Can operations and implementation research guide today's unprecedented efforts to scale-up HIV/AIDS prevention, treatment, care, and support in resource-limited settings? Our study of patients with HIV/AIDS who were first seen at the Central Hospital (Yaoundé, Cameroon) to begin antiretroviral therapy demonstrates the value of using operations research to explore programs, policies, and guidelines used in health care. We studied one group of patients, those lost to follow-up. Our findings confirmed the value of early treatment, systems to follow individuals, free treatment, and resources that enable operations research. We encourage health-care workers and program managers to perform operational research in their own context, and we emphasize the importance of allocating adequate human, financial, and logistic resources for this activity. Finally, we stress that the health-care workers, program managers, and researchers must work together to better inform policy and guidelines.
Our study in Cameroonian rural district hospitals showed that the immunologic and clinical failure criteria had poor performance to identify human immunodeficiency virus drug resistance in a timely manner. Switching to second-line antiretroviral therapy after 2 consecutive viral loads ≥5000 copies/mL, as recommended by the World Health Organization, appeared to be the most appropriate strategy.
Cameroon is a low–middle income country with a rich diversity of culture and cuisine. Chronic kidney disease (CKD) is common in Cameroon and over 80 % of patients present late for care, precluding the use of therapies such as low protein diets (LPDs) that slow its progression. Moreover, the prescription of LPDs is challenging in Cameroon because dieticians are scarce, there are no renal dieticians, and people often have to fund their own healthcare. The few nephrologists that provide care for CKD patients have limited expertise in LPD design. Therefore, only moderate LPDs of 0.6 g protein per kg bodyweight per day, or relatively mild LPDs of 0.7–0.8 g protein per kg bodyweight per day are prescribed. The moderate LPD is prescribed to patients with stage 3 or 4 CKD with non-nephrotic proteinuria, no evidence of malnutrition and no interrcurrent acute illnesses. The mild LPD is prescribed to patients with stage 3 or 4 CKD with nephrotic proteinuria, non-symptomatic stage 5 CKD patients or stage 5 CKD patients on non-dialysis treatment. In the absence of local sources of amino and keto acid supplements, traditional mixed LPDs are used. For patients with limited and sporadic access to animal proteins, the prescribed LPDs do not restrict vegetable proteins, but limit intake of animal proteins (when available) to 70 % of total daily protein intake. For those with better access to animal proteins, the prescribed LPDs limit intake of animal proteins to 50–70 % of total daily protein intake, depending on their meal plan. Images of 100 g portions of meat, fish and readily available composite meals serve as visual guides of quantities for patients. Nutritional status is assessed before LPD prescription and during follow up using a subjective global assessment and serum albumin. In conclusion, LPDs are underutilised and challenging to prescribe in Cameroon because of weakness in the health system, the rarity of dieticians, a wide diversity of dietary habits, the limited nutritional expertise of nephrologists and the unavailability of amino and keto acid supplements.
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