Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration

AIMS: To compare the gender distribution of HIV-infected adults receiving highly active antiretroviral treatment (HAART) in resource-constrained settings with estimates of the gender distribution of HIV infection; to describe the clinical characteristics of women and men receiving HAART. METHODS: The Antiretroviral Therapy in Lower-Income Countries, ART-LINC Collaboration is a network of clinics providing HAART in Africa, Latin America, and Asia. We compared UNAIDS data on the gender distribution of HIV infection with the proportions of women and men receiving HAART in the ART-LINC Collaboration. RESULTS: Twenty-nine centers in 13 countries participated. Among 33,164 individuals, 19,989 (60.3%) were women. Proportions of women receiving HAART in ART-LINC centers were similar to, or higher than, UNAIDS estimates of the proportions of HIV-infected women in all but two centers. There were fewer women receiving HAART than expected from UNAIDS data in one center in Uganda and one center in India. Taking into account heterogeneity across cohorts, women were younger than men, less likely to have advanced HIV infection, and more likely to be anemic at HAART initiation. CONCLUSIONS: Women in resource-constrained settings are not necessarily disadvantaged in their access to HAART. More attention needs to be paid to ensuring that HIV-infected men are seeking care and starting HAART.

Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America

OBJECTIVES: To describe temporal trends in baseline clinical characteristics, initial treatment regimens and monitoring of patients starting antiretroviral therapy (ART) in resource-limited settings. METHODS: We analysed data from 17 ART programmes in 12 countries in sub-Saharan Africa, South America and Asia. Patients aged 16 years or older with documented date of start of highly active ART (HAART) were included. Data were analysed by calculating medians, interquartile ranges (IQR) and percentages by regions and time periods. Not all centres provided data for 2006 and 2005 and 2006 were therefore combined. RESULTS: A total of 36,715 patients who started ART 1996-2006 were included in the analysis. Patient numbers increased substantially in sub-Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005-2006. In South America 20 regimes were used in 2005-2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/microl (IQR 53-194) in 2005-2006 in Africa, 134 cells/microl (IQR 72-191) in Asia, and 197 cells/microl (IQR 61-277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/microl in 2005-2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/microl in Africa, 65 cells/microl in Asia and 10 cells/microl in South America. In 2005-2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America. Corresponding figures for 6-month CD4 cell counts were 74%, 77% and 81%. CONCLUSIONS: The public health approach to providing ART proposed by the World Health Organization has been implemented in sub-Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV-infected men.

Digital processing and data compilation approach for using remotely sensed imagery to identify geological lineaments in hard-rock terrains : an application for groundwater explorations in Nicaragua

Sustainable yields from water wells in hard-rock aquifers are achieved when the well bore intersects fracture networks. Fracture networks are often not readily discernable at the surface. Lineament analysis using remotely sensed satellite imagery has been employed to identify surface expressions of fracturing, and a variety of image-analysis techniques have been successfully applied in “ideal” settings. An ideal setting for lineament detection is where the influences of human development, vegetation, and climatic situations are minimal and hydrogeological conditions and geologic structure are known. There is not yet a well-accepted protocol for mapping lineaments nor have different approaches been compared in non-ideal settings. A new approach for image-processing/synthesis was developed to identify successful satellite imagery types for lineament analysis in non-ideal terrain. Four satellite sensors (ASTER, Landsat7 ETM+, QuickBird, RADARSAT-1) and a digital elevation model were evaluated for lineament analysis in Boaco, Nicaragua, where the landscape is subject to varied vegetative cover, a plethora of anthropogenic features, and frequent cloud cover that limit the availability of optical satellite data. A variety of digital image processing techniques were employed and lineament interpretations were performed to obtain 12 complementary image products that were evaluated subjectively to identify lineaments. The 12 lineament interpretations were synthesized to create a raster image of lineament zone coincidence that shows the level of agreement among the 12 interpretations. A composite lineament interpretation was made using the coincidence raster to restrict lineament observations to areas where multiple interpretations (at least 4) agree. Nine of the 11 previously mapped faults were identified from the coincidence raster. An additional 26 lineaments were identified from the coincidence raster, and the locations of 10 were confirmed by field observation. Four manual pumping tests suggest that well productivity is higher for wells proximal to lineament features. Interpretations from RADARSAT-1 products were superior to interpretations from other sensor products, suggesting that quality lineament interpretation in this region requires anthropogenic features to be minimized and topographic expressions to be maximized. The approach developed in this study has the potential to improve siting wells in non-ideal regions.

DIFFERENTIATING PATH AND SOURCE PROCESSES IN COMPLEX GEOLOGIC STRUCTURE THROUGH PASSIVE SEISMIC STUDIES: BERING GLACIER, ALASKA AND VILLARRICA VOLCANO, CHILE

Measuring shallow seismic sources provides a way to reveal processes that cannot be directly observed, but the correct interpretation and value of these signals depend on the ability to distinguish source from propagation effects. Furthermore, seismic signals produced by a resonating source can look almost identical to those produced by impulsive sources, but modified along the path. Distinguishing these two phenomena can be accomplished by examining the wavefield with small aperture arrays or by recording seismicity near to the source when possible. We examine source and path effects in two different environments: Bering Glacier, Alaska and Villarrica Volcano, Chile. Using three 3-element seismic arrays near the terminus of the Bering Glacier, we have identified and located both terminus calving and iceberg breakup events. We show that automated array analysis provided a robust way to locate icequake events using P waves. This analysis also showed that arrivals within the long-period codas were incoherent within the small aperture arrays, demonstrating that these codas previously attributed to crack resonance were in fact a result of a complicated path rather than a source effect. At Villarrica Volcano, seismometers deployed from near the vent to ~10 km revealed that a several cycle long-period source signal recorded at the vent appeared elongated in the far-field. We used data collected from the stations nearest to the vent to invert for the repetitive seismic source, and found it corresponded to a shallow force within the lava lake oriented N75°E and dipping 7° from horizontal. We also used this repetitive signal to search the data for additional seismic and infrasonic properties which included calculating seismic-acoustic delay times, volcano acoustic-seismic ratios and energies, event frequency, and real-time seismic amplitude measurements. These calculations revealed lava lake level and activity fluctuations consistent with lava lake level changes inferred from the persistent infrasonic tremor.

Helena and Ennis Talc Deposits

The purpose of this report is to collect geologic data concerning two Montana talc occurrences at Helena and Ennis and to offer some explanation as to their origin. The two deposits cited are in somewhat similar lithologic settings and both possess the same mineralogical and structural features. Because of this similarity only the Helena deposit is covered in detail.

Great Falls Tectonic Zone: A Perspective from Idaho

An overview of geologic constraints on the age and extent of the Great Falls tectonic zone, a northeast-trending set of faults identified in west-central Montana.

Expert-novice Differences in Geologic Field Mapping and Related Cognition

The geosciences are often characterized as a visuospatial field - that is, one in which success depends upon the ability to mentally manipulate, rotate, project, and bend objects. To what extent is the assumption of strong spatial visualization skills among geoscientists correct? This talk will discuss two studies that investigated geoscience expert and novice spatial visualization, both in laboratory experiments and in a novel field study.

Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis

BACKGROUND: The retention of patients in antiretroviral therapy (ART) programmes is an important issue in resource-limited settings. Loss to follow up can be substantial, but it is unclear what the outcomes are in patients who are lost to programmes. METHODS AND FINDINGS: We searched the PubMed, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Indian Medlars Centre (IndMed) and African Index Medicus (AIM) databases and the abstracts of three conferences for studies that traced patients lost to follow up to ascertain their vital status. Main outcomes were the proportion of patients traced, the proportion found to be alive and the proportion that had died. Where available, we also examined the reasons why some patients could not be traced, why patients found to be alive did not return to the clinic, and the causes of death. We combined mortality data from several studies using random-effects meta-analysis. Seventeen studies were eligible. All were from sub-Saharan Africa, except one study from India, and none were conducted in children. A total of 6420 patients (range 44 to 1343 patients) were included. Patients were traced using telephone calls, home visits and through social networks. Overall the vital status of 4021 patients could be ascertained (63%, range across studies: 45% to 86%); 1602 patients had died. The combined mortality was 40% (95% confidence interval 33%-48%), with substantial heterogeneity between studies (P<0.0001). Mortality in African programmes ranged from 12% to 87% of patients lost to follow-up. Mortality was inversely associated with the rate of loss to follow up in the programme: it declined from around 60% to 20% as the percentage of patients lost to the programme increased from 5% to 50%. Among patients not found, telephone numbers and addresses were frequently incorrect or missing. Common reasons for not returning to the clinic were transfer to another programme, financial problems and improving or deteriorating health. Causes of death were available for 47 deaths: 29 (62%) died of an AIDS defining illness. CONCLUSIONS: In ART programmes in resource-limited settings a substantial minority of adults lost to follow up cannot be traced, and among those traced 20% to 60% had died. Our findings have implications both for patient care and the monitoring and evaluation of programmes.

Switching to second-line antiretroviral therapy in resource-limited settings: comparison of programmes with and without viral load monitoring

BACKGROUND: In high-income countries, viral load is routinely measured to detect failure of antiretroviral therapy (ART) and guide switching to second-line ART. Viral load monitoring is not generally available in resource-limited settings. We examined switching from nonnucleoside reverse transcriptase inhibitor (NNRTI)-based first-line regimens to protease inhibitor-based regimens in Africa, South America and Asia. DESIGN AND METHODS: Multicohort study of 17 ART programmes. All sites monitored CD4 cell count and had access to second-line ART and 10 sites monitored viral load. We compared times to switching, CD4 cell counts at switching and obtained adjusted hazard ratios for switching (aHRs) with 95% confidence intervals (CIs) from random-effects Weibull models. RESULTS: A total of 20 113 patients, including 6369 (31.7%) patients from 10 programmes with access to viral load monitoring, were analysed; 576 patients (2.9%) switched. Low CD4 cell counts at ART initiation were associated with switching in all programmes. Median time to switching was 16.3 months [interquartile range (IQR) 10.1-26.6] in programmes with viral load monitoring and 21.8 months (IQR 14.0-21.8) in programmes without viral load monitoring (P < 0.001). Median CD4 cell counts at switching were 161 cells/microl (IQR 77-265) in programmes with viral load monitoring and 102 cells/microl (44-181) in programmes without viral load monitoring (P < 0.001). Switching was more common in programmes with viral load monitoring during months 7-18 after starting ART (aHR 1.38; 95% CI 0.97-1.98), similar during months 19-30 (aHR 0.97; 95% CI 0.58-1.60) and less common during months 31-42 (aHR 0.29; 95% CI 0.11-0.79). CONCLUSION: In resource-limited settings, switching to second-line regimens tends to occur earlier and at higher CD4 cell counts in ART programmes with viral load monitoring compared with programmes without viral load monitoring.

Interview and translation strategies: coping with multilingual settings and data

Central Eastern Europe, the research area this paper is concerned with, is a region characterized by a high diversity of languages and cultures. It is, at the same time, an area where political, cultural and social conflicts have emerged over time, nowadays especially in border zones, where people of different ethnic, cultural or linguistic background live. In this context, it is important for us researchers to get balanced interview data, and consequently we very often have to conduct interviews in several different languages and within changing cultural contexts. In order to avoid "communication problems" or even conflictual (interview) situations, which might damage the outcome of the research, we are thus challenged to find appropriate communication strategies for any of these situations. This is especially difficult when we are confronted with language or culture-specific terminology or taboo expressions that carry political meaning(s). Once the interview data is collected and it comes to translating and analysing it, we face further challenges and new questions arise. First of all, we have to decide what a good translation strategy would be. Many words and phrases that exist in one language do not have an exact equivalent in another. Therefore we have to find a solution for translating these expressions and concepts in a way that their meanings do not get "lost by translation". In this paper I discuss and provide insights to these challenges by presenting and discussing numerous examples from the region in question. Specifically, I focus on the deconstruction of the meaning of geographical names and politically loaded expressions in order to show the sensitivities of language, the difficulties of research in multilingual settings and with multilingual data as well as the strategies or "ways out" of certain dilemmas.