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Antiretroviral therapy (ART) inhibits HIV replication, allowing recovery of CD4+ T cell numbers and the restoration of immune function; its introduction has led to improved outcomes for individuals with HIV infection. However, it has been observed that some individuals responding to ART experience a clinical deterioration with symptoms and signs of an inflammatory illness. Immune reconstitution inflammatory syndrome (IRIS) results from pathological immune responses occurring during immune reconstitution. IRIS is best considered a group of disorders with a wide range of clinical manifestations, incorporating disease resulting from pathological inflammation to pathogens, immune-mediated inflammatory disease and autoimmune disease. Clinical effects range from a mild, self-limiting illness to severe morbidity and mortality. Clinicians working in the field of HIV medicine can expect to encounter individuals with IRIS. In this review, we discuss definitions, describe clinical presentations, summarize research relating to pathogenesis and identify risk factors, preventive and management strategies.

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Introduction of pneumococcal polysaccharide (PPV23) and conjugate vaccine (PCV7) programmes were expected to change the epidemiology of invasive pneumococcal disease (IPD) and pneumonia in the UK. We describe the epidemiology of IPD and hospitalization with pneumonia using high-quality surveillance data over an 8-year period, 2002-2009. Although PPV23 uptake increased from 49% to 70% and PCV7 uptake reached 98% by 2009, the overall incidence of IPD increased from 11.8/100 000 to 16.4/100 000 (P=0.13), and the incidence of hospitalization with pneumonia increased from 143/100 000 to 207/100 000 (P<0.001). Although a reduction in the proportion of IPD caused by PCV7 serotypes was observed, concurrent increases in PPV23 and non-vaccine serotype IPD contributed to an increased IPD burden overall. Marked inequalities in the geographical distribution of disease were observed. Existing vaccination programmes have, so far, not been sufficient to address an increasing burden of pneumococcal disease in our locality.

Sierra Leone has the world’s highest estimated maternal mortality. Following the 2014–16 Ebola outbreak, we described health outcomes and health-seeking behaviour amongst pregnant women to inform health policy. In October 2016–January 2017, we conducted a sequential mixed-methods study in urban and rural areas of Tonkolili District comprising: household survey targeting women who had given birth since onset of the Ebola outbreak; structured interviews at rural sites investigating maternal deaths and reporting; and in-depth interviews (IDIs) targeting mothers, community leaders and health workers. We selected 30 clusters in each area: by random GPS points (urban) and by random village selection stratified by population size (rural). We collected data on health-seeking behaviours, barriers to healthcare, childbirth and outcomes using structured questionnaires. IDIs exploring topics identified through the survey were conducted with a purposive sample and analysed thematically. We surveyed 608 women and conducted 29 structured and 72 IDIs. Barriers, including costs of healthcare and physical inaccessibility of healthcare facilities, delayed or prevented 90% [95% confidence interval (CI): 80–95] (rural) vs 59% (95% CI: 48–68) (urban) pregnant women from receiving healthcare. Despite a general preference for biomedical care, 48% of rural and 31% of urban women gave birth outside of a health facility; of those, just 4% and 34%, respectively received skilled assistance. Women expressed mistrust of healthcare workers (HCWs) primarily due to payment demanded for ‘free’ healthcare. HCWs described lack of pay and poor conditions precluding provision of quality care. Twenty percent of women reported labour complications. Twenty-eight percent of villages had materials to record maternal deaths. Pregnant women faced important barriers to care, particularly in rural areas, leading to high preventable mortality and morbidity. Women wanted to access healthcare, but services available were often costly, unreachable and poor quality. We recommend urgent interventions, including health promotion, free healthcare access and strengthening rural services to address barriers to maternal healthcare.

a 53% TB case detection rate (World Health Organization target 70%); there is currently no systematic programme for tracing contacts of TB cases for screening. The Swaziland Ministry of Health has identifi ed inadequate investigation of household contacts as one reason why the national TB response is insuffi cient, and it has committed to conducting systematic investigation of contacts.The aim of the present study is to evaluate hospitalbased contact screening and test approaches to improve effectiveness, through community follow-up. METHODS Study settingThe present study was conducted in the TB department of Good Shepherd Hospital (GSH), a regional rural hospital serving a population of 200 000. The hospital provides support to community clinics and outreach services such as trained fi eld offi cers, known as motorcycle adherence offi cers. Study designThis is an evaluation of hospital-based universal TB household contact screening, conducted from November 2011 to October 2012. It includes a quality improvement project evaluating three enhanced models to investigate the effectiveness of community follow-up. Study populationAll household contacts of index patients were included in the study. An index patient was defi ned as any patient aged >5 years with pulmonary TB or <5 years with any form of TB. A household contact was defi ned as someone living under the same roof as an index case at the time of, or within 3 months of, diagnosis. InterventionNewly diagnosed index patients providing consent for contact tracing were asked to list their household contacts. The standard (hospital-based) model for TB contact tracing was as follows: 1) all contacts attending the TB clinic with the index patient at any appointment were offered TB screening, and 2) a letter was given to the index patient to invite household contacts for screening at the hospital.Adult contacts were screened by clinical assessment using the Swaziland TB screening tool (Table 1). 9 In high HIV prevalence settings, symptom-based screening tools are sensitive in adults (84%), although not very specifi c (60%). 12 Contacts aged <5 years were screened by the paediatrician, and investigated using chest X-ray Interna onal Union Against Tuberculosis and Lung DiseaseHealth solu ons for the poor VOL 3 NO 4 PUBLISHED 21 DECEMBER 2013http://dx.doi.org/10.5588/pha.13.0070Setting: A regional hospital in rural Swaziland. Objectives: To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness. Design: An evaluation and quality improvement study of tuberculosis (TB) contact tracing services. Results: Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to...

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