Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared

Introduction: Lesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho. Methods: The two catchment areas comprise two hospitals and 12 HCs. Patients ≥16 years starting ART at a hospital or HC between 2008 and 2011 were included. Loss to follow-up (LTFU) was defined as not returning to the facility for ≥180 days after the last visit, no follow-up (no FUP) as not returning after starting ART, and retention in care as alive and on ART at the facility. The data were analysed using logistic regression, competing risk regression and Kaplan-Meier methods. Multivariable analyses were adjusted for sex, age, CD4 cell count, World Health Organization stage, catchment area and type of ART. All analyses were stratified by gender. Results: Of 3747 patients, 2042 (54.5%) started ART at HCs. Both women and men at hospitals had more advanced clinical and immunological stages of disease than those at HCs. Over 5445 patient-years, 420 died and 475 were LTFU. Kaplan-Meier estimates for three-year retention were 68.7 and 69.7% at HCs and hospitals, respectively, among women (p=0.81) and 68.8% at HCs versus 54.7% at hospitals among men (p<0.001). These findings persisted in adjusted analyses, with similar retention at HCs and hospitals among women (odds ratio (OR): 0.89, 95% confidence interval (CI): 0.73-1.09) and higher retention at HCs among men (OR: 1.53, 95% CI: 1.20-1.96). The latter result was mainly driven by a lower proportion of patients LTFU at HCs (OR: 0.68, 95% CI: 0.51-0.93). Conclusions: In rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.

Cryptococcal Antigenemia in Immunocompromised Human Immunodeficiency Virus Patients in Rural Tanzania: A Preventable Cause of Early Mortality

Background.  Cryptococcal meningitis is a leading cause of death in people living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome. The World Health Organizations recommends pre-antiretroviral treatment (ART) cryptococcal antigen (CRAG) screening in persons with CD4 below 100 cells/µL. We assessed the prevalence and outcome of cryptococcal antigenemia in rural southern Tanzania. Methods.  We conducted a retrospective study including all ART-naive adults with CD4 <150 cells/µL prospectively enrolled in the Kilombero and Ulanga Antiretroviral Cohort between 2008 and 2012. Cryptococcal antigen was assessed in cryopreserved pre-ART plasma. Cox regression estimated the composite outcome of death or loss to follow-up (LFU) by CRAG status and fluconazole use. Results.  Of 750 ART-naive adults, 28 (3.7%) were CRAG-positive, corresponding to a prevalence of 4.4% (23 of 520) in CD4 <100 and 2.2% (5 of 230) in CD4 100-150 cells/µL. Within 1 year, 75% (21 of 28) of CRAG-positive and 42% (302 of 722) of CRAG-negative patients were dead or LFU (P<.001), with no differences across CD4 strata. Cryptococcal antigen positivity was an independent predictor of death or LFU after adjusting for relevant confounders (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.29-4.83; P = .006). Cryptococcal meningitis occurred in 39% (11 of 28) of CRAG-positive patients, with similar retention-in-care regardless of meningitis diagnosis (P = .8). Cryptococcal antigen titer >1:160 was associated with meningitis development (odds ratio, 4.83; 95% CI, 1.24-8.41; P = .008). Fluconazole receipt decreased death or LFU in CRAG-positive patients (HR, 0.18; 95% CI, .04-.78; P = .022). Conclusions.  Cryptococcal antigenemia predicted mortality or LFU among ART-naive HIV-infected persons with CD4 <150 cells/µL, and fluconazole increased survival or retention-in-care, suggesting that targeted pre-ART CRAG screening may decrease early mortality or LFU. A CRAG screening threshold of CD4 <100 cells/µL missed 18% of CRAG-positive patients, suggesting guidelines should consider a higher threshold.

Integration of a World Heritage Site in an agricultural environment in the Simen Mountains (Ethiopia)

The conflict between nature-orientated conservation and man-orientated rural development is examined, along with the degree to which ecological research contributes to mountain development, and whether conservation areas can be protected from being areas of natural resources ultimately to be used by man in life-threatening need. A high mountain national park in Ethiopia is taken as an example within UNESCO's concept of Biosphere Reserves. The main finding is that conservation without development will fail, and therefore the focus is more on the area surrounding a national park than on the park itself. A buffer zone must be developed as an economically stable and socially secure area for man, so that his needs do not drive him to exploit the last natural resource area in his vicinity. Simen is a World Heritage Site for future generations. Man and nature, development and conservation, belong together in this unique mountain area.

El desarrollo rural y las contribuciones de la Psicología : Un estado de la cuestión

En todo el mundo, el 70 de la población pobre vive en áreas rurales. A pesar de los programas para revertir la pobreza, los resultados han sido limitados. El desarrollo rural busca reducir la desigualdad. Varios obstáculos que se les presentan a estos programas son psicosociales. El objetivo de este trabajo es explorar y describir las vinculaciones entre la Psicología y los procesos de desarrollo rural territorial en 111 publicaciones aparecidas entre 1985 y 2012. En la revisión, se encontró que los constructos utilizados fueron, entre otros, percepción, creencias, decisión, actitudes, participación y fortalecimiento. La Psicología puede realizar contribuciones al desarrollo rural territorial

El desarrollo rural y las contribuciones de la Psicología : Un estado de la cuestión

En todo el mundo, el 70 de la población pobre vive en áreas rurales. A pesar de los programas para revertir la pobreza, los resultados han sido limitados. El desarrollo rural busca reducir la desigualdad. Varios obstáculos que se les presentan a estos programas son psicosociales. El objetivo de este trabajo es explorar y describir las vinculaciones entre la Psicología y los procesos de desarrollo rural territorial en 111 publicaciones aparecidas entre 1985 y 2012. En la revisión, se encontró que los constructos utilizados fueron, entre otros, percepción, creencias, decisión, actitudes, participación y fortalecimiento. La Psicología puede realizar contribuciones al desarrollo rural territorial

El desarrollo rural y las contribuciones de la Psicología : Un estado de la cuestión

En todo el mundo, el 70 de la población pobre vive en áreas rurales. A pesar de los programas para revertir la pobreza, los resultados han sido limitados. El desarrollo rural busca reducir la desigualdad. Varios obstáculos que se les presentan a estos programas son psicosociales. El objetivo de este trabajo es explorar y describir las vinculaciones entre la Psicología y los procesos de desarrollo rural territorial en 111 publicaciones aparecidas entre 1985 y 2012. En la revisión, se encontró que los constructos utilizados fueron, entre otros, percepción, creencias, decisión, actitudes, participación y fortalecimiento. La Psicología puede realizar contribuciones al desarrollo rural territorial

The integration of project competences within the post-graduate programme: a case study of the International Masters in Rural Development AGRIS MUNDUS

Experiences relating to the InternationalMasters in Rural Development from the Technical University of Madrid (Universidad Politécnica de Madrid, UPM), the first Spanish programme to receive a mention as a Registered Education Programme by InternationalProject Management Association (IPMA) are considered. Backed by an educational strategy based on Project-Based Learning dating back twenty years, this programme has managed to adapt to the competence evaluation requirements proposed by the European Space for Higher Education (ESHE). In order to do this the training is linked to the professional qualification using competences as a reference leading to the qualification in project management as established by the IPMA.

Space-time analysis of the urban-rural grafient in the metropolitan area of Madrid and ist surroundings -Guadalajara and Toledo.

According to UN provisions in the period from 2007 to 2050 world population will grow up to 9200 million people. In fact, for the first time in history, in the year 2008 world urban population became higher than rural population. The increase of urban areas and their transport infrastructures has influenced agricultural land use due to their irreversible change, especially when they remain as periurban vacant land, losing their character and identity. In the Europe of the nineties, the traditional urban-rural gradient, characterized by a neat contact between both land types, has become so complex that it has change to a gradient in which it is difficult to separate urban and rural land uses. [Antrop 2004]. A literature review has been made on methodologies used for the urban-rural gradient analysis. One of these methodologies was selected that integrates ecological characterization based on the use of spatial metrics and geographical characterization based on spatial components. Cartographical sources used were Corine Land Cover at 1: 100000 scale and the Spanish Land Use Information System at 1:25000 scale. Urban-rural gradient paradigm is an analysis methodology, coming from landscape ecology, which enables to investigate how urbanization provokes changes in ecological patterns and processes into landscape. [Hahs and McDonnell 2006].The present research adapt this methodology to study the urban-rural gradient in the outskirts of Madrid, Toledo and Guadalajara. Both scales (1:25000 and 1:100000) were simultaneously used to reach the next objectives: 1) Analysis of landscape pattern dynamics in relation to distance to the town centre and major infrastructures. 2) Analysis of landscape pattern dynamics in the fringe of protected areas. The paper presents a new approach to the urban-rural relationship which allows better planning and management of urban áreas.

La evaluación como herramienta para la mejora de planes,programas y proyectos: evolución y contribuciones al desarrollo rural.

Evaluation is a new discipline and, whilst it has a long way to go, it has already made many advances. The growing importance of this field is exemplified in its increasing use in international organizations and public policies at a national, regional or local level, as well as in the exponential growth of evaluation societies around the world. The expansion of an ?evaluation culture? is explained by its significant utility by providing evidence to help decision-making and by providing a value system that establishes criteria and explicit standards by which to judge the interventions. These contributions have great relevance in the rural development field,thus, evaluation has become a great support for achieving sustainable development processes.

Characterisation of the operation & maintenance phase in PV rural electrification programmes

Con 1.300 millones de personas en el mundo sin acceso a la electricidad (la mayoría en entornos rurales de países empobrecidos), la energía solar fotovoltaica constituye una solución viable técnica y económicamente para electrificar las zonas más remotas del planeta donde las redes eléctricas convencionales no llegan. Casi todos los países en el mundo han desarrollado algún tipo de programa de electrificación fotovoltaica rural durante los últimos 40 años, principalmente los países más pobres, donde a través de diferentes modelos de financiación, se han instalado millones de sistemas solares domiciliarios (pequeños sistemas fotovoltaicos para uso doméstico). Durante este largo período, se han ido superando muchas barreras, como la mejora de la calidad de los sistemas fotovoltaicos, la reducción de costes, la optimización del diseño y del dimensionado de los sistemas, la disponibilidad financiera para implantar programas de electrificación rural, etc. Gracias a esto, la electrificación rural descentralizada ha experimentado recientemente un salto de escala caracterizada por la implantación de grandes programas con miles de sistemas solares domiciliarios e integrando largos períodos de mantenimiento. Muchos de estos grandes programas se están llevando a cabo con limitado éxito, ya que generalmente parten de supuestos e hipótesis poco contrastadas con la realidad, comprometiendo así un retorno económico que permita el desarrollo de esta actividad a largo plazo. En este escenario surge un nuevo reto: el de cómo garantizar la sostenibilidad de los grandes programas de electrificación rural fotovoltaica. Se argumenta que la principal causa de esta falta de rentabilidad es el imprevisto alto coste de la fase de operación y mantenimiento. Cuestiones clave tales como la estructura de costes de operación y mantenimiento o la fiabilidad de los componentes del sistema fotovoltaico no están bien caracterizados hoy en día. Esta situación limita la capacidad de diseñar estructuras de mantenimiento capaces de asegurar la sostenibilidad y la rentabilidad del servicio de operación y mantenimiento en estos programas. Esta tesis doctoral tiene como objetivo responder a estas cuestiones. Se ha realizado varios estudios sobre la base de un gran programa de electrificación rural fotovoltaica real llevado a cabo en Marruecos con más de 13.000 sistemas solares domiciliarios instalados. Sobre la base de este programa se ha hecho una evaluación en profundidad de la fiabilidad de los sistemas solares a partir de los datos de mantenimiento recogidos durante 5 años con más de 80.000 inputs. Los resultados han permitido establecer las funciones de fiabilidad de los equipos tal y como se comportan en condiciones reales de operación, las tasas de fallos y los tiempos medios hasta el fallo para los principales componentes del sistema, siendo este el primer caso de divulgación de resultados de este tipo en el campo de la electrificación rural fotovoltaica. Los dos principales componentes del sistema solar domiciliario, la batería y el módulo fotovoltaico, han sido analizados en campo a través de una muestra de 41 sistemas trabajando en condiciones reales pertenecientes al programa solar marroquí. Por un lado se ha estudiado la degradación de la capacidad de las baterías y por otro la degradación de potencia de los módulos fotovoltaicos. En el caso de las baterías, los resultados nos han permitido caracterizar la curva de degradación en capacidad llegando a obtener una propuesta de nueva definición del umbral de vida útil de las baterías en electrificación rural. También sobre la base del programa solar de Marruecos se ha llevado a cabo un estudio de caracterización de los costes reales de operación y mantenimiento a partir de la base de datos de contabilidad del programa registrados durante 5 años. Los resultados del estudio han permitido definir cuáles son costes que más incidencia tienen en el coste global. Se han obtenido los costes unitarios por sistema instalado y se han calculado los montantes de las cuotas de mantenimiento de los usuarios para garantizar la rentabilidad de la operación y mantenimiento. Finalmente, se propone un modelo de optimización matemática para diseñar estructuras de mantenimiento basado en los resultados de los estudios anteriores. La herramienta, elaborada mediante programación lineal entera mixta, se ha aplicado al programa marroquí con el fin de validar el modelo propuesto. ABSTRACT With 1,300 million people worldwide deprived of access to electricity (mostly in rural environments), photovoltaic solar energy has proven to be a cost‐effective solution and the only hope for electrifying the most remote inhabitants of the planet, where conventional electric grids do not reach because they are unaffordable. Almost all countries in the world have had some kind of rural photovoltaic electrification programme during the past 40 years, mainly the poorer countries, where through different organizational models, millions of solar home systems (small photovoltaic systems for domestic use) have been installed. During this long period, many barriers have been overcome, such as quality enhancement, cost reduction, the optimization of designing and sizing, financial availability, etc. Thanks to this, decentralized rural electrification has recently experienced a change of scale characterized by new programmes with thousands of solar home systems and long maintenance periods. Many of these large programmes are being developed with limited success, as they have generally been based on assumptions that do not correspond to reality, compromising the economic return that allows long term activity. In this scenario a new challenge emerges, which approaches the sustainability of large programmes. It is argued that the main cause of unprofitability is the unexpected high cost of the operation and maintenance of the solar systems. In fact, the lack of a paradigm in decentralized rural services has led to many private companies to carry out decentralized electrification programmes blindly. Issues such as the operation and maintenance cost structure or the reliability of the solar home system components have still not been characterized. This situation does not allow optimized maintenance structure to be designed to assure the sustainability and profitability of the operation and maintenance service. This PhD thesis aims to respond to these needs. Several studies have been carried out based on a real and large photovoltaic rural electrification programme carried out in Morocco with more than 13,000 solar home systems. An in‐depth reliability assessment has been made from a 5‐year maintenance database with more than 80,000 maintenance inputs. The results have allowed us to establish the real reliability functions, the failure rate and the main time to failure of the main components of the system, reporting these findings for the first time in the field of rural electrification. Both in‐field experiments on the capacity degradation of batteries and power degradation of photovoltaic modules have been carried out. During the experiments both samples of batteries and modules were operating under real conditions integrated into the solar home systems of the Moroccan programme. In the case of the batteries, the results have enabled us to obtain a proposal of definition of death of batteries in rural electrification. A cost assessment of the Moroccan experience based on a 5‐year accounting database has been carried out to characterize the cost structure of the programme. The results have allowed the major costs of the photovoltaic electrification to be defined. The overall cost ratio per installed system has been calculated together with the necessary fees that users would have to pay to make the operation and maintenance affordable. Finally, a mathematical optimization model has been proposed to design maintenance structures based on the previous study results. The tool has been applied to the Moroccan programme with the aim of validating the model.

Technology transfer of renewable energy for rural development: historical evolution and lessons of experience from the model WWP

Technology transfer (TT) in the area of renewable energy (RE) throughout history has been an important tool for rural development (RD). Initially, the TT has been conceptualized as the purchase or donation of machinery from first world countries - without any consideration of staff training and contextual conditions for the adaptation of technology to the needs of the country. Various researches have revealed the existence of different approaches to planning the TT of RE, demonstrating the high complexity of projects from the social and contextual dimension. This paper addresses the conceptual evolution of the TT of RE for RD, examining its different periods considered for three criteria: historical events occurred, the role of stakeholders and changing objectives for the TT of RE for RD. For the conceptual analysis of changes the model Working With People (WWP) is used for planning and project management of high social complexity in RD. The analysis defines the existence of four historical periods in the TT of RE and synthesizes the lessons of experience from the three dimensions (ethical-social, technical-entrepreneurial, and political-contextual) of the WWP model.