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Global AIDS programs such as the US President's Emergency Plan for AIDS Relief (PEPFAR) face a challenging health care management transition. HIV care must evolve from vertically-organized, externally-supported efforts to sustainable, locally controlled components that are integrated into the horizontal primary health care systems of host nations. We compared four southern African nations in AIDS care, financial, literacy, and health worker capacity parameters (2005 to 2009) to contrast in their capacities to absorb the huge HIV care and prevention endeavors that are now managed with international technical and fiscal support. Botswana has a relatively high national income, a small population, and an advanced HIV/AIDS care program; it is well poised to take on management of its HIV/AIDS programs. South Africa has had a slower start, given HIV denialism philosophies of the previous government leadership. Nonetheless, South Africa has the national income, health care management, and health worker capacity to succeed in fully local management. The sheer magnitude of the burden is daunting, however, and South Africa will need continuing fiscal assistance. In contrast, Zambia and Mozambique have comparatively lower per capita incomes, many fewer health care workers per capita, and lower national literacy rates. It is improbable that fully independent management of their HIV programs is feasible on the timetable being contemplated by donors, nor is locally sustainable financing conceivable at present. A tailored nation-by-nation approach is needed for the transition to full local capacitation; donor nation policymakers must ensure that global resources and technical support are not removed prematurely.
BACKGROUND - Previous research has demonstrated that heavy prenatal alcohol exposure affects the size and shape of the corpus callosum (CC) and compromises interhemispheric transfer of information. The aim of this study was to confirm the previous reports of poorer performance on a finger localization test (FLT) of interhemispheric transfer in a cohort of heavily exposed children and to extend these findings to a cohort of moderately exposed young adults.
METHODS - In Study 1, the FLT was administered to 40 heavily exposed and 23 nonexposed children from the Cape Coloured community of Cape Town, South Africa, who were evaluated for fetal alcohol syndrome (FAS) dysmorphology and growth. Anatomical images of the CC were obtained using structural MRI on a subset of these children. In Study 2, the FLT was administered to a cohort of 85 moderate-to-heavily exposed young adults participating in a 19-year follow-up assessment of the Detroit Prenatal Alcohol Exposure cohort, whose alcohol exposure had been ascertained prospectively during gestation.
RESULTS - In Study 1, children with FAS showed more transfer-related errors than controls after adjustment for confounding, and increased transfer-related errors were associated with volume reductions in the isthmus and splenium of the CC. In Study 2, transfer-related errors were associated with quantity of alcohol consumed per occasion during pregnancy. More errors were made if the mother reported binge drinking (> or =5 standard drinks) during pregnancy than if she drank regularly (M > or = 1 drink/day) without binge drinking.
CONCLUSIONS - These findings confirm a previous report of impaired interhemispheric transfer of tactile information in children heavily exposed to alcohol in utero and extend these findings to show that these deficits are also seen in more moderately exposed individuals, particularly those exposed to binge-like pregnancy drinking.
Associations have been reported between an MDR1 variant and responses to nonnucleoside reverse-transcriptase inhibitors. We explored associations between MDR1, CYP2B6, and CYP3A polymorphisms and nevirapine hepatotoxicity. Among participants in a randomized study in South Africa (FTC-302), MDR1 3435C-->T was significantly associated with decreased risk of hepatotoxicity (risk ratio, 0.30; P=.016).
Helicobacter pylori is a genetically diverse bacterial species that chronically infects human stomachs and sometimes causes severe gastroduodenal disease. Studies of polymorphic DNA sequences can suggest geographic origins of individual strains. Here, we describe a 180-bp insertion (ins180), which is just after the translation stop of a gene of unknown function, near the promoter of jhp0152-jhp0151 two-component signal transduction genes in strain J99, and absent from this site in strain 26695. This ins180 insertion was found in 9 of 9 Gambian (West African), 9 of 20 (45%) South African, and 9 of 40 (23%) Spanish strains but in only 2 of 20 (10%) North American strains and none of 20 Lithuanian, 20 Indian, and 20 Japanese strains. Four South African isolates that lacked ins180 and that belonged to an unusual outlier group contained a 480-bp insertion at this site (ins480), whereas none of 181 other strains screened contained ins480. In further tests 56% (10 of 18) of strains from African Americans but only 17% (3 of 18) of strains from Caucasian Americans carried ins180 (P < 0.05). Thus, the H. pylori strains of modern African Americans seem to retain traces of African roots, despite the multiple generations since their ancestors were taken from West Africa. Fragmentary ins180-like sequences were found at numerous sites in H. pylori genomes, always between genes. Such sequences might affect regulation of transcription and could facilitate genome rearrangement by homologous recombination. Apparent differences between African-American and Caucasian-American H. pylori gene pools may bear on our understanding of H. pylori transmission and disease outcome.
Seventy-two patients with rheumatoid arthritis (RA) and 82 controls have been typed with the XI Histocompatibility Workshop DRB1 and DQB1 sequence-specific oligonucleotide probes. The increase of DRB1*04 corresponds to an increase of the serologically defined DR4, previously found in a small group of Zimbabwean RA patients and we now show that this increase is due to the subtype DRB1*0405 in association with DQB1*0302. In addition there is a clearcut increase of DRB1*1001 equivalent to the serologically defined DR10. There was no increase amongst RA patients of DRB1*0102 which was the predominant DR1 sub-type amongst controls. In the course of our investigation, we observed a DRB1*04 variant which corresponds to DRB1*0412, newly defined in the XIth Histocompatibility Workshop.
OBJECTIVE - To evaluate specified biomedical, socio-economic, and psychosocial criteria as predictors of therapeutic success to optimize patient selection for continuous ambulatory peritoneal dialysis (CAPD) in a developing country.
DESIGN - A retrospective cohort study investigating the relationship between episodes of peritonitis and exitsite infection, and predetermined biomedical, socioeconomic, and psychosocial data.
SETTING - A CAPD unit in a large tertiary care teaching hospital.
PATIENTS - All 132 patients entering the CAPD program between 1987 and 1991.
RESULTS - Overall mean survival time on CAPD was 17.3 months. Peritonitis rates were high, especially among blacks. Multivariate analysis demonstrated that increased peritonitis rates were associated with age, black race, diabetes, and strongly so with several psychosocial factors. Because being black was strongly linked to poor socioeconomic conditions, repeat analysis excluding blacks showed the same associations with the above variables, but, additionally, several socioeconomic factors were associated with high peritonitis rates. No significant explanatory variables were shown for exit-site infections.
CONCLUSIONS - The association of biomedical, socioeconomic, and psychosocial variables with high peritonitis rates has important implications for the selection of patients for CAPD in this setting.
The etiology of crescentic nephritis (CN) in the developing world differs from that of Europe and North America. This retrospective study of 73 patients is the largest series of CN in the developing world. The records of all renal biopsies performed at Groote Schuur Hospital, Cape Town, South Africa, over thirteen years, between January 1977 and April 1991, were reviewed. Specimens selected for this study had six or more glomeruli and over 50% of these glomeruli had crescent formation. It confirms that post infectious glomerulonephritis (PIGN) (n = 21) is the commonest cause of CN in this setting. In addition there were 15 patients with CN associated with systemic lupus erythematosus (SLE). These two groups make this study unique as they are the largest series of each described in the literature. Thirty-nine (53%) patients in this series progressed to end-stage renal failure (ESRF) and only nine (12%) patients recovered renal function to a normal serum creatinine. Eight (38%) patients in the PIGN group developed ESRF, indicating the poor prognosis of this condition. Six of eight patients in the PIGN group treated with steroids and cyclophosphamide recovered to a serum creatinine level less than 200 mumol/l and only one progressed to ESRF, which may indicate that this form of therapy is beneficial. Thirteen (87%) patients with SLE either developed ESRF or died which suggests that the presence of crescents in this condition is associated with a poor prognosis.