Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies

BACKGROUND Few estimates exist of the life expectancy of HIV-positive adults receiving antiretroviral treatment (ART) in low- and middle-income countries. We aimed to estimate the life expectancy of patients starting ART in South Africa and compare it with that of HIV-negative adults. METHODS AND FINDINGS Data were collected from six South African ART cohorts. Analysis was restricted to 37,740 HIV-positive adults starting ART for the first time. Estimates of mortality were obtained by linking patient records to the national population register. Relative survival models were used to estimate the excess mortality attributable to HIV by age, for different baseline CD4 categories and different durations. Non-HIV mortality was estimated using a South African demographic model. The average life expectancy of men starting ART varied between 27.6 y (95% CI: 25.2-30.2) at age 20 y and 10.1 y (95% CI: 9.3-10.8) at age 60 y, while estimates for women at the same ages were substantially higher, at 36.8 y (95% CI: 34.0-39.7) and 14.4 y (95% CI: 13.3-15.3), respectively. The life expectancy of a 20-y-old woman was 43.1 y (95% CI: 40.1-46.0) if her baseline CD4 count was ≥ 200 cells/µl, compared to 29.5 y (95% CI: 26.2-33.0) if her baseline CD4 count was <50 cells/µl. Life expectancies of patients with baseline CD4 counts ≥ 200 cells/µl were between 70% and 86% of those in HIV-negative adults of the same age and sex, and life expectancies were increased by 15%-20% in patients who had survived 2 y after starting ART. However, the analysis was limited by a lack of mortality data at longer durations. CONCLUSIONS South African HIV-positive adults can have a near-normal life expectancy, provided that they start ART before their CD4 count drops below 200 cells/µl. These findings demonstrate that the near-normal life expectancies of HIV-positive individuals receiving ART in high-income countries can apply to low- and middle-income countries as well. Please see later in the article for the Editors' Summary.

Prognosis of Children with HIV-1 Infection Starting Antiretroviral Therapy in Southern Africa: A Collaborative Analysis of Treatment Programs

BACKGROUND: Prognostic models for children starting antiretroviral therapy (ART) in Africa are lacking. We developed models to estimate the probability of death during the first year receiving ART in Southern Africa. METHODS: We analyzed data from children ≤10 years old who started ART in Malawi, South Africa, Zambia or Zimbabwe from 2004-2010. Children lost to follow-up or transferred were excluded. The primary outcome was all-cause mortality in the first year of ART. We used Weibull survival models to construct two prognostic models: one with CD4%, age, WHO clinical stage, weight-for-age z-score (WAZ) and anemia and one without CD4%, because it is not routinely measured in many programs. We used multiple imputation to account for missing data. RESULTS: Among 12655 children, 877 (6.9%) died in the first year of ART. 1780 children were lost to follow-up/transferred and excluded from main analyses; 10875 children were included. With the CD4% model probability of death at 1 year ranged from 1.8% (95% CI: 1.5-2.3) in children 5-10 years with CD4% ≥10%, WHO stage I/II, WAZ ≥-2 and without severe anemia to 46.3% (95% CI: 38.2-55.2) in children <1 year with CD4% <5%, stage III/IV, WAZ< -3 and severe anemia. The corresponding range for the model without CD4% was 2.2% (95% CI: 1.8-2.7) to 33.4% (95% CI: 28.2-39.3). Agreement between predicted and observed mortality was good (C-statistics=0.753 and 0.745 for models with and without CD4% respectively). CONCLUSION: These models may be useful to counsel children/caregivers, for program planning and to assess program outcomes after allowing for differences in patient disease severity characteristics.

When to start antiretroviral therapy in children aged 2-5 years: a collaborative causal modelling analysis of cohort studies from southern Africa

BACKGROUND There is limited evidence on the optimal timing of antiretroviral therapy (ART) initiation in children 2-5 y of age. We conducted a causal modelling analysis using the International Epidemiologic Databases to Evaluate AIDS-Southern Africa (IeDEA-SA) collaborative dataset to determine the difference in mortality when starting ART in children aged 2-5 y immediately (irrespective of CD4 criteria), as recommended in the World Health Organization (WHO) 2013 guidelines, compared to deferring to lower CD4 thresholds, for example, the WHO 2010 recommended threshold of CD4 count <750 cells/mm(3) or CD4 percentage (CD4%) <25%. METHODS AND FINDINGS ART-naïve children enrolling in HIV care at IeDEA-SA sites who were between 24 and 59 mo of age at first visit and with ≥1 visit prior to ART initiation and ≥1 follow-up visit were included. We estimated mortality for ART initiation at different CD4 thresholds for up to 3 y using g-computation, adjusting for measured time-dependent confounding of CD4 percent, CD4 count, and weight-for-age z-score. Confidence intervals were constructed using bootstrapping. The median (first; third quartile) age at first visit of 2,934 children (51% male) included in the analysis was 3.3 y (2.6; 4.1), with a median (first; third quartile) CD4 count of 592 cells/mm(3) (356; 895) and median (first; third quartile) CD4% of 16% (10%; 23%). The estimated cumulative mortality after 3 y for ART initiation at different CD4 thresholds ranged from 3.4% (95% CI: 2.1-6.5) (no ART) to 2.1% (95% CI: 1.3%-3.5%) (ART irrespective of CD4 value). Estimated mortality was overall higher when initiating ART at lower CD4 values or not at all. There was no mortality difference between starting ART immediately, irrespective of CD4 value, and ART initiation at the WHO 2010 recommended threshold of CD4 count <750 cells/mm(3) or CD4% <25%, with mortality estimates of 2.1% (95% CI: 1.3%-3.5%) and 2.2% (95% CI: 1.4%-3.5%) after 3 y, respectively. The analysis was limited by loss to follow-up and the unavailability of WHO staging data. CONCLUSIONS The results indicate no mortality difference for up to 3 y between ART initiation irrespective of CD4 value and ART initiation at a threshold of CD4 count <750 cells/mm(3) or CD4% <25%, but there are overall higher point estimates for mortality when ART is initiated at lower CD4 values. Please see later in the article for the Editors' Summary.

Consumer Health Information for Asians (CHIA): a collaborative project.

According to the 2000 United States Census, the Asian population in Houston, Texas, has increased more than 67% in the last ten years. To supplement an already active consumer health information program, the staff of the Houston Academy of Medicine-Texas Medical Center Library worked with community partners to bring health information to predominantly Asian neighborhoods. Brochures on health topics of concern to the Asian community were translated and placed in eight informational kiosks in Asian centers such as temples and an Asian grocery store. A press conference and a ribbon cutting ceremony were held to debut the kiosks and to introduce the Consumer Health Information for Asians (CHIA) program. Project goals for the future include digitizing the translated brochures, mounting them on the Houston HealthWays Website, and developing touch-screen kiosks. The CHIA group is investigating adding health resources in other Asian languages, as well as Spanish. Funding for this project has come from outside sources rather than from the regular library budget.

New Technologies and Concepts for Rehabilitation in the Acute Phase of Stroke: A Collaborative Matrix

The process of developing a successful stroke rehabilitation methodology requires four key components: a good understanding of the pathophysiological mechanisms underlying this brain disease, clear neuroscientific hypotheses to guide therapy, adequate clinical assessments of its efficacy on multiple timescales, and a systematic approach to the application of modern technologies to assist in the everyday work of therapists. Achieving this goal requires collaboration between neuroscientists, technologists and clinicians to develop well-founded systems and clinical protocols that are able to provide quantitatively validated improvements in patient rehabilitation outcomes. In this article we present three new applications of complementary technologies developed in an interdisciplinary matrix for acute-phase upper limb stroke rehabilitation – functional electrical stimulation, arm robot-assisted therapy and virtual reality-based cognitive therapy. We also outline the neuroscientific basis of our approach, present our detailed clinical assessment protocol and provide preliminary results from patient testing of each of the three systems showing their viability for patient use.

Collaborative Conversations for Change: A SolutionFocused Approach to Family Centered Practice

The renewed interest in Family Centered Practice, prompted by the funding of Family Preservation and Support Programs, has created a need for training practitioners at a number of different levels and for a variety of roles. This paper will describe a training program for Family Centered Practice. Building on an empowerment model, the author presents an approach for working with families and children that views the tragedies of the past as resources, rather than the major cause of present problems. Collaborative Conversations for Change adapts the solution-focused therapy model to nontherapy roles that are required for a program to be family centered. Although these roles are not therapy, they are nevertheless therapeutic and reinforce clients' strengths. These collaborative conversations, however brief they may be, recognize that the client is the expert on his/her pain and struggles and the practitioner is the expert on assisting her/him plan change. Additionally, illustrations from a cross-cultural perspective demonstrate the utility of collaborative conversation in enhancing cultural competence.

What’s Our Responsibility? How Individuals and Organizations Can Proactively Address Human Trafficking

Human trafficking is regarded by Interpol as the second largest and fastest growing criminal industry in the world. This letter is submitted in response to the topic of Human Trafficking addressed in Volume 2, Issue 1. In response to the ever-increasing attention to this problem, various programs focus on the rescue of survivors in anti-trafficking efforts - sometimes overshadowing efforts to prevent human trafficking and rehabilitate those harmed. A comprehensive, responsible approach requires a system of rescue and rehabilitation with a deliberate eye toward prevention. The basic human rights of survivors are at risk of being violated by “so-called rescue missions, despite the good intentions of would-be rescuers.” At the prevention level, a firm human rights approach is needed. When interventions shift their emphasis to prevention and tackle the innate contributors to inequality, then the roots of trafficking and slavery can be firmly extirpated. By taking a thoughtful and vested approach to tackling all areas of trafficking— including prevention, rescue, and rehabilitation—resources can be used more effectively, and communities are likely to have a more extensive impact in the fight against this hideous crime against humanity.

The World Trade Organization’s Legitimacy Crisis: What Does The Beast Look Like?

The concept of legitimacy has many facets. The article reviews from a politics and law perspective the diagnosis of an ``institution in crisis''. This article is divided into three sections. It starts with a cautionary note on existing fallacies about assessing multilateral intergovernmental institutions and discusses competing schools of thought that approach the World Trade Organization (WTO) with varying perceptions of democracy and legitimacy. Section II takes up the actual debate on redesigning the WTO and directs attention to the question of balancing input and output legitimacy. Section III sketches potential avenues of research that have been neglected in the past.

The Democratizing Effects of Multilateral Organizations: A Cautionary Note on the WTO

The field of international relations has been obsessed with democracy and democratization and its effects on international cooperation for a long time. More recently, research has turned its focus on how international organizations enhance democracy. This article contributes to this debate and applies a prominent liberal framework to study the ‘outside-in’ effects of the World Trade Organization. The article offers a critical reading of democratization through IO membership. It provides for an assessment of the dominant framework put forward by Keohane et al. (2009). In doing so, it develops a set of empirical strategies to test conjectured causal mechanisms with respect to the WTO, and illustrates the potential application by drawing on selected empirical evidence from trade politics. Finally, it proposes a number of analytical revisions to the liberal framework and outlines avenues for future research.

Introduction to “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates”

Abstract Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. It is the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).

Collaborative Learning in Context: The Problem with Peer Tutoring

Describes the effects that institutionalization of peer tutoring is having on the teaching-learning relationship.

HIV encephalopathy: incidence, definition and pathogenesis. Results of a Swiss collaborative study

The incidence of HIV encephalopathies was determined in an ongoing consecutive autopsy study. Among 345 patients who died from AIDS in Switzerland during 1981-1990, 68 (19%) showed morphological evidence of HIV encephalopathy. Two major histopathological manifestations were observed. Progressive diffuse leukoencephalopathy (PDL) was present in 33 cases and is characterized by a diffuse loss of myelin staining in the deep white matter of the cerebral and cerebellar hemispheres, with scattered multinucleated giant cells but little or no inflammatory reaction. Multinucleated giant cell encephalitis (MGCE) was diagnosed in 32 cases; it's hallmarks are accumulations of multinucleated giant cells with prominent inflammatory reaction and focal necroses. In 3 patients both types of lesions overlapped. Brain tissue from 27 patients was analyzed for the presence of HIV gag sequences using the polymerase chain reaction (PCR) with primers encoding a 109 base pair segment of the viral gene. Amplification succeeded in all patients with clinical and histopathological evidence for HIV encephalopathy but was absent in AIDS patients with opportunistic bacterial, parasitic and/or viral infections. Potential mechanisms by which HIV exerts it's adverse effects on the human CNS are discussed.

Keeping citizens, companies, and organizations informed by Web KnowARR

For the main part, electronic government (or e-government for short) aims to put digital public services at disposal for citizens, companies, and organizations. To that end, in particular, e-government comprises the application of Information and Communications Technology (ICT) to support government operations and provide better governmental services (Fraga, 2002) as possible with traditional means. Accordingly, e-government services go further as traditional governmental services and aim to fundamentally alter the processes in which public services are generated and delivered, after this manner transforming the entire spectrum of relationships of public bodies with its citizens, businesses and other government agencies (Leitner, 2003). To implement this transformation, one of the most important points is to inform the citizen, business, and/or other government agencies faithfully and in an accessible way. This allows all the partaking participants of governmental affairs for a transition from passive information access to active participation (Palvia and Sharma, 2007). In addition, by a corresponding handling of the participants' data, a personalization towards these participants may even be accomplished. For instance, by creating significant user profiles as a kind of participants' tailored knowledge structures, a better-quality governmental service may be provided (i.e., expressed by individualized governmental services). To create such knowledge structures, thus known information (e.g., a social security number) can be enriched by vague information that may be accurate to a certain degree only. Hence, fuzzy knowledge structures can be generated, which help improve governmental-participants relationship. The Web KnowARR framework (Portmann and Thiessen, 2013; Portmann and Pedrycz, 2014; Portmann and Kaltenrieder, 2014), which I introduce in my presentation, allows just all these participants to be automatically informed about changes of Web content regarding a- respective governmental action. The name Web KnowARR thereby stands for a self-acting entity (i.e. instantiated form the conceptual framework) that knows or apprehends the Web. In this talk, the frameworks respective three main components from artificial intelligence research (i.e. knowledge aggregation, representation, and reasoning), as well as its specific use in electronic government will be briefly introduced and discussed.