Tracing of patients lost to follow-up and HIV transmission: Mathematical modelling study based on two large ART programmes in Malawi

OBJECTIVES: Treatment as prevention depends on retaining HIV-infected patients in care. We investigated the effect on HIV transmission of bringing patients lost to follow up (LTFU) back into care. DESIGN: Mathematical model. METHODS: Stochastic mathematical model of cohorts of 1000 HIV-infected patients on antiretroviral therapy (ART), based on data from two clinics in Lilongwe, Malawi. We calculated cohort viral load (CVL; sum of individual mean viral loads each year) and used a mathematical relationship between viral load and transmission probability to estimate the number of new HIV infections. We simulated four scenarios: 'no LTFU' (all patients stay in care); 'no tracing' (patients LTFU are not traced); 'immediate tracing' (after missed clinic appointment); and, 'delayed tracing' (after six months). RESULTS: About 440 of 1000 patients were LTFU over five years. CVL (million copies/ml per 1000 patients) were 3.7 (95% prediction interval [PrI] 2.9-4.9) for no LTFU, 8.6 (95% PrI 7.3-10.0) for no tracing, 7.7 (95% PrI 6.2-9.1) for immediate, and 8.0 (95% PrI 6.7-9.5) for delayed tracing. Comparing no LTFU with no tracing the number of new infections increased from 33 (95% PrI 29-38) to 54 (95% PrI 47-60) per 1000 patients. Immediate tracing prevented 3.6 (95% PrI -3.3-12.8) and delayed tracing 2.5 (95% PrI -5.8-11.1) new infections per 1000. Immediate tracing was more efficient than delayed tracing: 116 and to 142 tracing efforts, respectively, were needed to prevent one new infection. CONCLUSION: Tracing of patients LTFU enhances the preventive effect of ART, but the number of transmissions prevented is small.

Impact of viral load and the duration of primary infection on HIV transmission

Abstract Objectives: HIV 'treatment as prevention' (TasP) describes early treatment of HIV-infected patients intended to reduce viral load and transmission. Crucial assumptions for estimating TasP's effectiveness are the underlying estimates of transmission risk. We aimed to determine transmission risk during primary infection, and of the relation of HIV transmission risk to viral load. Design: A systematic review and meta-analysis. Methods: We searched PubMed and Embase databases for studies that established a relationship between viral load and transmission risk, or primary infection and transmission risk, in serodiscordant couples. We analysed assumptions about the relationship between viral load and transmission risk, and between duration of primary infection and transmission risk. Results: We found 36 eligible articles, based on six different study populations. Studies consistently found that larger viral loads lead to higher HIV transmission rates, but assumptions about the shape of this increase varied from exponential increase to saturation. The assumed duration of primary infection ranged from 1.5 to 12 months; for each additional month, the log10 transmission rate ratio between primary and asymptomatic infection decreased by 0.40. Conclusion: Assumptions and estimates of the relationship between viral load and transmission risk, and the relationship between primary infection and transmission risk, vary substantially and predictions of TasP's effectiveness should take this uncertainty into account.

Social Meets Molecular: Combining Phylogenetic and Latent Class Analyses to Understand HIV-1 Transmission in Switzerland

Switzerland has a complex human immunodeficiency virus (HIV) epidemic involving several populations. We examined transmission of HIV type 1 (HIV-1) in a national cohort study. Latent class analysis was used to identify socioeconomic and behavioral groups among 6,027 patients enrolled in the Swiss HIV Cohort Study between 2000 and 2011. Phylogenetic analysis of sequence data, available for 4,013 patients, was used to identify transmission clusters. Concordance between sociobehavioral groups and transmission clusters was assessed in correlation and multiple correspondence analyses. A total of 2,696 patients were infected with subtype B, 203 with subtype C, 196 with subtype A, and 733 with recombinant subtypes (mainly CRF02_AG and CRF01_AE). Latent class analysis identified 8 patient groups. Most transmission clusters of subtype B were shared between groups of gay men (groups 1-3) or between the heterosexual groups "heterosexual people of lower socioeconomic position" (group 4) and "injection drug users" (group 8). Clusters linking homosexual and heterosexual groups were associated with "older heterosexual and gay people on welfare" (group 5). "Migrant women in heterosexual partnerships" (group 6) and "heterosexual migrants on welfare" (group 7) shared non-B clusters with groups 4 and 5. Combining approaches from social and molecular epidemiology can provide insights into HIV-1 transmission and inform the design of prevention strategies.

Implicit Motives of Elite Athletes, Sport Students, and Non-Sport Students: Power, Affiliation, and Achievement

Research on performance and participation in (elite) sports has predominantly focused on variables relating to the achievement motive. However, some authors describe that athletes in interactive sports (e.g. tennis) are assumed to exhibit a strong power motive in order to win competitive matches, usually resulting in the demonstration of dominance or the experience of inferiority. The affiliation motive, by contrast, is not functional in elite sports due to their competitive rather than social character. In the present chapter we discuss how the three basic implicit motives of power, affiliation, and achievement relate to the sports field and describe how they can affect athletes’ performance. We present empirical evidence for the existence of different strengths of the three basic motives in three studies with elite athletes (Study 1), non-elite athletes (sport students, Study 2), and non-sport students infrequently involved in sports (Study 3). Our results suggest that elite athletes show higher levels of the implicit power motive compared to sport students, who in turn have higher power motives than non-sport students. Surprisingly, elite athletes do not differ from non-sport students regarding their implicit achievement motive. Moreover, non-sport students exhibit higher implicit affiliation motive scores than sport students and elite athletes. We propose that research on motivational processes of highly competitive athletes should – in addition to the achievement motive – focus more on motive themes like the implicit motives of power and affiliation.

Ethnography of a Land-Deal. Local Perceptions and Vertical Perspectives of a Large Scale Land Acquisition Project in Northern Sierra Leone

Despite an increased scientific interest in the relatively new phenomenon of large-scale land acquisition (LSLA), data on processes on the local level remain sparse and superficial. However, knowledge about the concrete implementation of LSLA projects and the different impacts they have on the heterogeneous group of project affected people is indispensable for a deepened understanding of the phenomenon. In order to address this research gap, a team of two anthropologists and a human geographer conducted in-depth fieldwork on the LSLA project of Swiss based Addax Bioenergy in Sierra Leone. After the devastating civil war, the Sierra Leonean government created favourable conditions for foreign investors willing to lease large areas of land and to bring “development” to the country. Being one of the numerous investing companies, Addax Bioenergy has leased 57’000 hectares of land to develop a sugarcane plantation and an ethanol factory to produce biofuel for the export to the European market. Based on participatory observation, qualitative interview techniques and a network analysis, the research team aimed a) at identifying the different actors that were necessary for the implementation of this project on a vertical level and b) exploring various impacts of the project in the local context of two villages on a horizontal level. The network analysis reveals a complex pattern of companies, institutions, nongovernmental organisations and prominent personalities acting within a shifting technological and discursive framework linking global scales to a unique local context. Findings from the latter indicate that affected people initially welcomed the project but now remain frustrated since many promises and expectations have not been fulfilled. Although some local people are able to benefit from the project, the loss of natural resources that comes along with the land lease affects livelihoods of vulnerable groups – especially women and land users – considerably. However, this research doesn’t only disclose impacts on local people’s previous lives but also addresses strategies they adopt in the newly created situation that has opened up alternative spaces for renegotiations of power and legitimatisation. Therewith, this explorative study reveals new aspects of LSLA that have not been considered adequately by the investing company nor by the general academic discourse on LSLA.

Placing Strategy Discourse in Context : Sociomateriality, Sensemaking, and Power

There has been increasing interest in the discursive aspects of strategy over the last two decades. In this editorial we review the existing literature, focusing on six major bodies of discursive scholarship: post-structural, critical discourse analysis, narrative, rhetoric, conversation analysis and metaphor. Our review reveals the significant contributions of research on strategy and discourse, but also the potential to advance research in this area by bringing together research on discursive practices and research on other practices we know to be important in strategy work. We explore the potential of discursive scholarship in integrating between significant theoretical domains (sensemaking, power and sociomateriality), and realms of analysis (institutional, organizational and the episodic), relevant to strategy scholarship. This allows us to place the papers published in the special issue Strategy as Discourse: Its Significance, Challenges and Future Directions among the body of knowledge accumulated thus far, and to suggest a way forward for future scholarship.