polymorphisms was found to be the major determinant of CD4 decline in a multivariable model including other risk factors. This study reveals that, even before an immune response is mounted in the new host, the balance of these opposing factors can significantly influence the outcome of HIV-1 infection.

Community-Based Health Financing and Child Stunting in Rural Rwanda

OBJECTIVES

We analyzed the likelihood of rural children (aged 6-24 months) being stunted according to whether they were enrolled in Mutuelles, a community-based health-financing program providing health insurance to rural populations and granting them access to health care, including nutrition services.

METHODS

We retrieved health facility data from the District Health System Strengthening Tool and calculated the percentage of rural health centers that provided nutrition-related services required by Mutuelles' minimum service package. We used data from the 2010 Rwanda Demographic and Health Survey and performed multilevel logistic analysis to control for clustering effects and sociodemographic characteristics. The final sample was 1061 children.

RESULTS

Among 384 rural health centers, more than 90% conducted nutrition-related campaigns and malnutrition screening for children. Regardless of poverty status, the risk of being stunted was significantly lower (odds ratio = 0.60; 95% credible interval = 0.41, 0.83) for Mutuelles enrollees. This finding was robust to various model specifications (adjusted for Mutuelles enrollment, poverty status, other variables) or estimation methods (fixed and random effects).

CONCLUSIONS

This study provides evidence of the effectiveness of Mutuelles in improving child nutrition status and supported the hypothesis about the role of Mutuelles in expanding medical and nutritional care coverage for children.

Improving health outcomes through concurrent HIV program scale-up and health system development in Rwanda: 20 years of experience

The 1994 genocide against the Tutsi destroyed the health system in Rwanda. It is impressive that a small country like Rwanda has advanced its health system to the point of now offering near universal health insurance coverage. Through a series of strategic structural changes to its health system, catalyzed through international assistance, Rwanda has demonstrated a commitment towards improving patient and population health indicators. In particular, the rapid scale up of antiretroviral therapy (ART) has become a great success story for Rwanda. The country achieved universal coverage of ART at a CD4 cell count of 200 cells/mm(3) in 2007 and increased the threshold for initiation of ART to ≤350 cells/mm(3) in 2008. Further, 2013 guidelines raised the threshold for initiation to ≤500 cells/mm(3) and suggest immediate therapy for key affected populations. In 2015, guidelines recommend offering immediate treatment to all patients. By reviewing the history of HIV and the scale-up of treatment delivery in Rwanda since the genocide, this paper highlights some of the key innovations of the Government of Rwanda and demonstrates the ways in which the national response to the HIV epidemic has catalyzed the implementation of interventions that have helped strengthen the overall health system.

Frequency of surgery and hospital admissions for communicable diseases in a high- and middle-income setting

BACKGROUND

In high-income countries, non-communicable diseases drive the demand for surgical healthcare. Middle-income countries face a double disease burden, of both communicable and non-communicable disease. The aim of this study was to describe the role of surgery for the in-hospital care of infectious conditions in the high-income country Sweden and the middle-income country South Africa.

METHODS

A retrospective cohort study was performed of 1.4 million infectious disease admissions. The study populations were the entire population of Sweden, and a cohort of 3.5 million South Africans with private healthcare insurance, during a 7-year interval. The outcome measures were frequency of surgical procedures across a spectrum of diseases, and sex and age during the medical care event.

RESULTS

Some 8.1 per cent of Swedish and 15.7 per cent of South African hospital admissions were because of infectious disease. The proportion of infectious disease admissions that were associated with surgery was constant over time: 8.0 (95 per cent c.i. 7.9 to 8.1) per cent in Sweden and 21.1 (21.0 to 21.2) per cent in South Africa. The frequency of surgery was 2.6 (2.6 to 2.7) times greater in South Africa, and 2.2 (2.2 to 2.3) times higher after standardization for age, sex and disease category.

CONCLUSION

The study suggests that surgical care is required to manage patients with communicable diseases, even in high-income settings with efficient prevention and functional primary care. These results further stress the importance of scaling up functional surgical health systems in low- and middle-income countries, where the disease burden is distinguished by infectious disease.

The necessity of social medicine in medical education

Research and clinical experience reliably and repeatedly demonstrate that the determinants of health are most accurately conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. Increased appreciation of biosocial approaches have already driven change in premedical education and focused attention on population health in current U.S. health care reform. Medical education, however, places primary emphasis on biomedicine and often fails to emphasize and educate students and trainees about the social forces that shape disease and illness patterns. The authors of this Commentary argue that medical education requires a comprehensive transformation to incorporate rigorous biosocial training to ensure that all future health professionals are equipped with the knowledge and skills necessary to practice social medicine. Three distinct models for accomplishing such transformation are presented: SocMed's monthlong, elective courses in Northern Uganda and Haiti; Harvard Medical School's semester-long, required social medicine course; and the Lebanese American University's curricular integration of social medicine throughout its entire four-year curriculum. Successful implementation of social medicine training requires the institutionalization of biosocial curricula; the utilization of innovative, engaging pedagogies; and the involvement of health professions students from broad demographic backgrounds and with all career interests. The achievement of such transformational and necessary change to medical education will prepare future health practitioners working in all settings to respond more proactively and comprehensively to the health needs of all populations.

Creating an African HIV clinical research and prevention trials network: HIV prevalence, incidence and transmission

HIV epidemiology informs prevention trial design and program planning. Nine clinical research centers (CRC) in sub-Saharan Africa conducted HIV observational epidemiology studies in populations at risk for HIV infection as part of an HIV prevention and vaccine trial network. Annual HIV incidence ranged from below 2% to above 10% and varied by CRC and risk group, with rates above 5% observed in Zambian men in an HIV-discordant relationship, Ugandan men from Lake Victoria fishing communities, men who have sex with men, and several cohorts of women. HIV incidence tended to fall after the first three months in the study and over calendar time. Among suspected transmission pairs, 28% of HIV infections were not from the reported partner. Volunteers with high incidence were successfully identified and enrolled into large scale cohort studies. Over a quarter of new cases in couples acquired infection from persons other than the suspected transmitting partner.

Redefining global health-care delivery

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and cooccurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

A simplified echocardiographic strategy for heart failure diagnosis and management within an integrated noncommunicable disease clinic at district hospital level for sub-Saharan Africa

OBJECTIVES

This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda.

BACKGROUND

Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery.

METHODS

Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record.

RESULTS

In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up.

CONCLUSIONS

In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.

Cumulative impact of host and viral factors on HIV-1 viral-load control during early infection

In HIV-1 infection, the early set-point viral load strongly predicts both viral transmission and disease progression. The factors responsible for the wide spectrum of set-point viral loads are complex and likely reflect an interplay between the transmitted virus and genetically defined factors in both the transmitting source partner and the seroconverter. Indeed, analysis of 195 transmission pairs from Lusaka, Zambia, revealed that the viral loads in transmitting source partners contributed only ∼2% of the variance in early set-point viral loads of seroconverters (P = 0.046 by univariable analysis). In multivariable models, early set-point viral loads in seroconverting partners were a complex function of (i) the viral load in the source partner, (ii) the gender of the seroconverter, (iii) specific HLA class I alleles in the newly infected partner, and (iv) sharing of HLA-I alleles between partners in a transmission pair. Each of these factors significantly and independently contributed to the set-point viral load in the newly infected partner, accounting for up to 37% of the variance observed and suggesting that many factors operate in concert to define the early virological phenotype in HIV-1 infection.

Human rights and health systems development: confronting the politics of exclusion and the economics of inequality

The social movements of the last two decades have fostered a rights-based approach to health systems development within the global discourse on national and international health governance. In this piece, we discuss ongoing challenges in the cavernous "implementation gap": translating legislative human rights victories into actual practice and delivery. Using accompaniment as an underlying principle, we focus primarily on constructing effective, equitable, and accountable public sector health systems. Public sector health care delivery is challenged by increasingly exclusive politics and inequitable economic policies that fundamentally limit the participatory power of marginalized citizens. Finally, we discuss the role of implementation science in closing the delivery gap in human rights practice.

Role of transmitted Gag CTL polymorphisms in defining replicative capacity and early HIV-1 pathogenesis

Initial studies of 88 transmission pairs in the Zambia Emory HIV Research Project cohort demonstrated that the number of transmitted HLA-B associated polymorphisms in Gag, but not Nef, was negatively correlated to set point viral load (VL) in the newly infected partners. These results suggested that accumulation of CTL escape mutations in Gag might attenuate viral replication and provide a clinical benefit during early stages of infection. Using a novel approach, we have cloned gag sequences isolated from the earliest seroconversion plasma sample from the acutely infected recipient of 149 epidemiologically linked Zambian transmission pairs into a primary isolate, subtype C proviral vector, MJ4. We determined the replicative capacity (RC) of these Gag-MJ4 chimeras by infecting the GXR25 cell line and quantifying virion production in supernatants via a radiolabeled reverse transcriptase assay. We observed a statistically significant positive correlation between RC conferred by the transmitted Gag sequence and set point VL in newly infected individuals (p = 0.02). Furthermore, the RC of Gag-MJ4 chimeras also correlated with the VL of chronically infected donors near the estimated date of infection (p = 0.01), demonstrating that virus replication contributes to VL in both acute and chronic infection. These studies also allowed for the elucidation of novel sites in Gag associated with changes in RC, where rare mutations had the greatest effect on fitness. Although we observed both advantageous and deleterious rare mutations, the latter could point to vulnerable targets in the HIV-1 genome. Importantly, RC correlated significantly (p = 0.029) with the rate of CD4+ T cell decline over the first 3 years of infection in a manner that is partially independent of VL, suggesting that the replication capacity of HIV-1 during the earliest stages of infection is a determinant of pathogenesis beyond what might be expected based on set point VL alone.

In the majority of HIV-1 cases, a single virus establishes infection. However, mutations in the viral genome accumulate over time in order to avoid recognition by the host immune response. Certain mutations in the main structural protein, Gag, driven by cytotoxic T lymphocytes are detrimental to viral replication, and we showed previously that, upon transmission, viruses with higher numbers of escape mutations in Gag were associated with lower early set point viral loads. We hypothesized that this could be attributed to attenuation of the transmitted virus. Here, we have cloned the gag gene from 149 newly infected individuals from linked transmission pairs into a clade C proviral vector and determined the replicative capacity in vitro. We found that the replicative capacity conferred by the transmitted Gag correlated with set point viral loads in newly infected individuals, as well as with the viral load of the transmitting partner, and we identified previously unrecognized residues associated with increasing and decreasing replicative capacity. Importantly, we demonstrate that transmitted viruses with high replicative capacity cause more rapid CD4+ decline over the first three years, independent of viral load. This suggests that the trajectory of pathogenesis may be affected very early in infection, before adaptive immunity can respond.

Excellent clinical outcomes and high retention in care among adults in a community-based HIV treatment program in rural Rwanda

BACKGROUND

Access to antiretroviral therapy (ART) has rapidly expanded; as of the end of 2010, an estimated 6.6 million people are receiving ART in low-income and middle-income countries. Few reports have focused on the experiences of rural health centers or the use of community health workers. We report clinical and programatic outcomes at 24 months for a cohort of patients enrolled in a community-based ART program in southeastern Rwanda under collaboration between Partners In Health and the Rwandan Ministry of Health.

METHODS AND FINDINGS

A retrospective medical record review was performed for a cohort of 1041 HIV+ adult patients initiating community-based ART between June 1, 2005, and April 30, 2006. Key programatic elements included free ART with direct observation by community health worker, tuberculosis screening and treatment, nutritional support, a transportation allowance, and social support. Among 1041 patients who initiated community-based ART, 961 (92.3%) were retained in care, 52 (5%) died and 28 (2.7%) were lost to follow-up. Median CD4 T-cell count increase was 336 cells per microliter [interquartile range: (IQR): 212-493] from median 190 cells per microliter (IQR: 116-270) at initiation.

CONCLUSIONS

A program of intensive community-based treatment support for ART in rural Rwanda had excellent outcomes in 24-month retention in care. Having committed to improving access to HIV treatment in sub-Saharan Africa, the international community, including country HIV programs, should set high programmatic outcome benchmarks.

Adolescents and the right to health: eliminating age-related barriers to HIV/AIDS services in Rwanda

Under international, regional, and domestic law, adolescents are entitled to measures ensuring the highest attainable standard of health. For HIV/AIDS, this is essential as adolescents lack many social and economic protections and are disproportionately vulnerable to the effects of the disease. In many countries, legal protections do not always ensure access to health care for adolescents, including for HIV/AIDS prevention, treatment, and care. Using Rwanda as an example, this article identifies gaps, policy barriers, and inconsistencies in legal protection that can create age-related barriers to HIV/AIDS services and care. One of the most pressing challenges is defining an age of majority for access to prevention measures, such as condoms, testing and treatment, and social support. Occasionally drawing on examples of existing and proposed laws in other African countries, Rwanda and other countries may strengthen their commitment to adolescents' rights and eliminate barriers to prevention, family planning, testing and disclosure, treatment, and support. Among the improvements, Rwanda and other countries must align its age of consent with the actual behavior of adolescents and ensure privacy to adolescents regarding family planning, HIV testing, disclosure, care, and treatment.

Eliminating the category II retreatment regimen from national tuberculosis programme guidelines: the Georgian experience

PROBLEM

The category II retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. It consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. A review of 6500 patients on category II therapy in Georgia showed poor outcomes and high rates of streptomycin resistance.

APPROACH

The National Tuberculosis Program used an evidence-based analysis of national data to convince policy-makers that category II therapy should be eliminated from national guidelines in Georgia.

LOCAL SETTING

The World Health Organization tuberculosis case-notification rate in Georgia is 102 per 100,000 population. All patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. In 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases.

RELEVANT CHANGES

Category II retreatment regimen is no longer used in Georgia. Treatment is guided by results of drug susceptibility testing--using rapid, molecular tests where possible--for all previously treated tuberculosis patients.

LESSONS LEARNT

There was little resistance to policy change because the review was initiated and led by the National Tuberculosis Program. This experience can serve as a successful model for other countries to make informed decisions about the use of category II therapy.