Faculty Bibliography

OBJECTIVES/OBJECTIVE:To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care. DESIGN/METHODS:Prospective cluster randomized controlled clinical trial. SETTING/METHODS:Villages surrounding 1 rural clinic in western Kenya. SUBJECTS/METHODS:HIV-infected adults clinically stable on antiretroviral therapy (ART). INTERVENTION/METHODS:The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. MAIN OUTCOMES MEASURED/METHODS:Viral load, CD4 count, Karnofsky score, stability of ART regimen, opportunistic infections, pregnancies, and number of clinic visits. RESULTS:After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in ART regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001). CONCLUSIONS:Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.

BACKGROUND:A major obstacle facing many lower-income countries in establishing and maintaining HIV treatment programmes is the scarcity of trained health care providers. To address this shortage, the World Health Organization has recommend task shifting to HIV-infected peers. METHODS:We designed a model of HIV care that utilizes HIV-infected patients, community care coordinators (CCCs), to care for their clinically stable peers with the assistance of preprogrammed personal digital assistants (PDAs). Rather than presenting for the standard of care, monthly clinic visits, in this model, patients were seen every three months in clinics and monthly by their CCCs in the community during the interim two months. This study was conducted in Kosirai Division, western Kenya, where eight of the 24 sub-locations (defined geographic areas) within the division were randomly assigned to the intervention with the remainder used as controls.Prior to entering the field, CCCs underwent intensive didactic training and mentoring related to the assessment and support of HIV patients, as well as the use of PDAs. PDAs were programmed with specific questions and to issue alerts if responses fell outside of pre-established parameters. CCCs were regularly evaluated in six performance areas. An impressionistic analysis on the transcripts from the monthly group meetings that formed the basis of the continuous feedback and quality improvement programme was used to assess this model. RESULTS:All eight of the assigned CCCs successfully passed their training and mentoring, entered the field and remained active for the two years of the study. On evaluation of the CCCs, 89% of their summary scores were documented as superior during Year 1 and 94% as superior during Year 2. Six themes emerged from the impressionistic analysis in Year 1: confidentiality and "community" disclosure; roles and responsibilities; logistics; clinical care partnership; antiretroviral adherence; and PDA issues. At the end of the trial, of those patients not lost to follow up, 64% (56 of 87) in the intervention and 52% (58 of 103) in the control group were willing to continue in the programme (p = 0.26). CONCLUSION/CONCLUSIONS:We found that an antiretroviral treatment delivery model that shifted patient monitoring and antiretroviral dispensing tasks into the community by HIV-infected patients was both acceptable and feasible. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov ID NCT00371540.

The cardiovascular community has witnessed an important transition over the past two decades-from awareness of the global nature of the cardiovascular disease epidemic, to identification of interventions to control it, and now to a resolution that global action is urgently required.

A debate has emerged as to what should be the 'appropriate' cardiovascular agenda for sub-Saharan Africa. This Clinical Advance article reviews a recent study by Sliwa et al., which describes patients with newly diagnosed cardiovascular disease (CVD) presenting to a tertiary-care center in South Africa. The most common conditions among these patients were hypertension, heart failure, valvular heart disease, and coronary artery disease. Atherosclerotic risk factors were widely prevalent--only 13% of patients had no risk factors at all. Furthermore, a substantial proportion of patients presented at an advanced stage of disease. This study, which used state-of-the-art diagnostic technology, is an important addition to the growing database of information indicating that CVD in sub-Saharan Africa spans the spectrum from 'traditional', nonischemic etiologies to 'modern' diseases of lifestyle. The societal response to this diverse epidemiology should be similarly multifaceted. Moreover, efforts should be made to improve primary-care screening, early detection and treatment of CVD, and prompt referral of patients at early stages of disease.

We present the case of a 67-year-old woman with chronic cor pulmonale. She never smoked tobacco and had no other risk factors for pulmonary disease. In developed nations, chronic obstructive lung disease and cor pulmonale are overwhelmingly associated with tobacco use. However, indoor air pollution, most commonly due to burning of solid biomass fuel such as wood, can cause similar clinical syndromes. At our teaching hospital, there is an epidemic of chronic cor pulmonale among nonsmoking women. We attribute this sex predilection to women's greater exposure to wood smoke. Physicians must be cognizant of its risks and counsel patients on prevention strategies such as improved ventilation.

Interns are expected to teach medical students, yet there is little formal training in medical school to prepare them for this role. To enhance the teaching skills of our graduating students we initiated a 4-hour "teaching to teach" course as part of the end of the fourth-year curriculum. Course evaluations demonstrate that students strongly support this program (overall ratings 2000 to 2005: mean=4.4 [scale 1 to 5], n=224). When 2004 course participants were surveyed during the last month of their internship, 84%"agree" or "strongly agree" with the statement: "The teaching to teach course helped prepare me for my role as a teacher during internship" (2005: mean 4.2 [scale 1 to 5], n=45, response rate 60%). A course preparing fourth-year students to teach during internship is both feasible and reproducible, with a minimal commitment of faculty and resident time. Participants identify it as an important addition to their education and as useful during internship.

BACKGROUND:Environmental factors, including microbial exposures and close animal contact, are implicated in the lower prevalence of asthma and allergy in rural vs urban children. OBJECTIVES/OBJECTIVE:To determine (1) the prevalence of asthma, rhinitis, eczema, and atopic sensitization in rural and urban children in India; (2) differences in microbial and animal exposures in these locales; and (3) whether differences in environmental exposures account for the different rates of asthma and atopy in these locales. METHODS:One child from each of 50 urban (Mysore) and 50 rural (Vinobha) households in southern India was randomly selected for data analysis. Allergy, asthma, health, environment, and lifestyle information was obtained using a questionnaire and household inspections. Atopy was determined via skin prick testing for common allergens. Endotoxin content was measured in house dust samples. RESULTS:Children from rural vs urban areas had lower prevalences of self-reported asthma (8% vs 30%; P = .005), rhinitis (22% vs 42%; P = .03), and atopic sensitization (36% vs 58%; P = .03). Higher median dust endotoxin loads were found in rural vs urban households (6.50 x 10(4) EU/m2 vs 1.27 x 10(4) EU/m2; P < .001). In multivariate analysis, close indoor animal contact (adjusted odds ratio [OR] 0.2; 90% confidence interval [CI], 0.05-0.9), outdoor animal contact (OR, 0.3; 90% CI, 0.1-0.8), and exclusive breastfeeding for at least 6 months (OR, 0.2; 90% CI, 0.1-0.5) were associated with lower atopic sensitization; mud flooring was associated with lower self-reported wheezing (OR, 0.1; 90% CI, 0.02-1.0). CONCLUSION/CONCLUSIONS:Children in India who live with close animal contact and mud flooring and who were exclusively breastfed in infancy are less likely to develop asthma, rhinitis, and atopic sensitization.