Scale-up Efforts Research Articles

The development and unraveling of marine resource co-management in the Pemba Channel, Zanzibar: institutions, governance, and the politics of scale

Marine resource management programs face conflicting mandates: to scale-up marine conservation efforts to cover larger areas and meet national and international conservation targets, while simultaneously to downscale and decentralize management authority to resource users and local communities. These conflicting goals create tensions in marine resource management. This paper explores these tensions by presenting and evaluating the outcomes of a fisheries co-management program on the island of Pemba, Tanzania, where institutions and scale were configured and reconfigured under externally funded programs to improve marine conservation through co-management. The initial institutional arrangements for co-management supported a functioning system to protect marine resources, ensure fishermen’s access, and distribute tourism revenues. However, a subsequent push to scale-up marine management reconfigured institutional arrangements and power in a more hierarchical and potentially weaker system. With the expansion of the co-management program, protected area coverage, financial resources, and the number of community organizations created for fisheries co-management expanded tremendously; however, community participation in marine management decreased, and the fishermen’s association previously involved in co-management dissolved. Several factors contributed to this outcome: inadequate time to solidify co-management institutions and arrangements, diverse resource users inexperienced with local management, a sudden and substantial new source of funding, and political pressures to restructure marine management. Rather than focusing primarily on expanding coverage and devolving authority, it is important to adapt co-management arrangements to the local contexts in which they operate.

Person-centered care planning and service engagement: a study protocol for a randomized controlled trial.

BackgroundService disengagement is a pervasive challenge the mental health care system faces. Mental health services are of little value should persons with mental illnesses continue to opt out of receiving them. Consumers attribute disengagement from care to an absence of choice in their treatment. In response, the mental health system is adopting a person-centered model, based upon recovery principles, to engage consumers more actively in their care. Person-centered care planning is a promising practice involving collaboration to develop and implement an actionable plan to assist the person in achieving personal recovery goals.Methods/designThis study design combines a parallel-group randomized controlled trial of community mental health organizations with qualitative methods to assess the effectiveness of person-centered care planning. Participants at 14 sites in Delaware and Connecticut will be randomized to treatment as usual or the person-centered care planning intervention. Participants will be in leadership (n = 70) or supervisory or direct care (n = 210) roles. The person-centered care planning intervention involves intensive staff training and 12 months of ongoing technical assistance. Quantitative survey data will be collected at baseline, 6 months and 12 months measuringperson-centered care planning competency and organizational factors. Consumer outcomes (engagement, medication adherence, functioning and consumer satisfaction) will be assessed by Medicaid and state-level data. Qualitative data focused on process factors will include staff and consumer interviews and focus groups. In this intent-to-treat analysis, we will use mixed-effects multivariate regression models to evaluate the differential impact of the person-centered care planning intervention on each consumer and implementation outcome as well as the extent to which clinician assessments of organizational factors are associated with the implementation outcome. Mixed methods will triangulate and strengthen the interpretation of outcomes.DiscussionThe aim of this study is to generate valuable guidance for state systems engaged in scale-up and transformation efforts. Targeted staff selection for training to support sustainability will serve to provide further insight into important intervention implementation strategies. Person-centered care planning has the potential to enhance the impact of all evidence-based and recovery-oriented practices and bring practice into line with the emerging national guidelines in health care reform.Trial registrationThis trial was registered with ClinicalTrials.gov (Identifier: NCT02299492) on 21 November 2014 as New York University Protocol Record PCCP-13-9762, Person-Centered Care Planning and Service Engagement.

The Formation of CO by Thermal Decomposition of Formic Acid under Electrochemical Conditions of CO2 Reduction

We report that the thermal decomposition of formic acid to CO may occur under electrochemically-relevant conditions by mild heating. These thermal effects may play a role in the outcome of electrolytic experiments as an artifact of resistive, local heating and illumination. This non-Faradaic reactivity pathway may therefore need consideration in the analysis of electrochemical data on CO2 reduction to formic acid and CO and may become a hindrance in scaleup efforts of these chemical transformations. IR visual thermometry provides evidence of macroscopic heating effects during electrolytic experiments.

Synergistic vulnerabilities: Antiretroviral treatment among women in Uganda

Despite being an early success story in the reduction of HIV infection rates, Uganda faces myriad challenges in the recent era of accelerated antiretroviral treatment (ARV) scale-up. For those able to access treatment, ongoing vulnerabilities of poverty and violence compound treatment-related costs and concerns. This paper explores experiences of one particularly vulnerable population – women on ARVs who have also experienced intimate partner violence (IPV). Data were collected over 12 months in Uganda. They include ethnographic interviews (n = 40) drawn from a larger sample of women on ARV and semi-structured interviews with policy-makers and service providers (n = 42), examining the intersection of experiences and responses to treatment from multiple perspectives. Women's narratives show that due to treatment, immediate health concerns take on secondary importance, while other forms of vulnerability, including IPV and poverty, can continue to shape treatment experiences and the decision to stay in violent relationships. Providers likewise face difficulties in overburdened clinics, though they recognise women's concerns and the importance of considering other forms of vulnerability in treatment. This analysis makes the case for integrating treatment with other types of social services and demonstrates the importance of understanding the ways in which synergistic and compounding vulnerabilities confound treatment scale-up efforts.

Scaling-up NLP Pipelines to Process Large Corpora of Clinical Notes.

This article is part of the Focus Theme of Methods of Information in Medicine on "Big Data and Analytics in Healthcare". This paper describes the scale-up efforts at the VA Salt Lake City Health Care System to address processing large corpora of clinical notes through a natural language processing (NLP) pipeline. The use case described is a current project focused on detecting the presence of an indwelling urinary catheter in hospitalized patients and subsequent catheter-associated urinary tract infections. An NLP algorithm using v3NLP was developed to detect the presence of an indwelling urinary catheter in hospitalized patients. The algorithm was tested on a small corpus of notes on patients for whom the presence or absence of a catheter was already known (reference standard). In planning for a scale-up, we estimated that the original algorithm would have taken 2.4 days to run on a larger corpus of notes for this project (550,000 notes), and 27 days for a corpus of 6 million records representative of a national sample of notes. We approached scaling-up NLP pipelines through three techniques: pipeline replication via multi-threading, intra-annotator threading for tasks that can be further decomposed, and remote annotator services which enable annotator scale-out. The scale-up resulted in reducing the average time to process a record from 206 milliseconds to 17 milliseconds or a 12- fold increase in performance when applied to a corpus of 550,000 notes. Purposely simplistic in nature, these scale-up efforts are the straight forward evolution from small scale NLP processing to larger scale extraction without incurring associated complexities that are inherited by the use of the underlying UIMA framework. These efforts represent generalizable and widely applicable techniques that will aid other computationally complex NLP pipelines that are of need to be scaled out for processing and analyzing big data.

Evidence-based programming for adolescent HIV prevention and care: operational research to inform best practices.

Globally, a staggering number of adolescents, approximately 2.1 million, were estimated to be living with HIV in 2012. Unique developmental, psychosocial, and environmental considerations make them particularly vulnerable to HIV acquisition and argue for a comprehensive response to address this burgeoning problem. This article explores the current state of the science of HIV prevention, treatment, and care for adolescents and identifies opportunities to address knowledge gaps and improve health outcomes for this age group. Over the past decade, several important milestones have been achieved in HIV prevention and care among adults, and despite evidence that adherence to care and medications among affected adolescents is significantly compromised, critical research among adolescents and young adults substantially lags behind. Operational research, in particular, is crucial to understanding how to use effective services and interventions for HIV prevention and care safely and effectively for adolescents who are in dire need. Operational research among adolescent populations affected by HIV is critically needed to close the knowledge and investment gaps, and scale-up efforts for HIV prevention, treatment, care, and support for this vulnerable age group.

AIDS policy responsiveness in Africa: Evidence from opinion surveys

As a result of massive scale-up efforts in developing countries, millions of people living with HIV are now receiving antiretroviral therapy (ART). However, countries have been uneven in their scale-up efforts with ART coverage rates exceeding expectations in some places and lagging behind expectation in others. This paper develops a model that explains ART scale-up as a function of the responsiveness of political parties to their primary constituents. Specifically, the paper argues that, faced with a perilous ‘threat to the nation’, countries responded in one of two ways, both of which were designed to appeal to their primary constituents – either adopting a ‘Geneva Consensus’ response, or depicting the epidemic as a Western disease and adopting a ‘pan-African’ response. The article tests this theory using Afrobarometer data for eleven countries. The paper finds that HIV/AIDS is generally a non-partisan issue in most countries. However, the analysis does uncover some differences in partisan support for HIV/AIDS responses in both countries that have adopted Geneva Consensus and pan-African responses, though not in the direction hypothesised. The lack of congruence in policy preferences between the public and their governments suggests a democratic deficit in that these governments have acted independently of the preferences of core constituents.

Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International.

Contraceptive implants offer promising opportunities for addressing the high and growing unmet need for modern contraceptives in sub-Saharan Africa. Marie Stopes International (MSI) offers implants as one of many family planning options. Between 2008 and 2012, MSI scaled up voluntary access to implants in 15 sub-Saharan African countries, from 80,041 implants in 2008 to 754,329 implants in 2012. This 9-fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5-year period. High levels of client satisfaction were attained alongside service provision scale up by using existing MSI service delivery channels-mobile outreach, social franchising, and clinics-to implement strategies that broadened access for underserved clients and maintained service quality. Use of adaptive and context-specific service delivery models and attention to key operational components, including sufficient numbers of trained providers, strong supply chains, diverse financing mechanisms, and implant removal services, underpinned our service delivery efforts. Accounting for 70% of the implants delivered by MSI in 2012, mobile outreach services through dedicated MSI provider teams played a central role in scale-up efforts, fueled in part by the provision of free or heavily subsidized services. Social franchising also demonstrated promise for future program growth, along with MSI clinics. Continued high growth in implant provision between 2011 and 2012 in all sub-Saharan African countries indicates the region's capacity for further service delivery expansion. Meeting the expected rising demand for implants and ensuring long-term sustainable access to the method, as part of a comprehensive method mix, will require continued use of appropriate service delivery models, effective operations, and ongoing collaboration between the private, public, and nongovernmental sectors. MSI's experience can be instructive for future efforts to ensure contraceptive access and choice in sub-Saharan Africa, especially as the global health community works to achieve its Family Planning 2020 (FP2020) commitments to expand family planning access to 120 million new users.

Non-specialist psychosocial interventions for children and adolescents with intellectual disability or lower-functioning autism spectrum disorders: a systematic review.

The development of effective treatments for use by non-specialists is listed among the top research priorities for improving the lives of people with mental illness worldwide. The purpose of this review is to appraise which interventions for children with intellectual disabilities or lower-functioning autism spectrum disorders delivered by non-specialist care providers in community settings produce benefits when compared to either a no-treatment control group or treatment-as-usual comparator. We systematically searched electronic databases through 24 June 2013 to locate prospective controlled studies of psychosocial interventions delivered by non-specialist providers to children with intellectual disabilities or lower-functioning autism spectrum disorders. We screened 234 full papers, of which 34 articles describing 29 studies involving 1,305 participants were included. A majority of the studies included children exclusively with a diagnosis of lower-functioning autism spectrum disorders (15 of 29, 52%). Fifteen of twenty-nine studies (52%) were randomized controlled trials and just under half of all effect sizes (29 of 59, 49%) were greater than 0.50, of which 18 (62%) were statistically significant. For behavior analytic interventions, the best outcomes were shown for development and daily skills; cognitive rehabilitation, training, and support interventions were found to be most effective for improving developmental outcomes, and parent training interventions to be most effective for improving developmental, behavioral, and family outcomes. We also conducted additional subgroup analyses using harvest plots. Limitations include the studies' potential for performance bias and that few were conducted in lower- and middle-income countries. The findings of this review support the delivery of psychosocial interventions by non-specialist providers to children who have intellectual disabilities or lower-functioning autism spectrum disorders. Given the scarcity of specialists in many low-resource settings, including many lower- and middle-income countries, these findings may provide guidance for scale-up efforts for improving outcomes for children with developmental disorders or lower-functioning autism spectrum disorders. PROSPERO CRD42012002641

Scaling up Routine HIV Testing at Specialty Clinics

Scaling up routine HIV testing represents a key component of the National HIV/AIDS Strategy. Barriers to routine HIV testing have limited widespread adoption. Although many patients visit specialty care providers, few efforts to increase routine HIV testing in specialty care settings have been made. We report on use of a survey of barriers to routine testing coupled with academic detailing-type educational sessions to increase routine testing at specialty clinics in Chicago's main safety-net health system. We devised a survey to assess specialty provider knowledge, attitudes, and barriers to routine HIV testing. We administered this at 3 specialty clinics. Each clinic's survey responses informed content for academic detailing-type presentations to each clinic's medical providers. We provide descriptive statistics summarizing survey responses. We report changes in the HIV testing rates and use logistic regression to examine associations between time period and odds of testing at each clinic. Specialty clinic providers demonstrated varying knowledge regarding routine HIV testing guidelines-with trauma providers having the least knowledge. Concerns regarding arranging follow-up for patients with positive results was the most cited barrier to testing. Two of the 3 specialty clinics experienced significant increases in routine HIV testing, whereas the third specialty service, which uses more rotating residents, had downtrending routine testing rates. The increase in routine HIV testing in 2 of 3 specialty services suggests that academic detailing-type interventions can improve routine testing uptake in public safety-net specialty care settings and may represent a useful component to incorporate into system-wide scale-up efforts.

Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial.

To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process. To assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs). From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up. Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient's specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test. The prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis. There was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group. Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling. clinicaltrials.gov Identifier: NCT01154296.

Community Living and Participation: Embracing the Complexity and Forging Forward

Community Living and Participation: Embracing the Complexity and Forging Forward

Dimensional analysis of impulse loading resulting from detonation of shallow-buried charges

Purpose – Development of military vehicles capable of surviving shallow-buried explosive blast is seldom done using full-scale prototype testing because of the associated prohibitively high cost, the destructive nature of testing, and the requirements for large-scale experimental-test facilities and a large crew of engineers committed to the task. Instead, tests of small-scale models are generally employed and the model-based results are scaled up to the full-size vehicle. In these scale-up efforts, various dimensional analyses are used whose establishment and validation requires major experimental testing efforts and different-scale models. The paper aims to discuss these issues. Design/methodology/approach – In the present work, a critical assessment is carried out of some of the most important past efforts aimed at developing the basic dimensional analysis formulation for the problem of impulse loading experienced by target structures (e.g. vehicle hull) due to detonation of explosive charges buried to different depths in sand/soil (of different consistency, porosity, and saturation levels). Findings – It was found that the analysis can be substantially simplified if only the physical parameters associated with first-order effects are retained and if some of the sand/soil parameters are replaced with their counterparts which better reflect the role of soil (via the effects of soil compaction in the region surrounding the explosive and via the effects of sand-overburden stretching and acceleration before the associated sand bubble bursts and venting of the gaseous detonation products takes place). Once the dimensional analysis is reformulated, a variety of experimental results pertaining to the total blast impulse under different soil conditions, charge configurations, charge deployment strategies, and vehicle ground clearances are used to establish the underlying functional relations. Originality/value – The present work clearly established that due to the non-dimensional nature of the quantities formulated, the established relations can be utilized across different length scales, i.e. although they are obtained using mainly the small-scale model results, they can be applied at the full vehicle length scale.

Utilization of Cervical Cancer Screening Services and Trends in Screening Positivity Rates in a ‘Screen-And-Treat’ Program Integrated with HIV/AIDS Care in Zambia

BackgroundIn the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking.MethodsWe analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity.ResultsBetween January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006–2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women.ConclusionsThis is the first ‘real world’ demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.

Concurrent Computational and Dimensional Analyses of Design of Vehicle Floor-Plates for Landmine-Blast Survivability

Development of military vehicles capable of surviving landmine blast is seldom done using full-scale prototype testing because of the associated prohibitively-high cost, the destructive nature of testing, and the requirements for major large-scale experimental-test facilities and a large crew of engineers committed to the task. Instead, tests of small-scale models are generally employed and the model-based results are scaled up to the full-size vehicle. In these scale-up efforts, various dimensional analyses are used whose establishment and validation requires major experimental testing efforts and different-scale models. In the present work, an approach is proposed within which concurrent and interactive applications of the computational analyses (of landmine detonation and the interaction of detonation products and soil ejecta with the vehicle hull-floor) and the corresponding dimensional analysis are utilized. It is argued that this approach can guide the design of military-vehicle hull-floors which provide the required level of protection to the vehicle occupants under landmine blast attack without introducing unnecessarily high weight to the vehicle. To validate this approach, a combined Eulerian/Lagrangian formulation for landmine detonation and the interaction of detonation products and soil ejecta with the vehicle hull-floor (developed in our previous work) has been utilized along with the experimental results pertaining to small-scale model and full-scale vehicle testing.

Mobilizing women's groups for improved maternal and newborn health: Evidence for impact, and challenges for sustainability and scale up

Research conducted over the past decade has shown that community-based interventions can improve the survival and health of mothers and newborns in low- and middle-income countries. Interventions engaging women's groups in participatory learning and action meetings and other group activities, for example, have led to substantial increases in neonatal survival in high-mortality settings. Participatory interventions with women's groups work by providing a forum for communities to develop a common understanding of maternal and neonatal problems, as well as locally acceptable and sustainable strategies to address these. Potential partners for scaling up interventions with women's groups include government community health workers and volunteers, as well as organizations working with self-help groups. It is important to tailor scale-up efforts to local contexts, while retaining fidelity to the intervention, by ensuring that the mobilization of women's groups complements other local programs (e.g. home visits), and by providing capacity building for participatory learning and action methods across a range of nongovernmental organizations and government stakeholders. Research into scale-up mechanisms and effectiveness is needed to inform further implementation, and prospective surveillance of maternal and neonatal mortality in key scale-up sites can provide valuable data for measuring impact and for advocacy. There is a need for further research into the role of participatory interventions with women's groups to improve the quality of health services, health, and nutrition beyond the perinatal period, as well as the role of groups in influencing non-health issues, such as women's decision-making power.

Examining the Association Between Implementation and Outcomes

Although there is an established literature supporting the efficacy of a variety of prevention programs, there has been less empirical work on the translation of such research to everyday practice or when scaled-up state-wide. There is a considerable need for more research on factors that enhance implementation of programs and optimize outcomes, particularly in school settings. The current paper examines how the implementation fidelity of an increasingly popular and widely disseminated prevention model called, School-wide Positive Behavioral Interventions and Supports (SW-PBIS), relates to student outcomes within the context of a state-wide scale-up effort. Data come from a scale-up effort of SW-PBIS in Maryland; the sample included 421 elementary and middle schools trained in SW-PBIS. SW-PBIS fidelity, as measured by one of three fidelity measures, was found to be associated with higher math achievement, higher reading achievement, and lower truancy. School contextual factors were related to implementation levels and outcomes. Implications for scale-up efforts of behavioral and mental health interventions and measurement considerations are discussed.

Global Policy and Programme Guidance on Maternal Nutrition: What Exists, the Mechanisms for Providing It, and How to Improve Them?

Undernutrition in one form or another affects the majority of women of reproductive age in most developing countries. However, there are few or no effective programmes trying to solve maternal undernutrition problems. The purpose of the paper is to examine global policy and programme guidance mechanisms for nutrition, what their content is with regard to maternal nutrition in particular, as well as how these might be improved. Almost all countries have committed themselves politically to ensuring the right of pregnant and lactating women to good nutrition through the Convention on the Elimination of all Forms of Discrimination Against Women. Despite this, the World Health Organization (WHO) has not endorsed any policy commitments with regard to maternal nutrition. The only policy guidance coming from the various technical departments of WHO relates to the control of maternal anaemia. There is no policy or programme guidance concerning issues of maternal thinness, weight gain during pregnancy and/or low birthweight prevention. Few if any countries have maternal nutrition programmes beyond those for maternal anaemia, and most of those are not effective. The lack of importance given to maternal nutrition is related in part to a weakness of evidence, related to the difficulty of getting ethical clearance, as well as a generalised tendency to downplay the importance of those interventions found to be efficacious. No priority has been given to implementing existing policy and programme guidance for the control of maternal anaemia largely because of a lack of any dedicated funding, linked to a lack of Millennium Development Goals indicator status. This is partly due to the poor evidence base, as well as to the common belief that maternal anaemia programmes were not effective, even if efficacious. The process of providing evidence-based policy and programme guidance to member states is currently being revamped and strengthened by the Department of Nutrition for Health and Development of WHO through the Nutrition Guidance Expert Advisory Group processes. How and if programme guidance, as well as policy commitment for improved maternal nutrition, will be strengthened through the Nutrition Guidance Expert Advisory Group process is as yet unclear. The global movement to increase investment in programmes aimed at maternal and child undernutrition called Scaling Up Nutrition offers an opportunity to build developing country experience with efforts to improve nutrition during pregnancy and lactation. All member states are being encouraged by the World Health Assembly to scale-up efforts to improve maternal infant and young child nutrition. Hopefully Ministries of Health in countries most affected by maternal and child undernutrition will take leadership in the development of such plans, and ensure that the control of anaemia during pregnancy is given a great priority among these actions, as well as building programme experience with improved nutrition during pregnancy and lactation. For this to happen it is essential that donor support is assured, even if only to spearhead a few flagship countries.

Low-Cost Ultra-Wide Genotyping Using Roche/454 Pyrosequencing for Surveillance of HIV Drug Resistance

BackgroundGreat efforts have been made to increase accessibility of HIV antiretroviral therapy (ART) in low and middle-income countries. The threat of wide-scale emergence of drug resistance could severely hamper ART scale-up efforts. Population-based surveillance of transmitted HIV drug resistance ensures the use of appropriate first-line regimens to maximize efficacy of ART programs where drug options are limited. However, traditional HIV genotyping is extremely expensive, providing a cost barrier to wide-scale and frequent HIV drug resistance surveillance.Methods/ResultsWe have developed a low-cost laboratory-scale next-generation sequencing-based genotyping method to monitor drug resistance. We designed primers specifically to amplify protease and reverse transcriptase from Brazilian HIV subtypes and developed a multiplexing scheme using multiplex identifier tags to minimize cost while providing more robust data than traditional genotyping techniques. Using this approach, we characterized drug resistance from plasma in 81 HIV infected individuals collected in São Paulo, Brazil. We describe the complexities of analyzing next-generation sequencing data and present a simplified open-source workflow to analyze drug resistance data. From this data, we identified drug resistance mutations in 20% of treatment naïve individuals in our cohort, which is similar to frequencies identified using traditional genotyping in Brazilian patient samples.ConclusionThe developed ultra-wide sequencing approach described here allows multiplexing of at least 48 patient samples per sequencing run, 4 times more than the current genotyping method. This method is also 4-fold more sensitive (5% minimal detection frequency vs. 20%) at a cost 3–5× less than the traditional Sanger-based genotyping method. Lastly, by using a benchtop next-generation sequencer (Roche/454 GS Junior), this approach can be more easily implemented in low-resource settings. This data provides proof-of-concept that next-generation HIV drug resistance genotyping is a feasible and low-cost alternative to current genotyping methods and may be particularly beneficial for in-country surveillance of transmitted drug resistance.

Smartphone-Based Mobile Learning with Physician Trainees in Botswana

In recent years, mobile learning in medicine has been utilized to increase healthcare providers’ access to health information. This has improved healthcare providers’ ability to make appropriate clinical decisions at point-of-care, particularly in resource-limited settings. Mobile phones facilitate information and communication technology support for patient care and collaboration amongst providers. In this paper, the authors describe a smartphone-based mobile learning initiative with physician trainees at the University of Botswana School of Medicine, focusing on the authors’ experiences with recent scale-up efforts to remote areas of Botswana. The authors also explore the potential impact of mobile learning in developing health capacity.