1,009 research outputs found
Health systems and HIV treatment in sub-Saharan Africa: Matching intervention and program evaluation strategies
No full textObjectives International donors financing the delivery of antiretroviral treatment (ART) in developing countries have recently emphasized their commitment to rigorous evaluation of ART impact on population health. In the same time frame but different contexts, they have announced that they will shift funding from vertically-structured (i.e., disease-specific) interventions to horizontally-structured interventions (i.e., staff, systems and infrastructure that can deliver care for many diseases). We analyze likely effects of the latter shift on the feasibility of impact evaluation. Methods We examine the effect of the shift in intervention strategy on (i) outcome measurement, (ii) cost measurement, (iii) study-design options, and the (iv) technical and (v) political feasibility of program evaluation. Results As intervention structure changes from vertical to horizontal, outcome and cost measurement are likely to become more difficult (because the number of relevant outcomes and costs increases and the sources holding data on these measures become more diverse); study design options become more limited (because it is often impossible to identify a rigorously defined counterfactual in horizontal interventions); the technical feasibility of interventions is reduced (because lag times between intervention and impact increase in length and effect mediating and modifying factors increase in number); and political feasibility of evaluation is decreased (because national policymakers may be reluctant to support the evaluation). Conclusions In the choice of intervention strategy, policymakers need to consider the effect of intervention strategy on impact evaluation. Methodological studies are needed to identify the best approaches to evaluate the population health impact of horizontal interventions.Impact evaluation, health systems, HIV, antiretroviral treatment, Africa
A Mathematical Model for Estimating the Number of Health Workers Required for Universal Antiretroviral Treatment
No full textDespite recent international efforts to increase antiretroviral treatment (ART) coverage, it is estimated that more than 5 million people who need ART in developing countries do not receive such treatment. Shortages of human resources to treat HIV/AIDS (HRHA) are one of the main constraints to scaling up ART. We develop a discrete-time Markovian model to project the numbers of HRHA required to achieve universal ART coverage, taking into account the positive feedback from HRHA numbers to future HRHA need. Feedback occurs because ART is effective in prolonging the lives of HIV-positive people who need treatment, so that an increase in the number of people receiving treatment leads to an increase in the number of people needing it in future periods. We investigate the steady-state behavior of our model and apply it to different regions in the developing world. We find that taking into account the feedback from the current supply of HRHA to the future HRHA need substantially increases the projected numbers of HRHA required to achieve universal ART coverage. We discuss the policy implications of our model.
A Mathematical Model for Estimating the Number of Health Workers Required for Universal Antiretroviral Treatment
No full textDespite recent international efforts to increase antiretroviral treatment (ART) coverage, it is estimated that more than 5 million people who need ART in developing countries do not receive such treatment. Shortages of human resources to treat HIV/AIDS (HRHA) are one of the main constraints to scaling up ART. We develop a discrete-time Markovian model to project the numbers of HRHA required to achieve universal ART coverage, taking into account the positive feedback from HRHA numbers to future HRHA need. Feedback occurs because ART is effective in prolonging the lives of HIVpositive people who need treatment, so that an increase in the number of people receiving treatment leads to an increase in the number of people needing it in future periods. We investigate the steady-state behavior of our model and apply it to different regions in the developing world. We find that taking into account the feedback from the current supply of HRHA to the future HRHA need substantially increases the projected numbers of HRHA required to achieve universal ART coverage. We discuss the policy implications of our model.Mathematical model, health workers, universal antiretroviral treatment
Phylogenies inferred from mitochondrial gene orders: a cautionary tale from the parasitic flatworms
No full text[Extract] Mitochondrial genomes have been used in numerous studies to investigate phylogenetic relationships among eukaryotes at many levels (e.g., Smith et al. 1993; Boore et al. 1995; Boore, Lavrov, and Brown 1998). In recent years, the arrangement of genes in the mitochondrial genome has been regarded as a powerful record of historical relationships (Boore 1999). Changes in mitochondrial gene order are infrequent, even over considerable spans of time (Boore 1999), and are unlikely to exhibit homoplasy. Our research has focused on the relationships between two groups of human blood flukes within the genus Schistosoma. Our investigations on the mitochondrial genomes of these worms revealed striking divergences in mitochondrial gene order within the genus.
The schistosomes are among the most significant parasites of humans in the developing world. The disease they cause, schistosomiasis, is second only to malaria in public health importance, affecting some 200 million people in 75 countries and giving rise to severe morbidity or mortality in tens of millions. Recent molecular studies (Barker and Blair 1996) have demonstrated that the deepest split in the genus is between East the Asian species utilizing prosobranch snail hosts and the African species utilizing pulmonate snails. The depth of this split has led some authors to propose an early Tertiary divergence (Després et al. 1992). Species closely allied with the African group also occur in the Middle East, India, and parts of Southern Asia. One African species, Schistosoma mansoni, was probably introduced into the Americas by the slave trade during the 18th and 19th centuries (Després, Imbert-Establet, and Monnerot 1993). The Asian group contains fewer recognized species, and these are found primarily in East Asia (the Philippines, China, Malaysia, Indonesia, Cambodia, and Laos). There is a growing realization that African and East Asian schistosomes differ in many biological attributes, including morphological characters, infectivity to snails, range of definitive hosts, growth rates, egg production, prepatency periods, pathogenicity, and immunogenicity (McManus and Hope 1993). We expected our investigations of mitochondrial genomes in these two groups of species to provide more evidence of their phylogenetic distance. However, we were startled by the remarkable differences in mitochondrial gene order which came to light between the two groups and which we report here
La Suisse et les puissances européennes : Aux sources de l'indépendance (1813-1857)
No full textLa nation suisse n'existe pas, si ce n'est comme un espace géographique sur la carte européenne. Tel est le constat dressé en 1814 par Stratford Canning, envoyé spécial britannique en Suisse. Désunis, tiraillés par des intérêts divergents, les cantons se montrent incapables de reconstruire un Etat commun. La Suisse va-t-elle disparaître ? Soucieuses de la stabilité géopolitique de l'Europe, les grandes puissances ne le tolèrent pas. Sous leur pression, le Pacte de 1815 donne naissance à une nouvelle Confédération. Sa souveraineté reste toutefois très relative. Au protectorat français succède la tutelle des signataires du traité de Vienne. Un demi-siècle plus tard, la Confédération s'est défaite du statut d'Etat tampon sous influence pour s'affirmer comme un petit Etat neutre et indépendant. Emblématique, le traité négocié à Paris en 1857 contraint l'aigle prussien à retirer ses serres de Neuchâtel. Ce livre retrace le chemin parcouru en analysant les moteurs de la construction d'une Suisse pleinement souveraine
H U M / Daniel HUMAIR, batterie - René URTREGER, piano et Pierre MICHELOT, Basse
No full textTitre uniforme : [Laura]Titre uniforme : [Just one of those things]Titre uniforme : [Laura]Comprend : JUST ONE OF THOSE THINGS / Cole PORTER - BYE BYE BLACK BIRD / M. DIXON et R. HENDERSON - AH MOORE / Al COHN - MONSIEUR DE... / R. URTREGER - WELL YOU NEEDN'T / T. MONK - LAURA / RAKSIN et MERCER - AIREGIN / S. ROLLINS - C.T.A. / J. HEATH - NIGHT IN TUNISIA / Dizzy GILLESPIEBnF-Partenariats, Collection sonore - BelieveContient une table des matière
Human resources needs for universal access to antiretroviral therapy in South Africa: a time and motion study
No full text<p>Background - Although access to life-saving treatment for patients infected with HIV in South Africa has improved substantially since 2004, treating all eligible patients (universal access) remains elusive. As the prices of antiretroviral drugs have dropped over the past years, availability of human resources may now be the most important barrier to achieving universal access to HIV treatment in Africa. We quantify the number of HIV health workers (HHWs) required to be added to the current HIV workforce to achieve universal access to HIV treatment in South Africa, under different eligibility criteria.</p>
<p>Methods - We performed a time and motion study in three HIV clinics in a rural, primary care-based HIV treatment program in KwaZulu-Natal, South Africa, to estimate the average time per patient visit for doctors, nurses, and counselors. We estimated the additional number of HHWs needed to achieve universal access to HIV treatment within one year.</p>
<p>Results - For universal access to HIV treatment for all patients with a CD4 cell count of ≤350 cells/μl, an additional 2,200 nurses, 3,800 counselors, and 300 doctors would be required, at additional annual salary cost of 929 million South African rand (ZAR), equivalent to US 400 million).</p>
<p>Conclusions - Universal access to HIV treatment for patients with a CD4 cell count of ≤350 cells/μl in South Africa may be affordable, but the number of HHWs available for HIV treatment will need to be substantially increased. Treatment as prevention strategies will require considerable additional financial and human resources commitments.</p>
« Health & Pleasure » Le tourisme médico-sanitaire dans l'Arc lémanique et le Chablais vaudois : de la consommation de soins à l'innovation de produit (1850-1914)
No full textAu cours du XIXe siècle, la pratique sociale du tourisme prend de l'ampleur en Europe et génère un nouveau secteur économique, qui se déploie vigoureusement sur les rives du lac Léman et dans les Préalpes vaudoises. Parmi les multiples motivations qui poussent au voyage, le souci de prendre soin de sa santé gagne en intensité, générant une demande qui stimule en retour la mise en place d'une offre de santé nouvelle, offre qui s'inscrit dans les évolutions plus générales de la pratique touristique. Ainsi, la médecine se joint et participe à l'essor du tourisme régional, ce qui permet de créer des synergies inédites entre les deux secteurs, dont le développement intense s'accompagne d'effets d'entraînement sur le tissu économique lémanique.
Nous avons développé le concept de « tourisme médico-sanitaire » dans le but de saisir un objet historique complexe qui regroupe des motivations plurielles ainsi que des prestations aussi bien sanitaires que récréatives. Le tourisme médico-sanitaire englobe ainsi une diversité d'acteurs et de pratiques : c'est à la fois un patient adressé par son médecin traitant dans une station climatique ou thermale, ainsi que des professionnels de la santé les prenant en charge, souvent en collaboration avec des promoteurs touristiques. C'est aussi une cure de raisin, voire un régime alimentaire spécial, proposés par un établissement hôtelier à ses hôtes. C'est encore un patient qui subit une opération chirurgicale dans une clinique privée, ou alors un voyageur qui profite de traitements de wellness avant la lettre dans un institut paramédical.
Pourquoi l'Arc lémanique et le Chablais vaudois sont-ils parvenus à se profiler dans ce créneau ? Comment une offre attractive a-t-elle été implantée dans les stations et les villes touristiques ? Quel rôle les acteurs de la sphère médicale et les promoteurs touristiques ont-ils joué ? Le tourisme et la santé, deux phénomènes contemporains de première importance, sont analysés dans leurs interrelations complexes à travers le dépouillement d'un corpus de sources émanant d'acteurs tant touristiques que médicaux, permettant de saisir les interactions entre ces deux domaines. En combinant des approches qualitatives et quantitatives, cette recherche permet de jeter un regard neuf sur une composante de l'offre touristique globale d'une région
Good treatment outcomes among foreigners receiving antiretroviral therapy in Johannesburg, South Africa.
No full textForeigners, including displaced persons, often have limited health-care access, especially to HIV services. Outcomes of antiretroviral therapy (ART) in South Africans and foreigners were compared at a Johannesburg non-governmental clinic. Records were reviewed of 1297 adults enrolled between April 2004 and March 2007 (568 self-identified foreigners, 431 South Africans citizens and 298 with unknown origin). Compared with citizens, foreigners had fewer hospital admissions (39%, 90/303 versus 51%, 126/244; P < 0.001), less missed appointments for ART initiation (20%, 39/200 versus 25%, 51/206; P < 0.001), faster median time to ART initiation (14 versus 21 days, P = 0.008), better retention in care (88%, 325/369 versus 69%, 155/226; P < 0.001) and lower mortality (2.5%, 14/568 versus 10%, 44/431; P < 0.001) after 426 person-years. In logistic regression, after controlling for baseline CD4 count and tuberculosis status, foreigners were 55% less likely to fail ART than citizens (95% CI = 0.23-0.87). These findings support United Nations High Commissioner for Refugees recommendations that ART should not be withheld from displaced persons
The cost-effectiveness of herpes simplex virus-2 suppressive therapy with daily aciclovir for delaying HIV disease progression among HIV-1-infected women in South Africa.
No full textBACKGROUND: The Partners in Prevention HSV/HIV transmission trial (Partners HSV/HIV Transmission Study) showed that herpes simplex virus-2 (HSV-2) suppressive therapy with daily aciclovir could decrease HIV disease progression amongst HIV-1/HSV-2 coinfected individuals. The cost-effectiveness of daily aciclovir for delaying HIV-1 disease progression in women not eligible for antiretroviral therapy (ART) is estimated. METHODS: Resource use/cost data for delivering daily aciclovir at a primary health care HIV clinic were collected in Johannesburg. Effectiveness estimates were obtained from the Partners HSV/HIV Transmission Study trial and epidemiologic data from South Africa. A Markov model simulated the cost-effectiveness of daily aciclovir on HIV-1 disease progression in ART-naive women. Therapy was given to all HIV-1-infected women. Cost-effectiveness was compared against cost per life-year gained (∼US 0.026 per day for 2 × 400 mg aciclovir), the median cost per LYG is US 737 (95% CI: 373-2489) if the ART eligibility criteria is CD4 count <350 cells/μL. Both these projections compare favorably with the estimated cost-effectiveness of ART in South Africa (∼US 0.14 per day), if salary costs are higher and if HSV-2 prevalence amongst HIV-1-infected women are lower. Projections suggest HSV-2 suppressive therapy could dramatically increase the proportion of women initiating ART. CONCLUSIONS: HSV-2 suppressive therapy could be an affordable strategy for reducing HIV-1 disease progression and retaining women in care before ART initiation, but cheaply available aciclovir is needed
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