Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women ('Option B+') in Malawi

OBJECTIVE To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') in Malawi. DESIGN, SETTING, AND PARTICIPANTS We examined retention in care, from the date of ART initiation up to 6 months, for women in the Option B+ program. We analysed nationwide facility-level data on women who started ART at 540 facilities (n = 21 939), as well as individual-level data on patients who started ART at 19 large facilities (n = 11 534). RESULTS Of the women who started ART under Option B+ (n = 21 939), 17% appeared to be lost to follow-up 6 months after ART initiation. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4 cell count 350 cells/μl or less, to never return after their initial clinic visit [odds ratio (OR) 5.0, 95% confidence interval (CI) 4.2-6.1]. Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (OR 2.2, 95% CI 1.8-2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0 to 58%. CONCLUSION Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community or family-based models of care could improve its effectiveness.

Catheter removal versus retention in the management of catheter-associated enterococcal bloodstream infections

BACKGROUND Enterococci are an important cause of central venous catheter (CVC)-associated bloodstream infections (CA-BSI). It is unclear whether CVC removal is necessary to successfully manage enterococcal CA-BSI. METHODS A 12-month retrospective cohort study of adults with enterococcal CA-BSI was conducted at a tertiary care hospital; clinical, microbiological and outcome data were collected. RESULTS A total of 111 patients had an enterococcal CA-BSI. The median age was 58.2 years (range 21 to 94 years). There were 45 (40.5%) infections caused by Entercoccus faecalis (among which 10 [22%] were vancomycin resistant), 61 (55%) by Enterococcus faecium (57 [93%] vancomycin resistant) and five (4.5%) by other Enterococcus species. Patients were treated with linezolid (n=51 [46%]), vancomycin (n=37 [33%]), daptomycin (n=11 [10%]), ampicillin (n=2 [2%]) or quinupristin/dalfopristin (n=2 [2%]); seven (n=6%) patients did not receive adequate enterococcal treatment. Additionally, 24 (22%) patients received adjunctive gentamicin treatment. The CVC was retained in 29 (26.1%) patients. Patients with removed CVCs showed lower rates of in-hospital mortality (15 [18.3%] versus 11 [37.9]; P=0.03), but similar rates of recurrent bacteremia (nine [11.0%] versus two (7.0%); P=0.7) and a similar post-BSI length of hospital stay (median days [range]) (11.1 [1.7 to 63.1 days] versus 9.3 [1.9 to 31.8 days]; P=0.3). Catheter retention was an independent predictor of mortality (OR 3.34 [95% CI 1.21 to 9.26]). CONCLUSIONS To the authors' knowledge, the present article describes the largest enterococcal CA-BSI series to date. Mortality was increased among patients who had their catheter retained. Additional prospective studies are necessary to determine the optimal management of enterococcal CA-BSI.

Lateral sediment sources and knickzones as controls on spatio-temporal variations of sediment transport in an Alpine river

Modern mixed alluvial-bedrock channels in mountainous areas provide natural laboratories for understanding the time scales at which coarse-grained material has been entrained and transported from their sources to the adjacent sedimentary sink, where these deposits are preserved as conglomerates. This article assesses the shear stress conditions needed for the entrainment of the coarse-bed particles in the Glogn River that drains the 400 km2 Val Lumnezia basin, eastern Swiss Alps. In addition, quantitative data are presented on sediment transport patterns in this stream. The longitudinal stream profile of this river is characterized by three ca 500 m long knickzones where channel gradients range from 0·02 to 0·2 m m−1, and where the valley bottom confined into a <10 m wide gorge. Downstream of these knickzones, the stream is flat with gradients <0·01 m m−1 and widths ≥30 m. Measurements of the grain-size distribution along the trunk stream yield a mean D84 value of ca 270 mm, whereas the mean D50 is ca 100 mm. The consequences of the channel morphology and the grain-size distribution for the time scales of sediment transport were explored by using a one-dimensional step-backwater hydraulic model (Hydrologic Engineering Centre – River Analysis System). The results reveal that, along the entire trunk stream, a two to 10 year return period flood event is capable of mobilizing both the D50 and D84 fractions where the Shields stress exceeds the critical Shields stress for the initiation of particle motion. These return periods, however, varied substantially depending on the channel geometry and the pebble/boulder size distribution of the supplied material. Accordingly, the stream exhibits a highly dynamic boulder cover behaviour. It is likely that these time scales might also have been at work when coarse-grained conglomerates were constructed in the geological past.

Sediment dynamics in the subaquatic channel of the Rhone delta (Lake Geneva, France/Switzerland)

bstract With its smaller size, well-known boundary conditions, and the availability of detailed bathymetric data, Lake Geneva’s subaquatic canyon in the Rhone Delta is an excellent analogue to understand sedimentary pro- cesses in deep-water submarine channels. A multidisciplinary research effort was undertaken to unravel the sediment dynamics in the active canyon. This approach included innovative coring using the Russian MIR sub- mersibles, in situ geotechnical tests, and geophysical, sedimentological, geochemical and radiometric analysis techniques. The canyon floor/levee complex is character- ized by a classic turbiditic system with frequent spillover events. Sedimentary evolution in the active canyon is controlled by a complex interplay between erosion and sedimentation processes. In situ profiling of sediment strength in the upper layer was tested using a dynamic penetrometer and suggests that erosion is the governing mechanism in the proximal canyon floor while sedimen- tation dominates in the levee structure. Sedimentation rates progressively decrease down-channel along the levee structure, with accumulation exceeding 2.6 cm/year in the proximal levee. A decrease in the frequency of turbidites upwards along the canyon wall suggests a progressive confinement of the flow through time. The multi-proxy methodology has also enabled a qualitative slope-stability assessment in the levee structure. The rapid sediment loading, slope undercutting and over-steepening, and increased pore pressure due to high methane concentrations hint at a potential instability of the proximal levees. Fur- thermore, discrete sandy intervals show very high methane concentrations and low shear strength and thus could cor- respond to potentially weak layers prone to scarp failures.

Transient sediment supply in a high-altitude Alpine environment evidenced through a 10Be budget of the Etages catchment (French Western Alps)

Although beryllium-10 (10Be) concentrations in stream sediments provide useful synoptic views of catchment-wide erosion rates, little is known on the relative contributions of different sediment supply mechanisms to the acquisition of their initial signature in the headwaters. Here we address this issue by conducting a 10Be-budget of detrital materials that characterize the morphogenetic domains representative of high-altitude environments of the European Alps. We focus on the Etages catchment, located in the Ecrins-Pelvoux massif (southeast France), and illustrate how in situ 10Be concentrations can be used for tracing the origin of the sand fraction from the bedload in the trunk stream. The landscape of the Etages catchment is characterized by a geomorphic transient state, high topographic gradients, and a large variety of modern geomorphic domains ranging from glacial environments to scarcely vegetated alluvial plains. Beryllium-10 concentrations measured in the Etages catchment vary from similar to 1 x 104 to 4.5 x 105 atoms per gram quartz, while displaying consistent 10Be signatures within each representative morphogenetic unit. We show that the basic requirements for inferring catchment-wide denudation from 10Be concentration measurements are not satisfied in this small, dynamic catchment. However, the distinct 10Be signature observed for the geomorphic domains can be used as a tracer. We suggest that a terrestrial cosmogenic nuclide (TCN) budget approach provides a valuable tool for the tracing of material origin in basins where the let nature do the averaging' principles may be violated.

Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period.

OBJECTIVES The aim of this study was to quantify loss to follow-up (LTFU) in HIV care after delivery and to identify risk factors for LTFU, and implications for HIV disease progression and subsequent pregnancies. METHODS We used data on pregnancies within the Swiss HIV Cohort Study from 1996 to 2011. A delayed clinical visit was defined as > 180 days and LTFU as no visit for > 365 days after delivery. Logistic regression analysis was used to identify risk factors for LTFU. RESULTS A total of 695 pregnancies in 580 women were included in the study, of which 115 (17%) were subsequent pregnancies. Median maternal age was 32 years (IQR 28-36 years) and 104 (15%) women reported any history of injecting drug use (IDU). Overall, 233 of 695 (34%) women had a delayed visit in the year after delivery and 84 (12%) women were lost to follow-up. Being lost to follow-up was significantly associated with a history of IDU [adjusted odds ratio (aOR) 2.79; 95% confidence interval (CI) 1.32-5.88; P = 0.007] and not achieving an undetectable HIV viral load (VL) at delivery (aOR 2.42; 95% CI 1.21-4.85; P = 0.017) after adjusting for maternal age, ethnicity and being on antiretroviral therapy (ART) at conception. Forty-three of 84 (55%) women returned to care after LTFU. Half of them (20 of 41) with available CD4 had a CD4 count < 350 cells/μL and 15% (six of 41) a CD4 count < 200 cells/μL at their return. CONCLUSIONS A history of IDU and detectable HIV VL at delivery were associated with LTFU. Effective strategies are warranted to retain women in care beyond pregnancy and to avoid CD4 cell count decline. ART continuation should be advised especially if a subsequent pregnancy is planned.

Influence of noninjecting and injecting drug use on mortality, retention in the cohort, and antiretroviral therapy, in participants in the Swiss HIV Cohort Study.

OBJECTIVES We studied the influence of noninjecting and injecting drug use on mortality, dropout rate, and the course of antiretroviral therapy (ART), in the Swiss HIV Cohort Study (SHCS). METHODS Cohort participants, registered prior to April 2007 and with at least one drug use questionnaire completed until May 2013, were categorized according to their self-reported drug use behaviour. The probabilities of death and dropout were separately analysed using multivariable competing risks proportional hazards regression models with mutual correction for the other endpoint. Furthermore, we describe the influence of drug use on the course of ART. RESULTS A total of 6529 participants (including 31% women) were followed during 31 215 person-years; 5.1% participants died; 10.5% were lost to follow-up. Among persons with homosexual or heterosexual HIV transmission, noninjecting drug use was associated with higher all-cause mortality [subhazard rate (SHR) 1.73; 95% confidence interval (CI) 1.07-2.83], compared with no drug use. Also, mortality was increased among former injecting drug users (IDUs) who reported noninjecting drug use (SHR 2.34; 95% CI 1.49-3.69). Noninjecting drug use was associated with higher dropout rates. The mean proportion of time with suppressed viral replication was 82.2% in all participants, irrespective of ART status, and 91.2% in those on ART. Drug use lowered adherence, and increased rates of ART change and ART interruptions. Virological failure on ART was more frequent in participants who reported concomitant drug injections while on opiate substitution, and in current IDUs, but not among noninjecting drug users. CONCLUSIONS Noninjecting drug use and injecting drug use are modifiable risks for death, and they lower retention in a cohort and complicate ART.

Retention in care during the first 3 years of antiretroviral therapy for women in Malawi's option B+ programme: an observational cohort study

Background Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART. Methods We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up. Findings Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26 658 patients) after 12 months, 70·8% (18 306 of 25 849 patients) after 24 months, and 69·7% (17 787 of 25 535 patients) after 36 months. Patient-level data included 29 145 patients. 14 630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured. Interpretation Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+. Funding Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.

Retention in care of HIV-infected pregnant and lactating women starting art under Option B+ in rural Mozambique.

OBJECTIVE In 2013, Mozambique adopted Option B+, universal lifelong antiretroviral therapy (ART) for all pregnant and lactating women, as national strategy for prevention of mother-to-child transmission of HIV. We analyzed retention in care of pregnant and lactating women starting Option B+ in rural northern Mozambique. METHODS We compared ART outcomes in pregnant ("B+pregnant"), lactating ("B+lactating") and non-pregnant-non-lactating women of childbearing age starting ART after clinical and/or immunological criteria ("own health") between July 2013 and June 2014. Lost to follow-up was defined as no contact >180 days after the last visit. Multivariable competing risk models were adjusted for type of facility (type 1 vs. peripheral type 2 health center), age, WHO stage and time from HIV diagnosis to ART. RESULTS Over 333 person-years of follow-up (of 243 "B+pregnant", 65″B+lactating" and 317 "own health" women), 3.7% of women died and 48.5% were lost to follow-up. "B+pregnant" and "B+lactating" women were more likely to be lost in the first year (57% vs. 56.9% vs. 31.6%; p<0.001) and to have no follow-up after the first visit (42.4% vs. 29.2% vs. 16.4%; p<0.001) than "own health" women. In adjusted analyses, risk of being lost to follow-up was higher in "B+pregnant" (adjusted subhazard ratio [asHR]: 2.77; 95% CI: 2.18-3.50; p<0.001) and "B+lactating" (asHR: 1.94; 95% CI: 1.37-2.74; p<0.001). Type 2 health center was the only additional significant risk factor for loss to follow-up. CONCLUSIONS Retaining pregnant and lactating women in option B+ ART was poor; losses to follow-up were mainly early. The success of Option B+ for prevention of mother-to-child transmission of HIV in rural settings with weak health systems will depend on specific improvements in counseling and retention measures, especially at the beginning of treatment. This article is protected by copyright. All rights reserved.

An analysis of the effects of a peer mentor program and other factors on HIV patients' retention in care and clinical outcomes at Thomas Street Health Clinic, Houston Texas

Research examining programs designed to retain patients in health care focus on repeated interactions between outreach workers and patients (Bradford et al. 2007; Cheever 2007). The purpose of this study was to determine if patients who are peer-mentored at their intake exam remain in care longer and attend more physicians' visits than those who were not mentored. Using patients' medical records and a previously created mentor database, the study determined how many patients attended their intake visit but subsequently failed to establish regular care. The cohort study examined risk factors for establishing care, determined if patients lacking a peer mentor failed to establish care more than peer mentor assisted patients, and subsequently if peer mentored patients had better health outcomes. The sample consists of 1639 patients who were entered into the Thomas Street Patient Mentor Database between May 2005 and June 2007. The assignment to the mentored group was haphazardly conducted based on mentor availability. The data from the Mentor Database was then analyzed using descriptive statistical software (SPSS version 15; SPSS Inc., Chicago, Illinois, USA). Results indicated that patients who had a mentor at intake were more likely to return for primary care HIV visits at 90 and 180 days. Mentored patients also were more likely to be prescribed ART within 180 days from intake. Other risk factors that impacted remaining in care included gender, previous care status, time from diagnosis to intake visit, and intravenous drug use. Clinical health outcomes did not differ significantly between groups. This supports that mentoring did improve outcomes. Continuing to use peer-mentoring programs for HIV care may help in increasing retention of patients in care and improving patients' health in a cost effective manner. Future research on the effects of peer mentoring on mentors, and effects of concordance of mentor and patient demographics may help to further improve peer-mentoring programs. ^

The influence of social connectedness and self-esteem on participant retention in a bi-ethnic longitudinal study

In prospective studies it is essential that the study sample accurately represents the target population for meaningful inferences to be drawn. Understanding why some individuals do not participate, or fail to continue to participate, in longitudinal studies can provide an empirical basis for the development of effective recruitment and retention strategies to improve response rates. This study examined the influence of social connectedness and self-esteem on long-term retention of participants, using secondary data from the “San Antonio Longitudinal Study of Aging” (SALSA), a population-based study of Mexican Americans (MAs) and European Americans (EAs) aged over 65 years residing in San Antonio, Texas. We tested the effect of social connectedness, self-esteem and socioeconomic status on participant retention in both ethnic groups. In MAs only, we analyzed whether acculturation and assimilation moderated these associations and/or had a direct effect on participant retention. ^ Low income, low frequency of social contacts and length of recruitment interval were significant predictors of non-completer status. Participants with low levels of social contacts were almost twice as likely as those with high levels of social contacts to be non-completers, even after adjustment for age, sex, ethnic group, education, household income, and recruitment interval (OR = 1.95, 95% CI: 1.26–3.01, p = 0.003). Recruitment interval consistently and strongly predicted non-completer status in all the models tested. Depending on the model, for each year beyond baseline there was a 25–33% greater likelihood of non-completion. The only significant interaction, or moderating, effect observed was between social contacts and cultural values among MAs. Specifically, MAs with both low social contacts and low acculturation on cultural values (i.e., placed high value on preserving Mexican cultural origins) were three and half times more likely to be non-completers compared with MAs in other subgroups comprised of the combination of these variables, even after adjustment for covariates. ^ Long term studies with older and minority participants are challenging for participant retention. Strategies can be designed to enhance retention by paying special attention to participants with low social contacts and, in MAs, participants with both low social contacts and low acculturation on cultural values. Minimizing the time interval between baseline and follow-up recruitment, and maintaining frequent contact with participants during this interval should also be is integral to the study design.^

Maps of surface sediment distribution in the northern Wadden Sea, North Sea

From 1978 to 1981, intensive sedimentological investigations were carried out on the Northfrisian intertidal shoals between the small island of Gröde and Nordstrand lsland as a part of an interdisciplinary research projekt. The objective of this sedimentological study was to reveal long and short term tendencies in sedimentation and erosion in the environment. The presented study mainly concentrated on surface mapping in the tidal flats which based on more than 5000 sediment samples. The relative amounts of the grain-size fractions <0.063 mm and >0.125 mm are presented on maps. Predominant sediment typs are well sorted fine sands ("Wattsand") and muddy sands ("Schlicksand"), pure muds covering only small areas. The fine-grained deposits are either found in the lee-side of an island in elongated bays having a low waterdepth during high tide near the shore or near exposed "Klei" outcrops as well as sporadically on the edge of tidal rills. Together with standardized fields observations of biological and physical properties, the maps indicate a slight erosive tendency in large sections of the investigated area.

Particle flux measurements from moorings and surface sediment studies of sediment cores in the SE Pacific Ocean

Flux of siliceous plankton and taxonomic composition of diatom and silicoflagellate assemblages were determined from sediment trap samples collected in coastal upwelling-influenced waters off northern Chile (30°S, CH site) under "normal" or non-El Niño (1993-94) and El Niño conditions (1997-98). In addition, concentration of biogenic opal and siliceous plankton, and diatom and silicoflagellate assemblages preserved in surface sediments are provided for a wide area between 27° and 43°S off Chile. Regardless of the year, winter upwelling determines the maximum production pattern of siliceous microorganisms, with diatoms numerically dominating the biogenic opal flux. During the El Niño year the export is markedly lower: on an annual basis, total mass flux diminished by 60%, and diatom and silicoflagellate export by 75%. Major components of the diatom flora maintain much of their regular seasonal cycle of flux maxima and minima during both sampling periods. Neritic resting spores (RS) of Chaetoceros dominate the diatom flux, mirroring the influence of coastal-upwelled waters at the CH trap site. Occurrence of pelagic diatoms species Fragilariopsis doliolus, members of the Rhizosoleniaceae, Azpeitia spp. and Nitzschia interruptestriata, secondary components of the assemblage, reflects the intermingling of warmer waters of the Subtropical Gyre. Dictyocha messanensis dominates the silicoflagellate association almost year-around, but Distephanus pulchra delivers ca. 60% of its annual production in less than three weeks during the winter peak. The siliceous thanatocoenosis is largely dominated by diatoms, whose assemblage shows significant qualitative and quantitative variations from north to south. Between 27° and 35°S, the dominance of RS Chaetoceros, Thalassionema nitzschioides var. nitzschioides and Skeletonema costatum reflects strong export production associated with occurrence of coastal upwelling. Both highest biogenic opal content and diatom concentration at 35° and 41°-43°S coincide with highest pigment concentrations along the Chilean coast. Predominance of the diatom species Thalassiosira pacifica and T. poro-irregulata, and higher relative contribution of the silicoflagellate Distephanus speculum at 41°-43°S suggest the influence of more nutrient-rich waters and low sea surface temperatures, probably associated with the Antarctic Circumpolar Water.