Translating global health research aims into action: the example of the ALPHA network*

There is increasing consensus on the importance of strengthening global health research to meet health and development goals. Three key global health research aims are to ensure that research (i) addresses priority health needs, (ii) contributes to policy development, and (iii) adds value to investments in developing countries through South–South collaboration and capacity‐strengthening in the South. The ALPHA network (Analysing Longitudinal Population‐based HIV/AIDS data on Africa) is an illustrative example of how these global health research aims can be translated into action. The network facilitates additional collaborative HIV epidemiological research among six independent research projects in Africa studying population‐based cohorts. Under the first of the earlier mentioned aims, the network addresses key epidemiology research issues in HIV/AIDS which are crucial to making progress and monitoring progress in the response against HIV/AIDS. Under the second aim, the network’s scientific programme of research has contributed to strengthening the evidence base on HIV epidemiology in Africa and has informed policy development in areas such as targeted HIV prevention, social support, monitoring epidemic response and epidemic forecasting. Under the third aim, investment in the network has added value to the research investment in the individual projects through capacity development among African researchers as well as through the collaborative research outputs of the individual projects. Lessons from the network are relevant to collaborations facing similar challenges in other areas of global health research. These include the importance of establishing transparent and efficient governance for research collaborations, developing advance consensus on data sharing, ensuring effective communication for networking and demonstrating the added value of research investment in South–South collaborations.     

Perceptions About the Acceptability of Assessments of HIV Medication Adherence in Lilongwe, Malawi and Chennai, India

Little research exists on acceptability issues related to assessments of adherence to ART in resource-poor settings. To help prepare for two large-scale, multisite ART intervention trials, this qualitative study of individuals in Chennai, India (49 men, 11 women; 33 taking ART, 27 not) and Lilongwe, Malawi (5 men, 5 women, all taking ART) examined potential limitations of different types of adherence assessments: an adherence questionnaire, a pill diary, a pillbox, an electronic pill cap, and a medication punch card. Many participants reported that the various assessments would be acceptable. Potential limitations included issues surrounding literacy, the desire to appease one’s medical provider, privacy and stigma, and “cheating.” These potential limitations are similar to the limitations of these assessments in Western settings. However, the data highlight the need to consider individual patient level concerns when assessing ART adherence in different cultural settings. Innovative ways of monitoring adherence while maintaining standardization across sites are required in multisite trials.     

Evaluation of antiretroviral therapy results in Blantyre,Malawi

We performed a cross sectional study to evaluate treatment results of the paying antiretroviral therapy clinic of Queen Elizabeth Central Hospital, Blantyre. The only antiretroviral therapy was a fixed drug combination of stavudine, lamivudine and nevirapine.

Methods

Interviews, laboratory tests (CD4 count, viral load, nevirapine plasma levels, transaminases) and data extraction from files. 422 (59 %) of the patients who started antiretroviral therapy since 2000 were lost to follow up. The 176 patients enrolled in the study had good virological and excellent clinical treatment results. The most common side effect was peripheral neuropathy. Nevirapine plasma levels were remarkably high and associated with successful virological treatment results. Two simple adherence questions pertaining to the use of medication in the previous 8 days corresponded well with nevirapine levels. The most important reasons for non-adherence were shortage of drugs in the hospital pharmacy and personal financial constraints.

Conclusions

1. Many patients were lost to follow up.
2. High nevirapine levels contributed to good therapy results in those studied.
3. Simple adherence questions predicted sub-therapeutic nevirapine levels.
4. Antiretroviral drug supply needs to be uninterrupted and free of charge, to prevent avoidable non-adherence.

     

Determining best practice: comparison of three methods of femoral sheath removal after cardiac interventional procedures

OBJECTIVE: To test the null hypothesis that there is no significant difference between 3 methods of sheath removal: manual compression, mechanical compression with the Compressar, and mechanical compression with the Femostop. METHODS: The research design was experimental. Ninety patients were randomly assigned using a random-numbers table to undergo one of 3 methods of sheath removal. The principal investigator (L.M.B.) requested the patients' consent to undergo randomization of the sheath removal. Post procedure, each patient was told which method of sheath removal he or she would undergo based on results of the random-numbers table assignment. RESULTS: There were no significant differences between the groups with regard to age, body mass index, sheath size, heparin utilization, antiplatelet agents, or use of IIb-IIIa inhibitors. The complications between the methodologies for sheath removal were statistically significant. Patients who underwent manual sheath removal had fewer complications compared with those who underwent sheath removal using the Compressar or Femostop (chi2 P = .04). When complications were compared with the other parameters, only the presence of postprocedure heparin infusion (chi2 P = .014) and ACT values (Student t test P = .044) proved to be statistically significant. CONCLUSIONS: Based on the results of this study, staff in the study setting are currently exploring manual sheath removal as the preferred practice. Randomized controlled studies with larger sample populations at multicenter research sites are needed to ensure generalizability of results to larger populations. When using manual pressure application in conjunction with closure pad devices, hold times can be decreased, thus resulting in cost savings through decreased equipment use, earlier discharge times, and improved bed utilization.     

Childhood Malnutrition and Association of Lean Mass with Metabolome and Hormone Profile in Later Life

This study aimed to determine the associations of targeted metabolomics and hormone profiles data with lean mass index (LMI), which were estimated using bioelectrical impedance, in survivors of child severe malnutrition (SM) (n = 69) and controls (n = 77) in Malawi 7 years after being treated. Linear associations between individual metabolite or hormone and LMI were determined, including their interaction with nutrition status 7 years prior. Path analysis was performed to determine structural associations. Lastly, predictive models for LMI were developed using the metabolome and hormone profile by elastic net regularized regression (EN). Metabolites including several lipids, amino acids, and hormones were individually associated (p < 0.05 after false discovery rate correction) with LMI. However, plasma FGF21 (Control: β = −0.02, p = 0.59; Case: β = −0.14, p < 0.001) and tryptophan (Control: β = 0.15, p = 0.26; Case: β = 0.70, p < 0.001) were associated with LMI among cases but not among controls (both interaction p-values < 0.01). Moreover, path analysis revealed that tryptophan mediates the association between child SM and LMI. EN revealed that most predictors of LMI differed between groups, further indicating altered metabolic mechanisms driving lean mass accretion among SM survivors later in life.     

Tuberculosis in health care workers in Malawi.

Although sub-Saharan Africa has the highest rates of tuberculosis (TB) and human immunodeficiency virus (HIV) infection in the world, the rates of TB amongst its health care workers (HCWs) are poorly documented. We therefore conducted a country-wide investigation. All district/government and mission hospitals in Malawi that diagnose and care for TB patients were visited in order to obtain information on hospital-based HCWs and their incidence of TB in 1996. Hospital TB case loads, country-wide TB notification numbers and national population estimates for 1996 were obtained, which enabled TB case notification rates to be calculated. In 1996, 108 (3.6%) of 3042 HCWs from 40 hospitals were registered and treated for TB: 22 with smear-positive pulmonary TB (PTB), 40 with smear-negative PTB and 46 with extrapulmonary TB. The overall case fatality rate was 24%. Compared with the adult general population aged > or = 15 years, the relative risk [95% confidence interval (CI)] in HCWs of all types of TB was 11.9 [9.8-14.4], of smear-positive PTB 5.9 [3.9-9.0], of smear-negative PTB 13.0 [9.5-17.7] and of extrapulmonary TB 18.4 [13.8-24.6], P < 0.05. The 1996 hospital TB case load ranged from 29 to 915: there were no cases of TB in HCWs in hospitals whose case load was < or = 100 patients, while the TB case rate among HCWs was similar in hospitals with annual case loads of 101-300 or > 300. The annual risk of TB was high among all categories of HCW, especially clinical officers. This study shows a high rate of TB in HCWs in Malawi, and emphasizes the need for practical and affordable control measures for the protection of HCWs from TB in low-income countries.     

TNF-alpha promoter single nucleotide polymorphisms are markers of human ancestry

We present a map of single nucleotide polymorphisms (SNPs) in the human tumor necrosis factor (TNF)-alpha promoter based upon exploratory sequencing of 333 human TNF-alpha gene promoters from individuals of distinct ancestral backgrounds. We detect 10 TNF-alpha promoter SNPs that occur with distinct frequencies in populations of different ancestry. Consistent with these findings, we show that two TNF-alpha SNPs, the -243 SNP and the -856 SNP, are the first SNP markers of a sub-Saharan African-derived extended haplotype and an Amerindian HLA haplotype, respectively. Comparisons of TNF-alpha promoter SNP allele frequencies can thus help elucidate variation of HLA haplotypes and their distribution among existing ethnic groups and shed light into the history of human populations.     

Acceptability of Vegetable Fortified Ugali in Sub-Saharan Africa

Corn flour-based porridge like dough, ugali, is the staple food of low-income population in sub-Saharan Africa. Lack of vitamin A, carotenoids, and dietary fibers brings about serious health issues to this population. In this study, vegetables including bok choy, broccoli, cabbage, carrot, Chinese onion stalk (C_onion), mushroom, are added during the cooking of ugali, as nutritional supplements. The freeze-dried powder of each vegetable was used for its long storage, stable nutrients, and similar particle size. Sub-Saharan African assessors were trained and sensory evaluated the six different vegetable fortified ugali with the plain, unfortified as the control on five attributes. The plain ugali was indistinguishable with the C_onion stalk fortified in color, with the carrot and C_onion stalk fortified in odor, with all vegetables (except broccoli and mushroom) fortified ugali in taste, with carrot and C_onion stalk fortified in granularity, and with cabbage, carrot, C_onion stalk fortified in viscosity. Preference ranking analysis showed that the C_onion stalk fortified ugali is even more favorably preferred than the plain, unfortified ugali, probably due to the umami components in C_onion that serve as the taste enhancer. This study indicates that Chinese onion stalk is a potential vegetable supplement to population in the sub-Saharan Africa.