• Barriers and facilitators to combined ART initiation in pregnant women with HIV: lessons learnt from a PMTCT B+ pilot program in Swaziland

      Parker, L A; Jobanputra, K; Okello, V; Nhlangamandla, M; Mazibuko, S; Kourline, T; Kerschberger, B; Pavlopoulos, E; Teck, R (Lippincott Williams & Wilkins, 2015-01-26)
      In January 2013, Swaziland launched a PMTCT B+ implementation study in rural Shiselweni. We aimed to identify patient and health service determinants of combined antiretroviral therapy (ART) initiation, to help guide national implementation of PMTCT B+.
    • Barriers and solutions to finding rifampicin-resistant tuberculosis cases in older children and adolescents

      Mohr-Holland, E; Apolisi, I; Reuter, A; de Azevedo, V; Hill, J; Matthee, S; Seddon, JA; Isaakidis, P; Furin, J; Trivino-Duran, L (International Union Against Tuberculosis and Lung Disease, 2019-12-21)
      Little is known about the barriers to post-exposure management of rifampicin-resistant tuberculosis (RR-TB) in older children and adolescents. We report on implementation lessons from a pilot programme targeting household-exposed individuals aged 6–18 years in Khayelitsha, South Africa. Barriers included misperceptions regarding risk of exposure, multiple research and implementation stakeholders, additional workload for an overburdened healthcare system, logistical issues faced by families, and insufficient human and financial resources. Solutions to these barriers are possible, but creativity and persistence are required. Our experience can guide others looking to roll-out care for children and adolescents exposed to RR-TB.
    • Barriers to access to visceral leishmaniasis diagnosis and care among seasonal mobile workers in Western Tigray, Northern Ethiopia: A qualitative study

      Coulborn, RM; Gebrehiwot, TG; Schneider, M; Gerstl, S; Adera, C; Herrero, M; Porten, K; den Boer, M; Ritmeijer, K; Alvar, J; et al. (PLoS, 2018-11-08)
      Ethiopia bears a high burden of visceral leishmaniasis (VL). Early access to VL diagnosis and care improves clinical prognosis and reduces transmission from infected humans; however, significant obstacles exist. The approximate 250,000 seasonal mobile workers (MW) employed annually in northwestern Ethiopia may be particularly disadvantaged and at risk of VL acquisition and death. Our study aimed to assess barriers, and recommend interventions to increase access, to VL diagnosis and care among MWs.
    • Barriers to Health Care for Burmese Migrants in Phang Nga Province, Thailand

      Veerman, R; Reid, T; Médecins Sans Frontières, Brussels; Médecins Sans Frontières, Nairobi, Kenya (2010-12-29)
      The article describes barriers to health care experienced by Burmese migrants in a province of Thailand based on the experience of Medecins Sans Frontieres over the past three years. In addition to the barriers, the article makes suggestions for improving the conditions for the migrant workers.
    • Barriers to pilot mobile teleophthalmology in a rural hospital in Southern Malawi

      Pérez, Guillermo Martínez; Swart, Wayne; Munyenyembe, Jimmy Kondwani; Saranchuk, Peter (African Field Epidemiology Network, 2014-09-10)
    • Barriers to prompt and effective treatment of malaria in northern Sri Lanka.

      Reilley, B; Abeyasinghe, R; Pakianathar, M V; Medecins sans Frontieres, Colombo, Sri Lanka. (Wiley-Blackwell, 2002-09)
      BACKGROUND: For the past 18 years, northern Sri Lanka has been affected by armed ethnic conflict. This has had a heavy impact on displacement of civilians, health delivery services, number of health professionals in the area and infrastructure. The north of Sri Lanka has a severe malaria burden, with less than 5% of the national population suffering 34% of reported cases. Health care providers investigated treatment-seeking behaviour and levels of treatment failure believed to be the result of lack of adherence to treatment. METHODS: Pre- and post-treatment interviews with patients seeking treatment in the outpatient department (OPD) and focus groups. RESULTS: A total of 271 persons completed interviews: 54.4% sought treatment within 2 days of the onset of symptoms, and 91.9% self-treated with drugs with prior to seeking treatment, mainly with paracetamol. Self-treatment was associated with delaying treatment (RR 3.55, CI 1.23-10.24, P=0.002). In post-treatment interviews, self-reported default was 26.1%. The main reasons for not taking the entire regimen were side-effects (57.6%) and disappearance of symptoms (16.7%). Focus groups indicated some lack of confidence in chloroquine treatment and prophylaxis, and scant enthusiasm for prevention methods. CONCLUSIONS: A number of factors contribute to a lack of access and a lower quality of care for malaria: lack of medical staff and facilities because of the fighting; lack of confidence in treatment, and perception of malaria as a routine illness. Prevention efforts need to take into account certain beliefs and practices to be successful.
    • Baseline characteristics, response to and outcome of antiretroviral therapy among patients with HIV-1, HIV-2 and dual infection in Burkina Faso.

      Harries, Katie; Zachariah, Rony; Manzi, Marcel; Firmenich, Peter; Mathela, Richard; Drabo, Joseph; Onadja, G; Arnould, Line; Harries, A D; Médecins Sans Frontières, Medical Department (Operational Research), Brussels Operational Center, 68 Rue de Gasperich, L-1617, Luxembourg. (2009-09-22)
      In an urban district hospital in Burkina Faso we investigated the relative proportions of HIV-1, HIV-2 and HIV-1/2 among those tested, the baseline sociodemographic and clinical characteristics, and the response to and outcome of antiretroviral therapy (ART). A total of 7368 individuals (male=32%; median age=34 years) were included in the analysis over a 6 year period (2002-2008). The proportions of HIV-1, HIV-2 and dual infection were 94%, 2.5% and 3.6%, respectively. HIV-1-infected individuals were younger, whereas HIV-2-infected individuals were more likely to be male, have higher CD4 counts and be asymptomatic on presentation. ART was started in 4255 adult patients who were followed up for a total of 8679 person-years, during which time 469 deaths occurred. Mortality differences by serotype were not statistically significant, but were generally worse for HIV-2 and HIV-1/2 after controlling for age, CD4 count and WHO stage. Among severely immune-deficient patients, mortality was higher for HIV-2 than HIV-1. CD4 count recovery was poorest for HIV-2. HIV-2 and dually infected patients appeared to do less well on ART than HIV-1 patients. Reasons may include differences in age at baseline, lower intrinsic immune recovery in HIV-2, use of ineffective ART regimens (inappropriate prescribing) by clinicians, and poor drug adherence.
    • The battle for access--health care in Afghanistan.

      Reilley, B; Puertas, G; Coutin, A S; Médecins sans Frontières, New York, USA. (Massachusetts Medical Society, 2004-05-06)
    • A Bayesian Response-Adaptive Trial in Tuberculosis: The endTB Trial

      Cellamare, M; Ventz, S; Baudin, E; Mitnick, CD; Trippa, L (SAGE Publications, 2016-08-23)
      To evaluate the use of Bayesian adaptive randomization for clinical trials of new treatments for multidrug-resistant tuberculosis.
    • Be Near a Road: Humanitarian Practice and Displaced Persons in North Kivu

      Healy, S; Tiller, S (Oxford University Press We regret that this article is behind a paywall., 2016-06-01)
      In 2012, an uprising by the March 23 Movement in North Kivu led to significant internal displacement in Eastern Democratic Republic of the Congo. The humanitarian community’s strategy was to distribute assistance according to the principle of impartiality. A closer analysis, however, shows that assistance was not so much determined by need as by status and location – in other words, how people were displaced and their proximity to Goma had a large influence on the level of assistance they received. This article argues that such imbalances can be partly explained by policies adopted within the humanitarian community: first, by privileging the political considerations of the Congolese Government when deciding which groups of internally displaced persons would receive better levels of assistance and protection; secondly, through a growing unwillingness by many agencies to negotiate their own access to populations with all parties of the conflict; and thirdly, in an inflexibility towards programme financing and management, which added considerable bureaucratic delays and difficulties to the delivery of assistance. By reflecting on the choices made by aid agencies in the context of mass displacement, this article shows how humanitarianism can restrict rather than enhance the options of forcibly displaced populations.
    • Beauty and the beast.

      Cox, H; Isles, S; Médecins Sans Frontières, 7 Ganges Street, Maitama, Abuja, Nigeria. helenscox@yahoo.com.au (Elsevier, 2003-01)
    • Bedaquiline and delamanid in combination for treatment of drug-resistant tuberculosis

      Mohr, E; Ferlazzo, G; Hewison, C; De Azevedo, V; Isaakidis, P (Elsevier, 2019-05-01)
      Here we report on the final outcomes for the cohort of 28 patients from Armenia, India, and South Africa who initiated regimens containing the combination of bedaquiline and delamanid from January to August, 2016, for the treatment of multidrug-resistant tuberculosis in our cohort study.1 The median duration on combination treatment was 12 months (interquartile range [IQR] 5·9–20·0); 17 (61%) of 28 patients received the combination for more than 6 months.
    • Bedaquiline overdose: A case report

      Telnov, O; Alvarez, V; Graglia, E; Molfino, L; du Cros, P; Rich, M (Elsevier, 2019-07)
      We present a case report describing outcomes in a 21 year old HIV-negative man who received treatment with bedaquiline. Due to error, dosage received comprised 4 pills of 100 mg every second day in the 60 days following the first two weeks of 4 pills of 100 mg every day. On detection, treatment was continued as per standard dosing of 200 mg given three times per week, with enhanced monitoring of ECG and liver function. The man was asymptomatic, with no signs of jaundice, abdominal pain, or abnormal heart rhythm. Toxic effects at this dosage were therefore not observed.
    • Bedaquiline overdose: A case report

      Telnov, O; Alvarez, V; Gragila, E; Molfino, L; du Cros, P; Rich, M (Elsevier, 2019-04-02)
      We present a case report describing outcomes in a 21 year old HIV-negative man who received treatment with bedaquiline. Due to error, dosage received comprised 4 pills of 100 mg every second day in the 60 days following the first two weeks of 4 pills of 100 mg every day. On detection, treatment was continued as per standard dosing of 200 mg given three times per week, with enhanced monitoring of ECG and liver function. The man was asymptomatic, with no signs of jaundice, abdominal pain, or abnormal heart rhythm. Toxic effects at this dosage were therefore not observed.
    • Before the Bombing: High Burden of Traumatic Injuries in Kunduz Trauma Center, Kunduz, Afghanistan

      Hemat, H; Shah, S; Isaakidis, P; Das, M; Kyaw, NTT; Zaheer, S; Qasemy, AQ; Zakir, M; Mahama, G; Van Overloop, C; et al. (Public Library of Science, 2017-03-10)
      Médecins Sans Frontières (MSF) has been providing healthcare in Afghanistan since 1981 including specialized health services for trauma patients in Kunduz Trauma Center (KTC) from 2011. On October 3rd, 2015, a US airstrike hit the KTC, killing 42 people including 14 MSF staff. This study aims to demonstrate the impact on healthcare provision, after hospital destruction, by assessing the extent of care provided for trauma and injuries by the MSF KTC and to report on treatment outcomes from January 2014 to June 2015, three months prior to the bombing.
    • Behavioural characteristics, prevalence of Chlamydia trachomatis and antibiotic susceptibility of Neisseria gonorrhoeae in men with urethral discharge in Thyolo, Malawi.

      Zachariah, R; Harries, A D; Nkhoma, W; Arendt, V; Nchingula, D; Chantulo, A; Chimtulo, F; Kirpach, P; Médecins sans Frontières-Luxembourg, Thyolo District, Malawi. zachariah@internet.lu (Elsevier, 2008-01-25)
      A study was carried out in 2000/2001 in a rural district of Malawi among men presenting with urethral discharge, in order to (a) describe their health-seeking and sexual behaviour, (b) determine the prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis, and (c) verify the antibiotic susceptibility of N. gonorrhoeae. A total of 114 patients were entered into the study; 61% reported having taken some form of medication before coming to the sexually transmitted infections clinic. The most frequent alternative source of care was traditional healers. Sixty-eight (60%) patients reported sexual encounters during the symptomatic period, the majority (84%) not using condoms. Using ligase chain reaction on urine, N. gonorrhoeae was detected in 91 (80%) and C. trachomatis in 2 (2%) urine specimens. Forty five of 47 N. gonorrhoeae isolates produced penicillinase, 89% showing multi-antimicrobial resistance. This study emphasizes the need to integrate alternative care providers and particularly traditional healers in control activities, and to encourage their role in promoting safer sexual behaviour. In patients presenting with urethral discharge in our rural setting, C. trachomatis was not found to be a major pathogen. Antimicrobial susceptibility surveillance of N. gonorrhoeae is essential in order to prevent treatment failures and control the spread of resistant strains.
    • Behind the Scenes of South Africa’s Asylum Procedure: A Qualitative Study on Long-term Asylum-Seekers from the Democratic Republic of Congo

      Schockaert, L; Venables, E; Gil-Bazo, MT; Barnwell, G; Gerstenhaber, R; Whitehouse, K (Oxford University Press, 2020-02-20)
      Despite the difficulties experienced by asylum-seekers in South Africa, little research has explored long-term asylum applicants. This exploratory qualitative study describes how protracted asylum procedures and associated conditions are experienced by Congolese asylum-seekers in Tshwane, South Africa. Eighteen asylum-seekers and eight key informants participated in the study. All asylum-seekers had arrived in South Africa between 2003 and 2013, applied for asylum within a year of arrival in Tshwane, and were still in the asylum procedure at the time of the interview, with an average of 9 years since their application. Thematic analysis was used to analyse the data. The findings presented focus on the process of leaving the Democratic Republic of Congo, applying for asylum and aspirations of positive outcomes for one’s life. Subsequently, it describes the reality of prolonged periods of unfulfilled expectations and how protracted asylum procedures contribute to poor mental health. Furthermore, coping mechanisms to mitigate these negative effects are described. The findings suggest that protracted asylum procedures in South Africa cause undue psychological distress. Thus, there is both a need for adapted provision of mental health services to support asylum-seekers on arrival and during the asylum process, and systemic remediation of the implementation of asylum procedures.
    • The Beijing genotype and drug resistant tuberculosis in the Aral Sea region of Central Asia.

      Cox, H; Kubica, T; Doshetov, D; Kebede, Y; Rüsch-Gerdess, S; Niemann, S; Médecins Sans Frontières, Aral Sea Area Programme, Uzbekistan and Turkmenistan Tashkent, Uzbekistan. h.cox2@pgrad.unimelb.edu.au (2005)
      BACKGROUND: After the collapse of the Soviet Union, dramatically increasing rates of tuberculosis and multidrug-resistant tuberculosis (MDR-TB) have been reported from several countries. This development has been mainly attributed to the widespread breakdown of TB control systems and declining socio-economic status. However, recent studies have raised concern that the Beijing genotype of Mycobacterium tuberculosis might be contributing to the epidemic through its widespread presence and potentially enhanced ability to acquire resistance. METHODS: A total of 397 M. tuberculosis strains from a cross sectional survey performed in the Aral Sea region in Uzbekistan and Turkmenistan have been analysed by drug susceptibility testing, IS6110 fingerprinting, and spoligotyping. RESULTS: Fifteen isolates showed mixed banding patterns indicating simultaneous infection with 2 strains. Among the remaining 382 strains, 152 (40%) were grouped in 42 clusters with identical fingerprint and spoligotype patterns. Overall, 50% of all isolates were Beijing genotype, with 55% of these strains appearing in clusters compared to 25% of non-Beijing strains. The percentage of Beijing strains increased with increasing drug resistance among both new and previously treated patients; 38% of fully-susceptible isolates were Beijing genotype, while 75% of MDR-TB strains were of the Beijing type. CONCLUSION: The Beijing genotype is a major cause of tuberculosis in this region, it is strongly associated with drug resistance, independent of previous tuberculosis treatment and may be strongly contributing to the transmission of MDR-TB. Further investigation around the consequences of Beijing genotype infection for both tuberculosis transmission and outcomes of standard short course chemotherapy are urgently needed.
    • Benefit of viral load testing for confirmation of immunological failure in HIV patients treated in rural Malawi.

      Kanapathipillai, Rupa; McGuire, Megan; Mogha, Robert; Szumilin, Elisabeth; Heinzelmann, Annette; Pujades-Rodriguez, Mar; Médecins Sans Frontières, Chiradzulu, Malawi  Monash Medical Centre, Clayton, Vic., Australia  Epicentre, Paris, France  Médecins Sans Frontières, Paris, France. (2011-09-01)
      Objective  Viral load testing is used in the HIV programme of Chiradzulu, Malawi, to confirm the diagnosis of immunological failure to prevent unnecessary switching to second-line therapy. Our objective was to quantify the benefit of this strategy for management of treatment failure in a large decentralized HIV programme in Africa. Methods  Retrospective analysis of monitoring data from adults treated with first-line antiretroviral regimens for >1 year and meeting the WHO immunological failure criteria in an HIV programme in rural Malawi. The positive predictive value of using immunological failure criteria to diagnose virological failure (viral load >5000 copies/ml) was estimated. Results  Of the 227 patients with immunological failure (185 confirmed with a repeat CD4 measurement), 155 (68.2%) had confirmatory viral load testing. Forty-four (28.4%) had viral load >5000 copies/ml and 57 (36.8%) >1000 copies/ml. Positive predictive value was 28.4% (95% CI 21.4-36.2%). Repeat CD4 count testing showed that 41% of patients initially diagnosed with immunological failure did no longer meet failure criteria. Conclusions  Our results support the need for confirming all cases of immunological failure with viral load testing before switching to second-line ART to optimize the use of resources in developing countries.