This chapter explores how the nascent idea of Adaptation to Climate Change is translated in northern Tanzania. By interrogating how non-governmental organisations and other actors in northern Tanzania adapt to the idea of adaptation itself we gain insight into the ways in which a new development paradigm comes into being. Based on fourteen months of multi-sited ethnographic fieldwork this chapter reveals the politics of adaptation that emerge in the encounter between global ideas of adaptation and what it means for different stakeholders on the ground.
PurposeAspergillosis is uncommon in HIV patients and has been mostly reported in patients with CD4<50/µL. Data on risk factors and prognosis are scarce. We reviewed 19 cases of aspergillosis diagnosed in our HIV cohort.MethodsIn the Brussels Saint‐Pierre HIV cohort, 19 patients were diagnosed with aspergillosis between 1998 and 2012 (0.87/1000 patient/year of follow‐up). We analyzed retrospectively and described localization and invasiveness of aspergillosis, risk factors, treatment and outcome of these patients.ResultsPatients were mostly African (74%) and mean age was 40 years (22–60). Clinical presentation were 10 invasive aspergillosis (IA) (53%), 6 pulmonary aspergilloma (31%) and 3 sinus fungal ball (16%). The global mortality was 42%. IA was proven for 3 patients, probable for 4 patients and possible for 3 patients according to IDSA definitions. Risk factors for IA included CD4<200/µL (70%; 40%<50 CD4/µL), corticotherapy (50%), neutropenia (20%), intravenous drug use (20%), cirrhosis (20%). IA arose in the time course of septic shock in 30% and opportunistic infections occurred concomitantly in 40%. Seven patients out of 10 with IA died including 3 patients before antifungal therapy. The 3 survivors recovered without relapse. Four patients were treated with voriconazole, 2 with itraconazole, 2 with liposomal amphotericine, 1 with caspofungine, and 2 with bitherapy. Among patients with aspergilloma (n=6), the major associated risk factor was tuberculosis sequelae (80%). Two patients were successfully treated with surgery and voriconazole, 1 died from massive hemoptysis, 2 were lost to follow‐up, 1 is currently asymptomatic without treatment. Among patients with sinus fungal ball (n=3), all recovered without relapse with surgical treatment associated with voriconazole for one.ConclusionIncidence of aspergillosis in HIV patients remains low but in accordance to previous reports, mortality of IA is high (70%). CD4<200 is the most common risk factor (70%) but 80% of patients who died had other risk factors, mostly corticotherapy. IA is often concomitant with other infectious diseases (40% with other opportunistic infections and 30% in the time course of septic shock), which can potentially delay diagnosis. Prognosis of pulmonary aspergilloma and sinus fungal ball is better.
Purpose of the studyFever of unknown origin (FUO) is a challenging clinical entity in HIV patients. FDG‐PET/CT is well validated in the work‐up of FUO in HIV‐negative patients but in HIV viremic patients, metabolism of HIV reactive lymph nodes could decrease its specificity. We prospectively evaluated the usefulness of FDG‐PET/CT in FUO in HIV‐positive patients and in particular whether HIV viremia impacts on FDG‐PET/CT performance.MethodsFDG‐PET/CT was performed in 20 HIV patients with FUO and compared with FDG‐PET/CT in 10 HIV viremic patients without FUO. Final diagnosis for FUO was based on histopathology, microbiology, or clinical and imaging follow‐up. Mode of diagnosis, accordance of FDG‐PET/CT with final diagnosis, localization of invasive diagnosis procedures was recorded in order to assess usefulness of FDG‐PET/CT.ResultsFDG‐PET/CT showed a different pattern in FUO and asymptomatic viremic patients. Reactive HIV lymph nodes in asymptomatic viremic patients were mostly peripheral with mean SUVmax of 6.5. In patients with FUO and underlying focal pathologies, hypermetabolic lymph nodes were central with mean SUVmax of 11.6. Presence of central lymph nodes with high FDG uptake in had a 100% specificity for focal pathology, even in viremic patients and absence of these had 100% negative predictive value. Lymph node biopsy in central hypermetabolic areas allowed identifying underlying disease in all FUO patients. For peripheral lymph nodes, a ROC curve was built in order to define the best cut‐off of SUVmax for biopsy: SUVmax of 6–8 showed a sensitivity of 62.5% and specificity of 75%. Lymph nodes with SUVmax<4 had sensitivity of 0%.ConclusionsFDG‐PET/CT contributed to the diagnosis or exclusion of a focal etiology of the febrile state in 80% of HIV patients with FUO. Although number of patients was small, we could highlight several clear‐cut features to help interpreting FDG‐PET/CT in HIV patients with FUO. As in HIV‐negative patients, we showed the usefulness of FDG‐PET/CT in FUO in HIV patients even if they are viremic.
Incidence of anal cancer is increasing and risk of anal cancer is higher in MSM, especially if they are HIV+. European guidelines for treatment of HIV‐infected adults recommend anal cancer screening by digital rectal exam±Pap test with anuscopy if Pap test is abnormal. A systematic anal cancer screening in HIV+MSM with anal cytology (Pap smears) was established in June 2011 in our reference centre in Brussels. If anal cytology was abnormal, high‐resolution anuscopy (HRA) with biopsy was performed. 353 MSM HIV+were screened by anal smears between June 2011 and May 2012. 90% were Caucasians, median age was 44.5 years, 83% were on HAART and 74% had an undetectable viral load, median CD4 was 632/µl and 33% had a nadir CD4<200. Thirty‐three (9.3%) were excluded because of poor quality. Cytology was abnormal in 46% of the 320 remaining patients: high‐grade squamous intraepithelial lesion (HSIL) 3%, low‐grade squamous intraepithelial lesion (LSIL) 24%, atypical squamous cells of undetermined significance (ASC‐US) 16%, and atypical squamous cells / cannot rule out a high‐grade lesion (ASC‐H) 3%. Viral load (VL) was more frequently undetectable (82% vs 64%, p=0.0003) and median duration of HAART was longer (111 vs 61 months, p=0.0145) in patients with normal cytology. 80 HRA with biopsies have been performed. 12.5% were normal, 44% showed anal intraepithelial neoplasia (AIN) 1, 24% AIN 2 and 19% AIN 3. For this analysis, high‐grade AIN (2 and 3) were put together (AIN 2+). Among patients with AIN 2+(n=33), cytology had showed 8 (24%) ASC‐US, 3 (9%) ASC‐H, 19 (57%) LSIL, 3 (9%) HSIL. When patients with normal cytology or normal biopsy and patients with AIN 2+were compared, the only significant risk factor found for AIN 2+was a nadir CD4<100/µl (32% of the patients with AIN 2+vs 14% in patients with normal smear, p=0.0073). Anal precancerous lesions are frequent and at different stages. Among 46% abnormal cytology, 87% had abnormal biopsy including half AIN 2+.Cytology±biopsy is the only way to detect those lesions and should be performed systematically in HIV+MSM. Risk factor for AIN2+was a nadir CD4<100/µl. A normal cytology was associated with an undetectable VL and a longer duration of HAART. Those results provide further argument for early initiation of HAART.
The Paris Agreement established a global goal on adaptation and invites parties to review the effectiveness of adaptation actions. However, the measurement of adaptation success remains elusive. Focusing on the capabilities of households and governments to pursue a range of adaptation futures provides a more robust foundation.
Purpose of the studyTo investigate the impact of ART, HIV viremia and immunosuppression on triglyceride (TG), total cholesterol (TC) and high density lipoprotein cholesterol (HDL‐C) levels.MethodsWe considered the cross‐sectional associations between TG, TC and HDL‐C (mmol/l; first available measurement on/after enrolment in the D:A:D study) and use of ART, HIV viral load (VL; copies/ml), and CD4 count (cells/mm3) measured at the same time. TG was log10 transformed to ensure normality. Analyses were performed using linear regression and adjusted for other factors known to impact lipid levels (table footnote). ART and VL status were combined (off ART&VL >100,000, off ART&VL <100,000, on ART&VL <500, on ART&VL >500), current and nadir CD4 count were categorised as <200, 200–349, 350–499 and >500.Summary of results44,322/49,734 participants in the D:A:D Study (89.1%) contributed a TG measurement (median; IQR 1.52; 1.00–2.45), 45,169 (90.8%) a TC measurement (4.80; 4.00–5.70) and 38,604 (77.6%) a HDL‐C measurement (1.12; 0.90–1.40). Most participants were male (74%), of white ethnicity (51%), without AIDS (78%), were not receiving lipid‐lowering drugs (4%) and were ART experienced (61%) with 47% previously exposed to PIs, 61% previously exposed to NRTIs and 29% previously exposed to NNRTIs. The median (IQR) age, current CD4 count and CD4 nadir were 38 (36–45) years, 400 (242–590) cells/µl and 240 (100–410) cells/µl respectively. Compared to those on ART with a suppressed VL, all lipids were lower for those off ART (Table); non‐suppressive ART was also associated with lower TC and HDL‐C levels (no impact on TG). A low current CD4 count was associated with lower lipid levels, whereas a low nadir CD4 count was associated with higher TC and TG levels. Prior AIDS diagnosis was associated with higher TG and TC, but lower HDL‐C levels.
Impact of ART, immunosuppression and viraemia, on TG, TC and HDL‐C (mmol/l)
Average impact on log10TG*†
Average inpact on TC* Average impact on HDL‐C*
ART and VL
Off ART … VL≥100000 −0.09 (−0.10,−0.08) <0.001 −0.55 (−0.60,−0.51) <0.001 −0.14 (−0.16,−0.13) <0.001
Off ART … VL<100000 −0.04 (−0.06,−0.03) <0.001 −0.85 (−0.91,−0.78) <0.001 −0.31 (−0.33,−0.29) <0.001
On ART … VL<500 Ref
Ref
Ref
On ART … VL≥500 0.00 (−0.01, 0.00) 0.38 −0.40 (−0.44,−0.36) <0.001 −0.16 (−0.17,−0.15) <0.001
estimates included are mutually adjusted for each other and for the following demographic variables: age; gender; mode of infection; ethnicity; body mass index; smoking; family history of CVD; diabetes; use of lipid lowering drugs; co‐infection with hepatitis C; participating cohort; and year of entry into study. TG is log10 transformed. Thus, the results presented for TG reflect relative rather than absolute effects. For example, lipid levels for those off ART … VL ≥100000 are 9% lower than those on ART … VL < 500.
ConclusionAlthough specific drug classes were not considered, lipid levels are considerably higher in those on a suppressive ART regimen. The higher TC/TG and lower HDL‐C levels seen among those with low nadir CD4 count and with a prior AIDS diagnosis suggests severe immunosuppression may be associated with dyslipidaemia over the long‐term.
Many studies have focused on chronic kidney disease in HIV‐positive individuals, but few have studied the less frequent events, advanced renal disease (ARD) and end‐stage renal disease (ESRD). The aim of this study was to investigate incidence, predictors and outcomes for ARD/ESRD and renal death in EuroSIDA. ARD was defined as confirmed eGFR < 30 ml/min per 1.73 m2 (>3 months apart) using Cockcroft‐Gault. ESRD was defined as hemo‐ or peritoneal dialysis>1 month/renal transplant. Renal deaths were defined as renal failure as the underlying cause of death, using CoDe methodology. Patients were followed from baseline (first eGFR after 1/1/2004) until last eGFR, ARD/ESRD/renal death; whichever occurred first. Poisson regression was used to identify predictors. 8817 persons were included, the majority were white (87.3%), males (73.9%) infected though homosexual contact (41.5%) and with a median age of 42 years (IQR 36–49). 45 persons (0.5%) developed the composite endpoint; ARD (24), ESRD (19) and renal death (2) during a median follow up (FU) of 4.5 years (IQR 2.7–5.8), incidence rate (IR) 1.21/1000 PYFU (95% CI 0.86–1.57). Of 312 persons (3.5%) with baseline eGFR<60 ml/min/1.73 m2, 13.3% (7.5–18.9) are estimated to develop ARD/ESRD/renal death within 6 years after baseline compared to 0.86% (0.58–1.1) of all patients, using Kaplan‐Meier methods. Predictors in multivariate analysis were older age (IRR 1.29 per 10 years [0.95–1.75]) any cardiovascular risk (IRR 2.34 [1.23–4.45]), CD4 count (IRR 0.76 per 2‐fold higher [0.60–0.97]) and eGFR (IRR 0.63 per 5 ml/min/1.73 m2 higher [0.58–0.69]).imageEthnicity, gender, nadir CD4, VL, HBV and using potential nephrotoxic antiretrovirals were insignificant in uni‐ and multivariate analysis. At 1 year after ARD/ESRD, 23.3% (CI 9.8–36.8) were estimated to have died using Kaplan‐Meier methods. The 11 deaths were from renal causes (2), non‐AIDS‐defining malignancies (2), hepatitis‐associated liver failure (1), respiratory failure (1), cardiovascular disease (1), pancreatitis (1) and unknown causes (3). The ARD/ESRD/renal death incidence was low in this population with the available FU, and was associated with traditional and HIV‐related risk factors. Most persons with ARD/ESRD/renal death had pre‐existing renal impairment, but some experienced a rapid progression from initial normal levels. Prognosis after ARD/ESRD was poor. Larger studies are required to address the possible contribution of specific antiretrovirals.
Humanitarian disasters such as Typhoon Haiyan (SE Asia, 2013) and the Horn of Africa drought (2011–2012) are examples of natural hazards that were predicted, but where forecasts were not sufficiently acted upon, leading to considerable loss of life. These events, alongside international adoption of the Sendai Framework for Disaster Risk Reduction, have motivated efforts to enable early action from early warnings. Through initiatives such as Forecast-based Financing (FbF) and the Science for Humanitarian Emergencies and Resilience (SHEAR) programme, progress is being made towards the use of science and forecasts to support international humanitarian organisations and governments in taking early action and improving disaster resilience. However, many challenges remain in using forecasts systematically for preparedness and response. The research community in place through SHEAR enabled the UK government's Department for International Development to task a collaborative group of scientists to produce probabilistic real-time flood forecast and risk bulletins, aimed at humanitarian decision-makers, for Cyclones Idai and Kenneth, which impacted Mozambique in 2019. The process of bulletin creation during Idai and Kenneth is reviewed and critically evaluated, including evaluation of the forecast information alongside evidence for how useful the bulletins were. In this context, this work seeks to navigate the "murky landscape" of national and international mandates, capacities, and collaborations for forecasting, early warning and anticipatory action, with the ultimate aim of finding out what can be done better in the future. Lessons learnt and future recommendations are discussed to enable better collaboration between producers and users of forecast information.
