Offering ART refill through community health workers versus clinic-based follow-up after home-based same-day ART initiation in rural Lesotho: The VIBRA cluster-randomized clinical trial

BackgroundCommunity-based antiretroviral therapy (ART) dispensing by lay workers is an important differentiated service delivery model in sub-Sahara Africa. However, patients new in care are generally excluded from such models. Home-based same-day ART initiation is becoming widespread practice, but linkage to the clinic is challenging. The pragmatic VIBRA (Village-Based Refill of ART) trial compared ART refill by existing lay village health workers (VHWs) versus clinic-based refill after home-based same-day ART initiation.Methods and findingsThe VIBRA trial is a cluster-randomized open-label clinical superiority trial conducted in 249 rural villages in the catchment areas of 20 health facilities in 2 districts (Butha-Buthe and Mokhotlong) in Lesotho. In villages (clusters) randomized to the intervention arm, individuals found to be HIV-positive during a door-to-door HIV testing campaign were offered same-day ART initiation with the option of refill by VHWs. The trained VHWs dispensed drugs and scheduled clinic visits for viral load measurement at 6 and 12 months. In villages randomized to the control arm, participants were offered same-day ART initiation with clinic-based ART refill. The primary outcome was 12-month viral suppression. Secondary endpoints included linkage and 12-month engagement in care. Analyses were intention-to-treat. The trial was registered on ClinicalTrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT03630549","term_id":"NCT03630549"}}NCT03630549). From 16 August 2018 until 28 May 2019, 118 individuals from 108 households in 57 clusters in the intervention arm, and 139 individuals from 130 households in 60 clusters in the control arm, were enrolled (150 [58%] female; median age 36 years [interquartile range 30–48]; 200 [78%] newly diagnosed). In the intervention arm, 48/118 (41%) opted for VHW refill. At 12 months, 46/118 (39%) participants in the intervention arm and 64/139 (46%) in the control arm achieved viral suppression (adjusted risk difference −0.07 [95% CI −0.20 to 0.06]; p = 0.256). Arms were similar in linkage (adjusted risk difference 0.03 [−0.10 to 0.16]; p = 0.630), but engagement in care was non-significantly lower in the intervention arm (adjusted risk difference −0.12 [−0.23 to 0.003]; p = 0.058). Seven and 0 deaths occurred in the intervention and control arm, respectively. Of the intervention participants who did not opt for drug refill from the VHW at enrollment, 41/70 (59%) mentioned trust or conflict issues as the primary reason. Study limitations include a rather small sample size, 9% missing viral load measurements in the primary endpoint window, the low uptake of the VHW refill option in the intervention arm, and substantial migration among the study population.ConclusionsThe offer of village-based ART refill after same-day initiation led to similar outcomes as clinic-based refill. The intervention did not amplify the effect of home-based same-day ART initiation alone. The findings raise concerns about acceptance and safety of ART delivered by lay health workers after initiation in the community.Trial registrationRegistered with Clinicaltrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT03630549","term_id":"NCT03630549"}}NCT03630549).

Alain Amstutz and co-workers compare village- and clinic-based antiretroviral refills for people with HIV infection in Lesotho.     

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

BackgroundEarly mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”).ConclusionsTB, followed by bacterial infections, were the leading findings at autopsy among adults with advanced HIV enrolled from primary care clinics. To reduce mortality, strategies are needed to identify and direct those at highest risk into a structured pathway that includes expedited investigation and/or treatment of TB and other infections.     

Blood plasma model predictions for the proposed bone-seeking radiopharmaceutical [Sn]Sn(IV)-N,N′,N′-trimethylenephosphonate-poly(ethyleneimine)

In an attempt to elucidate the in vivo stability of the prospective radiopharmaceutical [^117mSn]Sn(IV)-PEI-MP, where PEI-MP stands for N,N′,N′-trimethylenephosphonate-polyethyleneimine, glass electrode potentiometry was used to determine the stability constants of the Sn⁴⁺ ion as complexed with a variety of physiological amino acids. In addition, linear free energy relationship (LFER) correlation plots were used to extrapolate the constants of the major blood plasma ligands, based on data from Cu²⁺, Pb²⁺, and Zn²⁺. In so doing, a thermodynamic model of blood plasma was established for Sn⁴⁺ from which the complexation tendencies of Sn⁴⁺ were predicted in the event of the intravenous administration of such a drug. It was found that the Sn(IV)-PEI-MP could succumb to competition by the glutamine amino acid, which forms more stable complex(es), whilst the PEI-MP gets taken up largely by Ca²⁺. Also, this study shows the value of the in vitro experiments and modeling performed for radiopharmaceutical research and for attempts to reduce the number of animal experiments.     

Demographic analysis of reproduction in Nearctic and Palearctic populations of Coccinella septempunctataand Propylea quatuordecimpunctata

Coccinella septempunctata and Propylea quatuordecimpunctata in North America have documented invasive capacity. Studies are needed to identify relevant life-history parameters responsible for their successful spatial spread. This study is a detailed analysis of phenotypic variation in reproductive traits of several Nearctic and Palearctic populations of these two coccinellid species. From 47 to 61% of C. septempunctata females laid their first batch of eggs within the first two weeks of their adult life. Within P. quatuordecimpunctatapopulations, 56 to 83% of females initiated oviposition within 2 weeks. The remaining females either had preoviposition periods > 2 weeks or never laid eggs during a 60-day observation period. Analysis of daily fecundity revealed differences in oviposition strategies among females within each population. Repeatability estimates of daily parity for C. septempunctata populations were 0.32 for Iowa (USA), 0.35 for Delaware (USA), 0.28 for France, and 0.33 for Ukraine. Repeatability estimates for P. quatuordecimpunctata populations were 0.35 for Canada, 0.25 for France, and 0.33 for Turkey. The within-female component accounted for most of the variation in daily parity; this was due to female variability in their daily oviposition rates. This revised version was published online in July 2006 with corrections to the Cover Date.     

Comparative Prey Suitability ofOstrinia nubilalisEggs andAcyrthosiphon pisumforColeomegilla maculata

The effects ofOstrinia nubilalis(Hübner) (Lepidoptera: Pyralidae) eggs andAcyrthosiphon pisum(Harris) (Homoptera: Aphididae), when provided as single prey species and in combination, on life history characteristics ofColeomegilla maculataDeGeer (Coleoptera: Coccinellidae) larvae and adults were quantified. Preimaginal development was not influenced by the larval prey regime; development at 26 ± 1°C was completed in approximately 13.5 days onO. nubilaliseggs,A. pisum,orA. pisumalternated daily withO. nubilaliseggs. The resulting adults weighed 13.0, 10.7, and 12.5 mg when reared onO. nubilaliseggs,A. pisum,andA. pisumalternated daily withO. nubilaliseggs, respectively. Eighteen percent of the individuals died when reared onA. pisum,28% died when reared onO. nubilaliseggs, and 22% died when fedA. pisumalternated daily withO. nubilaliseggs. Seven adult diet combinations, based on diet regimes of larvae and adults, did not cause significant differences in preoviposition period, interoviposition period, and the number of days on which eggs were laid. Total fecundity was influenced both by larval and adult diet. The diet that resulted in highly fecund females wasA. pisumalternated daily withO. nubilaliseggs for larvae andO. nubilaliseggs for adults. FemaleC. maculatafedO. nubilaliseggs had the highest intrinsic rate of increase and net reproductive rate.     

Overestimates of survival after HAART: implications for global scale-up efforts

Background

Monitoring the effectiveness of global antiretroviral therapy scale-up efforts in resource-limited settings is a global health priority, but is complicated by high rates of losses to follow-up after treatment initiation. Determining definitive outcomes of these lost patients, and the effects of losses to follow-up on estimates of survival and risk factors for death after HAART, are key to monitoring the effectiveness of global HAART scale-up efforts.

Methodology/Principal Findings

A cohort study comparing clinical outcomes and risk factors for death after HAART initiation as reported before and after tracing of patients lost to follow-up was conducted in Botswana''s National Antiretroviral Therapy Program. 410 HIV-infected adults consecutively presenting for HAART were evaluated. The main outcome measures were death or loss to follow-up within the first year after HAART initiation. Of 68 patients initially categorized as lost, over half (58.8%) were confirmed dead after tracing. Patient tracing resulted in reporting of significantly lower survival rates when death was used as the outcome and losses to follow-up were censored [1-year Kaplan Meier survival estimate 0.92 (95% confidence interval, 0.88–0.94 before tracing and 0.83 (95% confidence interval, 0.79–0.86) after tracing, log rank P<0.001]. In addition, a significantly increased risk of death after HAART among men [adjusted hazard ratio 1.74 (95% confidence interval, 1.05–2.87)] would have been missed had patients not been traced [adjusted hazard ratio 1.41 (95% confidence interval, 0.65–3.05)].

Conclusions/Significance

Due to high rates of death among patients lost to follow-up after HAART, survival rates may be inaccurate and important risk factors for death may be missed if patients are not actively traced. Patient tracing and uniform reporting of outcomes after HAART are needed to enable accurate monitoring of global HAART scale-up efforts.     

Application of Artificial Neural Network for predicting biomass growth during domestic wastewater treatment through a biological process

The biological treatment process is responsible for removing organic and inorganic matter in wastewater. This process relies heavily on microorganisms to successfully remove organic and inorganic matter. The aim of the study was to model biomass growth in the biological treatment process. Multilayer perceptron (MLP) Artificial Neural Network (ANN) algorithm was used to model biomass growth. Three metrics: coefficient of determination (R²), root mean squared error (RMSE), and mean squared error (MSE) were used to evaluate the performance of the model. Sensitivity analysis was applied to confirm variables that have a strong influence on biomass growth. The results of the study showed that MLP ANN algorithm was able to model biomass growth successfully. R² values were 0.844, 0.853, and 0.823 during training, validation, and testing phases, respectively. RMSE values were 0.7476, 1.1641, and 0.7798 during training, validation, and testing phases respectively. MSE values were 0.5589, 1.3551, and 0.6081 during training, validation, and testing phases, respectively. Sensitivity analysis results showed that temperature (47.2%) and dissolved oxygen (DO) concentration (40.2%) were the biggest drivers of biomass growth. Aeration period (4.3%), chemical oxygen demand (COD) concentration (3.2%), and oxygen uptake rate (OUR) (5.1%) contributed minimally. The biomass growth model can be applied at different wastewater treatment plants by different plant managers/operators in order to achieve optimum biomass growth. The optimum biomass growth will improve the removal of organic and inorganic matter in the biological treatment process.