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What are the emerging features of community health insurance schemes in East Africa?
No full textBackground: The three East African countries of Uganda, Tanzania, and Kenya are characterized by high poverty levels, population growth rates, prevalence of HIV/AIDS, under-funding of the health sector, poor access to quality health care, and small health insurance coverage. Tanzania and Kenya have user-fees whereas Uganda abolished user-fees in public-owned health units.
Objective: To provide comparative description of community health insurance (CHI) schemes in three East African countries of Uganda, Tanzania, and Kenya and thereafter provide a basis for future policy research for development of CHI schemes.
Methods: An analytical grid of 10 distinctive items pertaining to the nature of CHI schemes was developed so as to have a uniform lens of comparing country situations of CHI.
Results and conclusions: The majority of the schemes have been in existence for a relatively short time of less than 10 years and their number remains small. There is need for further research to identify what is the mix and weight of factors that cause people to refrain from joining schemes. Specific issues that could also be addressed in subsequent studies are whether the current schemes provide financial protection, increase access to quality of care and impact on the equity of health services financing and delivery. On the basis of this knowledge, rational policy decisions can be taken. The governments thereafter could consider an option of playing more roles in advocacy, paying for the poorest, and developing an enabling policy and legal framework
The impact of habitat fragmentation on tsetse abundance on the plateau of eastern Zambia
No full textTsetse-transmitted human or livestock trypanosomiasis is one of the major constraints to rural development in sub-Saharan Africa. The epidemiology of the disease is determined largely by tsetse fly density. A major factor, contributing to tsetse population density is the availability of suitable habitat. In large parts of Africa, encroachment of people and their livestock resulted in a destruction and fragmentation of such suitable habitat. To determine the effect of habitat change on tsetse density a study was initiated in a tsetse-infested zone of eastern Zambia. The study area represents a gradient of habitat change, starting from a zone with high levels of habitat destruction and ending in an area where livestock and people are almost absent. To determine the distribution and density of the fly, tsetse surveys were conducted throughout the study area in the dry and in the rainy season. Landsat ETM+ imagery covering the study area were classified into four land cover classes (munga, miombo, agriculture and settlements) and two auxiliary spectral classes (clouds and shadow) using a Gaussian Maximum Likelihood Classifier. The classes were regrouped into natural vegetation and agricultural zone. The binary images were overlaid with hexagons to obtain the spatial spectrum of spatial pattern. Hexagonal coverage was selected because of its compact and regular form. To identify scale-specific spatial patterns and associated entomological phenomena, the size of the hexagonal coverage was varied (250 and 500 m). Per coverage, total class area, mean patch size, number of patches and patch size standard deviation were used as fragmentation indices. Based on the fragmentation index values, the study zone was classified using a Partitioning Around Mediods (PAM) method. The number of classes was determined using the Wilks' lambda coefficient. To determine the impact of habitat fragmentation on tsetse abundance, the correlation between the fragmentation indices and the index of apparent density of the flies was determined and habitat changes most affecting tsetse abundance was identified. From this it followed that there is a clear relationship between habitat fragmentation and the abundance of tsetse flies. Heavily fragmented areas have lower numbers of tsetse flies, but when the fragmentation of natural vegetation decreases, the number of tsetse flies increases following a sigmoidal-like curve
Endemic type of animal trypanosomiasis is not associated with lower genotype variability of Trypanosoma congolense isolates circulating in livestock
No full textIn order to verify whether the low impact on livestock production in endemic areas is related to a low number of trypanosome strains circulating in livestock, 37 Trypanosoma congolense isolates collected from cattle in 11 sites in an endemic trypanosomiasis area in Eastern Zambia were characterised for genotype variability using a modified amplified fragment length polymorphism technique (AFLP). Isolates were further cloned to evaluate the occurrence of mixed infections in individuals. The results obtained revealed a high genotype diversity (94.6%) among these isolates. Apart from one site, all isolates gave different AFLP profiles in each of the sites. When clones were compared, three (8%) of the 37 isolates had mixed infections. These results indicate the circulation of a high number of strains in this trypanosomiasis endemic area despite the low impact the disease has on livestock production
Bilateral pedal edema in an HIV patient: Lopinavir/Ritonavir-containing treatment regimen as a potential cause?
No full textA large number of patients are switched to second-line antiretroviral therapy, especially in resource limited settings. Lopinavir/Ritonavir is the main drug used in second-line treatment regimens. We describe a patient attending an HIV treatment centre in Kampala, Uganda, who presented with bilateral non-tender pitting inflammatory edema two weeks after switching to a Lopinavir/Ritonavir-containing second-line treatment regimen. The lack of an alternate explanation led us to suspect that Lopinavir/Ritonavir was potentially responsible for the edema
Human Plasmodium knowlesi infections in young children in central Vietnam
No full textBACKGROUND: Considering increasing reports on human infections by Plasmodium knowlesi in Southeast Asian countries, blood samples collected during two large cross-sectional malariometric surveys carried out in a forested area of central Vietnam in 2004 and 2005 were screened for this parasite. METHODS: Blood samples collected at the 2004 survey and positive for Plasmodium malariae were randomly selected for PCR analysis detecting P. knowlesi. Blood samples collected in 2005 from the same individuals were screened again for P. knowlesi. Positive samples were confirmed by sequencing. Family members of positive cases who participated in both surveys were also screened. RESULTS: Ninety-five samples with P. malariae mono- or mixed infections identified by species-specific PCR were screened for P. knowlesi. Among the five (5.2%) positive samples by PCR, three were confirmed to be P. knowlesi infections by sequencing, two young children (<5 years old) and a young man, all asymptomatic at the time of the survey and for the next six months after the survey. One of the two children was still positive one year later. No infection was found among the family members. CONCLUSION: Plasmodium knowlesi infections in humans can be found in central Vietnam. A small child was positive for P. knowlesi in both surveys at one year interval, though it is unclear whether it was the same or a new infection
IFN-gamma production in response to Tax 161-233, and frequency of CD4+ Foxp3+ and Lin HLA-DRhigh CD123+ cells, discriminate HAM/TSP patients from asymptomatic HTLV-1-carriers in a Peruvian population
No full textHuman T-lymphotropic virus 1 (HTLV-1) can cause HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The objective of this study was to gain insight into the pathogenesis of HAM/TSP by focusing on the CD8(+) T-cell response. Twenty-three HTLV-1-seronegative controls (SC), 29 asymptomatic HTLV-1 carriers (AC) and 48 patients with HAM/TSP were enrolled in the study. We evaluated the production of interferon-gamma (IFN-gamma) in peripheral blood mononuclear cells stimulated with Tax overlapping peptides, the expression of genes related to the CD8(+) cytotoxic T-cell response, the frequency of CD4(+) Foxp3(+) cells and of dendritic cells, and the HTLV-1 provirus load (PVL). The frequency of cells producing IFN-gamma in response to Tax 161-233, but not to Tax 11-19, discriminated patients with HAM/TSP from AC. The increased pro-inflammatory response observed in patients with HAM/TSP was shared by AC with a high PVL, who also exhibited lower levels of granzyme H mRNA in unstimulated CD8(+) T cells than AC with a low PVL. Patients with HAM/TSP showed higher frequencies of CD4(+) Foxp3(+) cells and lower frequencies of plasmacytoid dendritic cells (pDC) than AC. Our findings are consistent with a model in which HTLV-1, along with the host genetic background, drives quantitative and qualitative changes in pDC and CD4(+) Foxp3(+) cells that lead to a predominance of inflammatory responses over lytic responses in the CD8(+) T-cell response of individuals predisposed to develop HAM/TSP
Pregnancy desires, and contraceptive knowledge and use among prevention of mother-to-child transmission clients in Rwanda
No full textObjective: To understand pregnancy intentions and contraception knowledge and use among HIV-positive and negative women in the national prevention of mother-to-child transmission (PMTCT) program in Rwanda.
Design: A cross-sectional survey of 236 HIV-positive and 162 HIV-negative postpartum women interviewed within 12 months of their expected delivery date in 12 randomly selected public-sector health facilities providing PMTCT services.
Methods: Bivariate analyses explored fertility intentions, and family planning knowledge and use by HIV status. Multivariate analysis identified socio-demographic and service delivery-related predictors of reporting a desire for additional children and modern family planning use.
Results: HIV-positive women were less likely to report wanting additional children than HIV-negative women (8 vs. 49%, P < 0.001), and although a majority of women reported discussing family planning with a health worker during their last pregnancy (HIV-positive 79% vs. HIV-negative 69%, P = 0.057), modern family planning use remained low in both groups (HIV-positive 43% vs. HIV-negative 12%, P < 0.001). Condoms were the most commonly used method among HIV-positive women (31%), whereas withdrawal was most frequently reported among HIV-negative women (19%). In multivariate analysis, HIV-negative women were 16 times more likely to report wanting additional children and nearly 85% less likely to use modern family planning. Women who reported making two or less antenatal care visits were 77% less likely to use modern family planning.
Conclusion: Our results highlight success in provision of family planning counseling in PMTCT services in Rwanda. As family planning use was low among HIV-positive and negative women, further efforts are needed to improve uptake of modern methods, including dual protection, in Rwandan PMTCT settings
An algorithm to optimize viral load testing in HIV-positive patients with suspected first-line antiretroviral therapy failure in Cambodia
No full textObjective: To develop an algorithm for optimal use of viral load testing in patients with suspected first-line antiretroviral treatment (ART) failure.
Methods: Data from a cohort of patients on first-line ART in Cambodia were analyzed in a cross-sectional way to detect markers for treatment failure. Markers with an adjusted likelihood ratio 1.5 were retained to calculate a predictor score. The accuracy of a 2-step algorithm based on this score followed by targeted viral load testing was compared with World Health Organization criteria for suspected treatment failure.
Results: One thousand eight hundred three viral load measurements of 764 patients were available for analysis. Prior ART exposure, CD4 count below baseline, 25% and 50% drop from peak CD4 count, hemoglobin drop of ≥1 g/dL, CD4 count <100 cells per microliter after 12 months of treatment, new onset of papular pruritic eruption, and visual analog scale <95% were included in the predictor score. A score ≥2 had the best combination of sensitivity and specificity and required confirmatory viral load testing for only 9% of patients. World Health Organization criteria had a similar sensitivity but a lower specificity and required viral load testing for 24.9% of patients.
Conclusion: An algorithm combining a predictor score with targeted viral load testing in patients with an intermediate probability of failure optimizes the use of scarce resources