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Integrating HIV Care into Primary Care Services: Quantifying Progress of an Intervention in South Africa
Kerry E. Uebel ,
Contributed equally to this work with: Kerry E. Uebel, Gina Joubert, Edwin Wouters, Willie F. Mollentze, Dingie H. C. J. van Rensburg
* E-mail: uebelke@fshealth.gov.za
Affiliation Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
Gina Joubert ,
Affiliation Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
Edwin Wouters ,
Affiliations Department of Sociology and Research Centre for Longitudinal and Life Course Studies, University of Antwerp, Belgium, Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
Willie F. Mollentze ,
Dingie H. C. J. van Rensburg
Affiliation Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
Kerry E. Uebel,
Gina Joubert,
Edwin Wouters,
Willie F. Mollentze,
Kerry E. Uebel Gina Joubert ... Dingie H. C. J. van Rensburg
Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated.
A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach's alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial.
Cronbach's alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score.
The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.
Citation: Uebel KE, Joubert G, Wouters E, Mollentze WF, van Rensburg DHCJ (2013) Integrating HIV Care into Primary Care Services: Quantifying Progress of an Intervention in South Africa. PLoS ONE 8(1): e54266. https://doi.org/10.1371/journal.pone.0054266
Editor: Kara K. Wools-Kaloustian, Indiana University, United States of America
Received: July 13, 2012; Accepted: December 10, 2012; Published: January 22, 2013
Copyright: © 2013 Uebel et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The National Research Fund of South Africa was the source of a doctoral bursary. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
There is international agreement that universal access to treatment for people with human immunodeficiency virus (HIV) in high-burden countries will not be achieved by vertical or single disease approaches to delivering HIV care, but rather by providing HIV care within general health systems [1], [2], [3]. Calls have been made to use international funding and support for HIV care to strengthen general health systems, and broaden existing vertical HIV programmes so as to provide HIV care within general health systems – the so-called diagonal approach [4], [5].Various strategies have been used in order to do this in countries with severe human resource shortages and struggling health care systems. These include shifting tasks from highly skilled to lower skilled and even lay health workers, mobilising community support and integrating HIV care into primary care services [3]. There are many reports of the effectiveness of task shifting [6], [7], [8], [9], [10], [11], and community mobilisation [12], [13] and guidelines have been published by the World Health Organization [14]. However, there are few clear recommendations on effective strategies to integrate HIV care into primary care services partly because there is still little evidence that integration of health care programmes does improve patient outcomes [15].
One of the problems is that integration is a broad concept. It has been defined as "a variety of managerial or operational changes to health systems to bring together inputs, delivery, management and organisation of particular service functions" [16].Integration may take place in all or any combination of a number of different health system functions including service delivery, management, financing, governance and monitoring and evaluation [17]. In order to provide evidence of the effectiveness of integration, controlled studies of integration are urgently needed. Such studies would need to describe what functions are being integrated and what strategies are used, but would also need to develop tools to monitor and quantify integration in order to correlate integration with outcomes achieved and compare outcomes across different studies [18].
There have been reports of strategies to integrate HIV care into primary care services including: co-location of vertically run HIV services in primary care facilities [19] down referral of stable patients on antiretroviral treatment (ART) to primary care clinics [20] and the provision of outreach support to primary care clinics from existing ART sites [21]. Other programmes have reported on strategies to integrate HIV care into all primary care consultations. These included staff training, standardised protocols, combined medical records and waiting areas, and the inclusion of HIV testing into triage [22], [23]. There are reports of improved access to ART with primary care driven models of HIV care [8], [21], [24], [25]. However all of these reports were observational and none were able to link patient outcomes with the extent to which HIV care was integrated.
This paper describes the development of a questionnaire as a tool to quantify integration of HIV care into primary care services achieved during a controlled trial of a complex intervention in the Free State Province of South Africa. This was a trial of a task shifting and integration intervention, monitoring the outcome of patients needing ART, called Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) [26]. The STRETCH trial is registered at isrctn.org (ISRCTN46836853)
Approval to conduct this study was obtained from the head of the Department of Health in the Free State. The protocol for this sub-study was approved by the ethics committee of the Faculty of Health Sciences of the University of the Free State. The main STRETCH trial protocol was approved by the ethics committees of the faculties of health sciences at the Universities of Cape Town and the Free State. Clinic managers provided written informed consent to take part in the trial. As the STRETCH trial was an educational and managerial intervention aimed at entire clinics and their staff, all patients in the intervention clinics would be exposed to the same intervention. Informed consent was not requested from individual patients. Patients in intervention clinics were given written information about the trial. Ethical principles for use of medical records for research without patients' consent were followed: the research had a clear public benefit, approval was obtained for the study from the lead doctors and nurses managing the programme, use of the data for research did not influence individuals' care, the data were already being used by the research team for programme evaluation on behalf of the provincial health department, and data confidentiality was strictly enforced. Only selected data managers had access to personal identifiers. Anonymised data were provided only to the principal investigators, the lead statistician and the health economist. This consent procedure was approved by both ethics committees.
Context of the study
The Free State province, with a population of 2.8 million [27], and an estimated HIV prevalence of 18.5% among 15–49 year olds [28], commenced the public sector rollout of ART in 2004 with a vertical approach to delivery of HIV care. Patients diagnosed as HIV-positive, by nurses from primary care clinics (who diagnose and treat common conditions) were referred for all further HIV care to designated ART nurses (also primary care nurses but appointed for the ART programme) at ART assessment sites located within selected primary care clinics. Patients eligible for ART (CD4 <200 cells/µl or Stage 4) had baseline bloods taken, received drug readiness training and then were referred for initiation of ART to doctors at ART treatment sites and subsequently fetched monthly supplies of ART at the assessment site. Those not yet eligible for ART continued to access care (CD4 counts through laboratory testing, staging, tuberculosis (TB) screening and cotrimoxazole prophylaxis) with ART nurses at the assessment site. By the end of 2007, 57 ART assessment and treatment sites were functioning [29]. However, the vast majority of primary care clinics in the province could not provide on-site access to HIV care but rather had to refer their patients to primary care clinics with ART assessment facilities. While patients on ART had good outcomes [30], [31], estimated coverage was only 25% [29], [32], the mortality rate amongst patients awaiting ART was high [30], and high rates of burnout in nurses working in ART clinics were recorded [33].
In order to assess strategies to improve access to ART, a pragmatic, cluster, randomised controlled trial, the STRETCH trial was conducted. All 31 existing ART assessment sites at the end of 2006, were randomised into 16 intervention and 15 control clinics within 9 clusters of between 2–7 clinics. Clinics in a cluster were usually under one local area or district management structure, or referred patients to doctors at the same ART treatment clinic, or both. The trial comprised two interventions: 1) nurse initiation and repeat prescription of ART and 2) integration of HIV care into primary care. The primary outcomes were survival of patients with CD4<350 and not yet on ART (patients eligible for ART or likely to become eligible during the trial) and 12 month viral load suppression rates for patients on ART [26], [34].
The integration intervention was developed in consultation with staff at all 31 clinics [34]. They reported that the existing system of ART nurses providing all HIV care at designated ART assessment sites was overloading these ART nurses and was also cumbersome for patients. One example of this was that HIV-positive patients on ART and those not yet eligible for ART who needed cotrimoxazole prophylaxis, accessed HIV care from ART nurses at the ART assessment site but had to fetch cotrimoxazole from primary care nurses at their local primary care clinic as cotrimoxazole was supplied from the clinic's primary care budget. The aims of the intervention developed with the staff were twofold: 1) HIV care was to be integrated into the work of all primary care nurses (and not just the ART nurses) within the ART clinic so that patients could access HIV care from any nurse at that clinic (internal integration) and, 2) HIV care was to be provided by nurses at all surrounding primary care clinics referring patients to that ART clinic, so that patients could access HIV care from their local clinic (mainstreaming HIV care). Staff also identified six elements of HIV care that needed to be integrated: 1) voluntary counselling and testing (VCT); 2) initial CD4 count; and 3) routine care including cotrimoxazole prophylaxis for those not yet eligible for ART (three elements of pre-ART care); 4) baseline blood tests; 5) drug readiness training; and 6) monthly supply of ART for patients eligible for ART (three elements of ART care). It was noted during development of the intervention that integration of pre-ART care had already commenced at some ART clinics and their surrounding primary care clinics ("referring primary care clinics"). ART prescription and adherence counselling could not be integrated into all primary care services during the trial as provincial authorisation of nurse ART prescription was limited to trained nurses in intervention clinics only.
The strategies used to implement the STRETCH interventions have been described elsewhere [34] and are summarised in Table 1. These included provincial training in diagnosis and care of TB, respiratory disease, sexually transmitted diseases and HIV at all primary care clinics using the PALSA PLUS primary care guidelines [35], [36], and extra training in ART prescription at intervention clinics using a STRETCH edition of PALSA PLUS. Clinic based teams, consisting of key clinic staff, implemented changes within intervention clinics. Local management teams comprising the local area manager, ART pharmacist and PALSA PLUS trainer, and clinic managers from the intervention clinic and referring primary care clinics, supported mainstreaming of HIV care. The STRETCH coordinator (KU) provided clinical and organisational support and was involved in facilitating the management teams. An implementation toolkit with descriptions of the trial interventions and changing roles of clinic staff, was distributed to members of the clinic based teams. The intervention was implemented in three phases at a pace decided by clinic teams.
Table 1. Intervention and control clinic characteristics during STRETCH trial.
Integration questionnaire
Although provincial tools existed to monitor provision of HIV care (such as HIV tests and CD4 counts) at primary care clinics, there was no tool to assess whether HIV care was integrated into all consultations within clinics. Thus, a new questionnaire was developed in consultation with clinic staff (see Additional File S1 and a summary in Table 2). There were eleven questions on internal integration. These questions assessed the integration of care for HIV-positive patients into the consultations of all nurses within the ART clinic. There were four questions on the integration of HIV care for patients not yet eligible for ART (pre-ART care) (Q1,3,5 and 7); four on the integration of HIV care for patients eligible for and on ART (ART care) (Q12,14,16 and 18) and three questions on the integration of primary care services needed by patients on ART at that clinic (TB diagnosis, dispensing of cotrimoxazole and contraception) (Q9,10 and 11). There were eight questions on mainstreaming HIV care. These questions assessed the provision of HIV care by nurses at referring primary care clinics. There were four questions each on the provision of pre-ART (Q2,4,6 and 8) and ART care (Q13,15,17 and 19).
Table 2. Component questions of the five different integration scores.
Based on the initial discussions with staff, each question had only two or three possible responses to describe integration. Answers were scored 0 for no integration, 2 for full integration and, in questions with three responses, 1 for partial integration. The scores for each question were combined to give a total integration score and four component integration scores. These different combinations of questions and the resulting integration scores are summarised in Table 2 and described below:
Total integration score – total score for all 19 questions.
Pre-ART integration score – total score for questions 1–8 on the provision of HIV care for patients not yet eligible for ART by all nurses (primary care and ART nurses) at the ART clinic and at referring primary care clinics
ART integration score – total score for questions 12–19 on the provision of HIV care for patients eligible for, and on ART by all nurses (primary care and ART nurses) at the ART clinic and at referring primary care clinics
Internal integration score – total score for questions 1,3,5,7,9,10,11,12,14,16 and 18 on the provision by all nurses within the ART clinic, of pre-ART and ART care and on the provision of three key primary care services for patients on ART
Mainstreaming HIV score – total score for questions 2,4,6,8,13,15,17,and 19 on the provision of pre-ART and ART care by nurses at referring primary care clinics
Internal integration scores could be calculated for all 31 clinics throughout the trial. However, the other integration scores could only be calculated for 23 clinics (13 intervention and 10 control) that still had primary care clinics referring patients to that ART clinic throughout the trial. New ART assessment clinics were established by the Department of Health during the trial and consequently eight of the 31 trial clinics no longer had patients referred from other primary care clinics by the last assessment of the trial.
The questionnaire was administered at all four assessments by the trial coordinator (KU) with the clinic manager or senior ART nurse at the clinic and preferably the same person at each assessment, but this was not always possible. The answer that best described the level of integration was decided by the interviewee in discussion with the coordinator. The coordinator was involved in local management teams responsible for the implementation of integration and so had independent confirmation about the progress of integration in each clinic. The assessments were done at all 31 clinics, as it could not be assumed that integration would not take place at control clinics [37]. Integration of HIV care into primary care services at the 16 intervention clinics commenced in Phase 1 of the trial and six-monthly integration assessments were planned. The first two assessments were conducted six months apart during early trial support visits. The last two assessments, when support visits were less frequent, were conducted telephonically, and the interval was extended to nine months as the trial had been extended due to a delay in nurse initiation of ART in some clinics. Time taken to complete the questionnaire was short (10–15 minutes), but as the coordinator had to travel to each clinic, or phone the interviewees at a time convenient to conduct the questionnaire, each round of assessments took four to six weeks to complete. A mean date of assessment was assigned in order to plot changes in mean scores.
Consistency and reliability of the questionnaire
Internal consistency of the questionnaire was tested using Cronbach's alpha coefficients. These were calculated from scores at the first assessment for the entire questionnaire, and then the groups of questions on internal integration and mainstreaming HIV care, as well as the questions on pre-ART and ART integration.
In order to test for inter-observer reliability, the interview was repeated by a different interviewer at five clinics (three intervention and two control) in two districts, two months after the first assessments. These clinics were chosen by convenient sampling from the 23 clinics that had primary care clinics referring patients throughout the trial and could give scores for all 19 questions.
Differences in the mean values of total integration scores and in the four component integration scores at intervention and control clinics were analysed with one way analysis of variance ANOVA (SPSS version 16.0) and a non-parametric analysis, Mann-Whitney (SAS version 9.2). Repeated measures ANOVA was used to analyse changes in mean scores over time (SPSS version 16.0). The level of significance was chosen as a p value of <0.05.
Internal consistency and reliability of the questionnaire
Cronbach's alpha coefficient was 0.85 for all 19 questions, 0.86 for the 8 questions on pre-ART integration, 0.68 for the 8 questions on ART integration, 0.73 for the eleven questions on internal integration and 0.69 for the eight questions on mainstreaming of HIV care.
The second observer, who conducted repeat interviews at 5 clinics, obtained the same integration score on all questions at two clinics, a one point difference on one question only at two other clinics and a total score of one point difference with three questions scoring differently at the fifth clinic. The mean total integration score was 23.5 (maximum possible score 38) for the two assessments at the 5 sampled clinics by both observers. The mean difference between the total integration scores at the 5 clinics done by the two different observers was −0.6, with a standard deviation of 0.55 giving 95% limits of agreement of −1.7 to 0.5.
Progress of integration
In an initial analysis of the changes in scores across all clinics for individual questions, the four questions that showed the largest absolute increases in integration scores (an increase of between 14–16 points) between the first and fourth assessments were questions 13,15,17 and 19 – all questions dealing with the mainstreaming of ART care. The questions that showed minimal variation in integration scores (absolute changes between 1–3 points) were questions 1–8 on mainstreaming and internal integration of pre-ART care.
The changes in mean integration scores for intervention and control clinics are plotted in Figures 1, 2, 3. As seen in Figure 1, mean total integration scores at the first assessment at intervention (25.7) and control clinics (25.4) were not significantly different. At the third assessment, conducted in the middle of the trial, the mean total integration score at intervention clinics (28.8) was significantly higher than at control clinics (23.7) (ANOVA, p = 0.0174; Mann-Whitney, p = 0.0267). The increase in mean total integration score at intervention clinics from the first (25.7) to the third assessment (28.8) was a significant change (rmANOVA, p = 0.0198). There was also a significant increase in mean total integration scores at control clinics that occurred late in the trial between the third (23.7) and fourth assessments (27.6) (rmANOVA, p = 0.0283). Consequently at the fourth assessment, there was no longer a significant difference between mean total integration scores at intervention and control clinics (ANOVA, p = 0.4581; Mann-Whitney, p = 0.5342).
Figure 1. Progress of mean total integration scores during the STRETCH trial.
Line graph of mean total integration scores at intervention and control clinics plotted against mean date of assessment, for four assessments during the STRETCH trail. Error bars depict standard error on the mean at each assessment.
Figure 2. Progress of mean pre-ART and ART integration scores during the STRETCH trial.
Two line graphs of mean pre-ART and ART integration scores at intervention and control clinics plotted against mean date of assessment, for four assessments during the STRETCH trial. Error bars depict standard error on the mean at each assessment.
Figure 3. Progress of mean internal integration and mainstreaming HIV scores during the STRETCH trial.
Two line graphs of mean internal integration and mainstreaming HIV scores at intervention and control clinics plotted against mean date of assessment, for four assessments during the STRETCH trial. Error bars depict standard error on the mean at each assessment.
In order to determine whether there was any change in which elements of HIV care had been integrated, differences in mean pre-ART and ART integration scores at intervention and control clinics and changes in these scores were analysed (see Figure 2). Mean pre-ART and ART integration scores at the first assessment at intervention clinics (14.4 and 6.2 respectively) and control clinics (15.4 and 5.1 respectively) were not significantly different. At the third assessment only, the mean ART integration score at intervention clinics (8.5) was significantly higher than at control clinics (3.8) (ANOVA, p = 0.0015; Mann-Whitney, p = 0.0029) and was significantly higher than at the first assessment (6.2) (rmANOVA, p = 0.004). However the mean pre-ART integration scores at intervention clinics were not significantly different from control clinics at any assessment, and there was no significant change at intervention or control clinics from the first assessment to the last assessment. Thus, integration of elements of ART care was the main contributor to the increased total integration scores at intervention clinics during the trial. The increase in mean total integration scores at control clinics late in the trial was likewise due to a significant increase in mean ART scores between the third (3.8) and fourth assessment (7.4) (rmANOVA, p = 0.0078). It was noted, however, that mean pre-ART integration scores were already close to the maximum possible score of 16 at the beginning of the trial and remained there throughout the trial.
In order to determine whether any significant change in integration at the two levels of primary care had taken place during the trial, differences in mean mainstreaming HIV and internal integration scores and changes in these scores were analysed (see Figure 3). Mean mainstreaming HIV and internal integration scores at the first assessment at intervention (9.7 and 16.1 respectively) and control clinics (8.8 and 17.1 respectively) were not significantly different. At the third assessment only, the mean mainstreaming HIV score at intervention clinics (11.3) was significantly higher than at control clinics (8.7) (ANOVA, p = 0.0073; Mann-Whitney, p = 0.0158) and significantly higher than at the first assessment (9.7) (rmANOVA, p = 0.0023). There were no significant differences in mean internal integration scores between intervention and control clinics at any assessment, and no significant changes in internal integration scores at intervention or control clinics from the first assessment to the last assessment. Mainstreaming of HIV care into primary care clinics was thus the main contributor to the level at which integration of HIV care into primary care took place at intervention clinics during the trial. The increase in mean total integration scores, late in the trial at control clinics, was also due to a significant increase in mean mainstreaming HIV scores occurring between the third (8.7) and fourth assessments (11.1) (rmANOVA, p = 0.0059).
This assessment shows that the strategies employed during the STRETCH trial resulted in significant increases in total integration scores at intervention clinics. The specific areas in which the integration score increased were in providing HIV care in primary care clinics not previously involved in the ART programme (mainstreaming HIV score) and in the provision of elements of ART care, namely, the taking of baseline blood tests, drug readiness training and monthly supply of ART for patients eligible for ART (ART score). These findings have been independently confirmed by a qualitative process evaluation of the STRETCH trial which found that patients and nurses appreciated the convenience of patients being able to access HIV care including ARVs at their local clinic instead of having to travel to an ART clinic [38]. There was no increase in mean pre-ART integration scores during the trial because these elements of HIV care, namely VCT, initial CD4 count and routine care for those not yet eligible for ART which had been identified by staff as critical elements of pre-ART needing integration, had already been substantially integrated into primary care services by local managers in the months leading up to the trial.
In contrast it appears that the strategies used in the STRETCH trial had no effect on internal integration scores at intervention clinics, with no significant shift towards patients being able to access HIV care from all nurses within the clinic. There may be other more effective strategies to achieve integration of HIV care into the work of all nurses within primary care clinics, or there may be factors that mitigate against internal integration. Topp et al described some strategies to integrate the provision of HIV care into the work of all nurses within two primary care clinics in Zambia [22]. These strategies included training of all staff in HIV care, as in the STRETCH trial, but also the use of other strategies not used in the STRETCH trial – combined medical records and waiting areas and the inclusion of HIV testing into triage of all patients. They did document increased uptake of HIV testing and good standards of HIV care. However, they also reported resistance on the part of nurses and patients to completely integrated ART services because of issues such as increased waiting times and the loss of informal support for patients on ART with the loss of ART waiting areas [22]. A synthesis of the findings of three qualitative studies on internal integration in Free State clinics conducted at the same time as the STRETCH trial found that administrative issues and patient and nurse preferences tended to mitigate against internal integration of HIV care (manuscript submitted for publication).
The increase in mean total integration, ARV and mainstreaming HIV scores by the fourth assessment late in the trial at control clinics, resulted from provincial implementation of a new national AIDS policy including nurse prescription of ART and the provision of ART in all primary care clinics – the two main interventions of the trial [39]. The STRETCH trial was a pragmatic trial conducted under real conditions which include such policy changes. The research team was able to negotiate with the province that nurse initiation of ART would not be implemented in control clinics till after the trial, but was not able to delay integration of HIV care into primary care services in control clinics in the last few months of the trial.
One of the strengths of this study is that it is a prospective assessment using a new semi- quantitative tool to document integration of HIV care. The contents of this questionnaire were likely to be valid as the elements of HIV care and the need to integrate them at both levels were identified in consultation with staff at ART clinics. Internal consistency as shown by Cronbach's alpha was good. Real validity of the questionnaire was demonstrated in that it captured an increase in integration scores at control clinics as a result of the implementation of a new policy to integrate HIV care into primary care in the last months of the trial.
There were some potential limitations to this study. The first two interviews were conducted during clinic visits while the last two were conducted telephonically, interviews were not always conducted with the same staff member and data on services at referring primary care clinics were based on reports from staff at the ART site and not at the primary care clinic. However, all interviews were conducted by the trial coordinator who was well known to the clinic staff and involved in local management teams implementing integration and thus was able to independently confirm progress of integration as described by the interviewee at each clinic. Though there is a possibility that the coordinator may have influenced answers, the results of inter-observer reliability tests suggest that this was negligible. The lack of progress in internal integration compared with the progress in mainstreaming HIV, captured by the questionnaire, suggests that the interviewees were not unduly influenced to report integration where there was none. The integration questionnaire was developed to assess the integration of HIV care into primary care as it affected service delivery for patients and was therefore not able to assess the effects of integration of other areas of health system functioning. The questionnaire was not able to document the impact of integration of HIV care on the provision of other primary care services. This is an important area of research, and is the subject of a project currently being conducted in all primary care clinics in the Free State.
This questionnaire was validated in the specific context of the Free State and may need some further development, but it could be a valuable tool for assessing integration of HIV care into primary care clinics in other settings. The main results of the STRETCH trial showed that patient survival was not significantly different in intervention clinics compared with control clinics [40].The integration scores obtained in this study will be correlated with survival of patients with CD4 below 350 and not yet on ART, from the STRETCH trial to determine if integration of HIV care may have had an independent effect on patient survival. These results, together with the process evaluation and results of the STRETCH study, should be useful in identifying whether integration is an effective strategy to improve survival of HIV-positive patients in need of ART.
The integration questionnaire developed in this study is a valid tool with potential to monitor integration in other high HIV-burden countries. This study demonstrated an increase in total integration scores in clinics in the Free State province during the STRETCH trial. This was achieved by integrating ART care, particularly at primary care clinics not previously designated as ART clinics but there was no increase in integration of HIV care into all consultations. The scores documented in this intervention will be used to determine if integration is associated with an improvement in survival of patients needing ART.
File S1.
Survey of integration of HIV care in ARV clinics and their referring primary care clinics.
Thanks to Tsotsa Polinyane for assistance with the questionnaire. Thanks also to Lara Fairall, Max Bachman, Merrick Zwarenstein, Carl Lombard, Simon Lewin, Daniella Georgeu, Chris Colvin, Eric Bateman, Gill Faris, Pat Meyers, Andrew Boulle, Dewald Steyn and Cloete van Vuuren from the STRETCH team.
Conceived and designed the experiments: KEU GJ DHCJVR. Performed the experiments: KEU. Analyzed the data: KEU GJ EW. Wrote the paper: KEU GJ EW WFM DHCJVR.
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20. Variava E (2006) Profile: HIV in North West Province South Africa. Southern African Journal of HIV Medicine 23: 35–37.
21. Barker P, McCannon C, Mehta N, Green C, Youngelson M, et al. (2007) Strategies for the scale-up of antiretroviral therapy in South Africa through health system optimisation. Journal of Infectious Diseases 196(Suppl 3): S457–463.
22. Topp S, Chipukuma J, Giganti M, Mwango L, Chiko L, et al. (2010) Strengthening health systems at facility-level: Feasibility of integrating antiretroviral therapy into primary health care services in Lusaka, Zambia. PLoS ONE 5: e11522.
23. Friedland G, Harries A, Coetzee D (2007) Implementation issues in tuberculosis/HIV collaboration and integration: three case studies. Journal of Infectious Diseases 196(Suppl 3): S114–123.
24. Bedelu M, Ford N, Hilderbrand K, Reuter H (2007) Implementing antiretroviral therapy in rural communities: The Lusiksiki model of decentralised HIV/AIDS care. Journal of Infectious Diseases 196(Suppl 3): S464–468.
25. Fredlund V, Nash J (2007) How far should they walk? Antiretroviral therapy access in a rural community in northern KwaZulu-Natal, South Africa. Journal of Infectious Diseases 196(Suppl 3): S469–S473.
26. Fairall L, Bachmann M, Zwarenstein M, Lombard C, Uebel K, et al. (2008) Streamlining tasks and roles to expand treatment and care for HIV: randomised controlled trial protocol. Trials 9: 21–26.
27. Statistics South Africa (2011) Mid-year population estimates. Available:<http://www.statssa.gov.za/publications/P0302/P03022011.pdf>. Accessed 2012 Sep 24.
28. Shisana O, Rehle T, Simbayi L, Zuma K, Jooste S, et al.. (2009) South African national HIV prevalence, incidence, behaviour and communication survey 2008: a turning tide among teenagers? Cape Town: HSRC Press.
29. Uebel K, Timmermans V, Ingle S, Van Rensburg D, Mollentze W (2010) Towards universal ARV access: achievements and challenges in the Free State, South Africa: a retrospective study. SAMJ 100: 589–593.
30. Fairall L, Bachmann M, Louwagie G, van Vuuren C, Chikobvu P, et al. (2008) Effectiveness of antiretroviral treatment in a South African program: a cohort study. Archives of Internal Medicine 168: 86–93.
31. Wouters E, Heunis C, Van Rensburg D, Meulemans H (2009) Physical and emotional health outcomes after 12 months of public-sector ART in the Free State Province of South African: a longitudinal study using structural equation modelling. BMC Public Health 9: 103.
32. Adam M, Johnson L (2009) Estimation of adult antiretroviral coverage in South Africa. South African Medical Journal 99: 661–667.
33. Engelbrecht M, Bester C, Van den Berg H, Van Rensburg H (2008) A study of predictors and levels of burnout: the case of professional nurses in primary health care facilities in the Free State. South African Journal of Economics 76: S15–S27.
34. Uebel K, Fairall L, Van Rensburg D, Mollentze W, Bachman M, et al. (2011) Task shifting and integration of HIV care into primary care in South Africa: the development and content of the streamlining tasks and roles to expand treatment and care of HIV (STRETCH) intervention. Implementation Science 6: 86.
35. English R, Bateman E, Zwarenstein M, Fairall L, Bheekie A, et al. (2008) Development of a South African integrated syndromic respiratory disease guideline for primary care. Primary Care Respiratory Journal 17: 156–163.
36. Fairall L, Zwarenstein M, Bateman E, Bachman M, Lombard C, et al. (2005) Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomized controlled trial. British Medical Journal 331: 750–754.
37. Oakley A, Strange V, Bonell C, Allen E, Stephenson J, et al. (2006) Process evaluation in randomized controlled trials of complex interventions. British Medical Journal 332: 413–416.
38. Georgeu D, Colvin C, Lewin S, Fairall L, Bachmann M, et al. (2012) Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial. Implementation Science 7: 66.
39. Colvin C, Fairall L, Lewin S, Goergeu D, Zwarenstein M, et al. (2010) Expanding access to ART in South Africa: The role of nurse-initiated treatment. South African Medical Journal 100: 210–212.
40. Fairall L, Bachmann M, Lombard C, Timmerman V, Uebel K, et al. (2012) Task shifting of antiretroviral treatment from doctors to primary care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised controlled trial. The Lancet 380: 889–898.
Is the Subject Area "HIV" applicable to this article?
Is the Subject Area "Primary care" applicable to this article?
Is the Subject Area "Nurses" applicable to this article?
HIV diagnosis and management
Is the Subject Area "HIV diagnosis and management" applicable to this article?
Antiretroviral therapy
Is the Subject Area "Antiretroviral therapy" applicable to this article?
Is the Subject Area "Analysis of variance" applicable to this article?
Is the Subject Area "Treatment guidelines" applicable to this article?
Is the Subject Area "Health services research" applicable to this article?


Inside is new car issues for January; new airplane issue in February from the High Tech Aircraft Series; and new cars fro March. . Model Ships ; Model Railroads; Model Airplanes; Tiny Town Bldgs.
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Eco-profiles form part of Life-Cycle Assessment (LCA). Whereas LCAs are cradle-to-grave analyses of the environmental impact of a product, eco-profiles stop at the factory gate ("Cradle-to-gate"). The eco-profiles of PVC were fully updated in 2015.
The key impacts calculated in these eco-profiles are aggregated according to a standard methodology and published in Environmental Declarations. These Environmental Declarations are similar to an Environmental Product Declaration (EPD) but, as PVC resin is not a finished product, the term Environmental Declaration is more appropriate.
PVC production processes have been continually improved in recent years and their environmental impact steadily reduced. The European PVC industry recognises that, along with all other manufacturing industries, it must pursue continual environmental improvement.
Eco-profiles and environmental product declarations for PVC and VCM.


Gummy vitamins make health fun!
Taking a MegaFood supplement and putting it in chewable gummy vitamin format is a no brainer!
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Give healthy gummy vitamins a try!


text:
Patoka Lake Winery
Wines/
Tasting Room/
Lodging/
Event Space/
Directions/
Dash for the Glass 5K supports Local Military surrounding Patoka Lake
December 12, 2017 / Patoka Lake Winery/ Rachel Lorett
On November 4th, 194 racers trekked through Newton-Stewart State Recreation Area (better known as the property surrounding Patoka Lake) in honor of current troops and Indiana veterans. The idea for a 5K began as a desire to bring people out to Patoka Lake Winery on an autumn afternoon and quickly grew to a race with a mission to serve those who continually serve.
The cause hit home for many, including State Representative Stephen Bartels, co-owner of Patoka Lake Winery. "Having a father killed in Vietnam, my 22 years of Military service and now a son serving as a combat medic has given me a deep sense of duty to help our veterans in need, and also extend that support to the families" shared Representative Bartels. The goal of the 5K was to send a resounding Thank you! to the veterans, spouses, children, and other family members who sacrifice before during and after deployment.
"We wanted this to be more than a run. We wanted people to love the event so that we can continue to raise support year after year," says Race Director, Rachel Lorett. "I didn't foresee the huge amount of support and community involvement we ended up with; it's amazing."
With almost 30 sponsors, multiple volunteers, and additional staff working to make the day a success, the race commenced with an after-party inside Patoka Lake Winery's event center. Food vendors offered hot samples of their products while music kept the crowd entertained. Ages of racers included 5th graders all the way to over 61. Those 21 and over received a glass of wine after crossing the finish line.
Following the race, Patoka Lake Winery donated the proceeds (over $3,500 divided evenly) to three different organizations: HHC 1-151 Family Readiness Group, Honor Flight Southern Indiana, and Team Red White & Blue. The Ferdinand/Jasper chapter of Team Red White and Blue will receive two electric clay target throwers and supplies for their social gatherings to promote connections between veterans and the local community.
Mark your calendars for next year's race: Saturday, November 3rd, 2018
December 12, 2017 / Patoka Lake Winery/ Rachel Lorett/
5K, Dash for the Glass, 2017, Local Military
Rachel Lorett
Not Just Another 5K
September 19, 2017 / Rachel Lorett
Did you know there's a 5K happening on Saturday, November 4th at Patoka Lake Winery? Wine and running, sure they go together. But why a 5K? There are plenty of races to choose from in Southern Indiana. In answer to the "why", imagine this:
You find out that your spouse's job is going to take them to a dangerous part of the world for about a year. No exact length of time, just a time frame. This is the farthest distance and longest time you've been apart in 26 years of marriage. Your spouse will be armed; you're thinking it's time you're armed, or it's at least time to get a big dog. And the out-of-state training begins next month. Oh, and you're raising a teenager.
This is your neighbor's story, your best friend's news, your nephew's announcement. This is why we run. The sudden seemingly single parent households. Even if we don't experience it the same way- all the stress, anxiety and fear associated with the upheaval of deployment and reintegration- we run to support. We are for connection and community.
We race to say, "We know your soldier isn't the only one sacrificing."
We can't say thank you enough for giving up the shared memories of birthdays, anniversaries, school performances, ball games and holidays with your loved one for this period of time. Thank you for sharing your family for all of our families. We live in the land of the free because of ALL the sacrifices made.
This one's for you, Momma. Thanks for your patience, your courage and your strength before, during and after Dad's deployment.
Who are you running for?
November 4th, 2017 2PM
Sign Up at http://getmeregistered.com/DashfortheGlass5K
September 19, 2017 / Rachel Lorett/
5K, Dash for the Glass, 2017
Patoka Lake Winery (open since June 2016) offers a wine tasting room open to the public, winery tours, winery lodging, event space, and gift shop. Located just outside the main entrance to Patoka Lake (Newton-Stewart SRA).
Current Winery Hours
Sunday - Thursday 11am-8pm
Friday & Saturday 11am-10pm
To Schedule a Large Group Tasting/Tour, email us!
Thank you! You will hear from us shortly.
Copyright 2016-2019 All rights reserved.
Site maintained by The Technological Edge, Inc.

redpajama_set_name: RedPajamaCommonCrawl


text:
Budweiser Gardens Tickets
99 Dundas St, London, ON
About The Venue Budweiser Gardens Events
Budweiser Gardens Tickets On Sale
Harry Potter and the Prisoner of Azkaban (Rescheduled from 5/23/20)
Sat, Mar 27 at 7:30 PM | Budweiser Gardens | London
Kane Brown (Rescheduled from 3/21/2020, 8/28/2020)
Sat, Apr 10 at 7:00 PM | Budweiser Gardens | London
Wed 7:30 PM
Randy Bachman (Rescheduled from 7/22/2020)
Wed, Jun 30 at 7:30 PM | Budweiser Gardens | London
Sun 3:00 PM
Jeff Dunham (Rescheduled from 3/18/2020, 7/12/2020, 11/18/2020)
Sun, Jul 11 at 3:00 PM | Budweiser Gardens | London
Thu 7:30 PM
Thu, Aug 26 at 7:30 PM | Budweiser Gardens | London
James Taylor with Bonnie Raitt (Rescheduled from 4/25/2020)
Thu, Sep 23 at 8:00 PM | Budweiser Gardens | London
99 Dundas St London ON N6A 6K1
Budweiser Gardens Info
Budweiser Gardens is a sports event venue in London Ontario, Canada. With a seating capacity that can range from 9000-10,200, it is the largest center of its kind in southwestern Ontario. The venue opened in 2002 and was originally named John Labatt Center after John Labatt, founder of the London Brewery. It later changed its name to Budweiser Gardens. The center was built to be the downtown home of London Ontario Hockey League team, the London Knights. It is currently home to London's National Basketball League of Canada team, the London Lightning.
The Budweiser Gardens 2021 event schedule includes Doobie Brothers, James Taylor and Jeff Dunham. TicketSales.com has the largest inventory of Budweiser Gardens tickets, so keep checking for great deals on resale tickets.
London Activities
Looking for fun activities in London? Explore exciting activities in London including Air, Helicopter & Balloon Tours, Classes & Workshops, Cruises, Sailing & Water Tours, & more!


What is Root Canal Therapy / Root Canal Treatment?
Root Canal Therapy / Root Canal Treatment is the removal of the infected soft tissue within the tooth and its replacement by a suitable neutral and bio compatible material. This procedure basically saves the tooth and eliminates dental pain.
Q) Why and when is root canal therapy/root canal treatment required?
A) Root Canal Therapy / Root Canal Treatment can be done in a single or more sittings. The number of appointments depends upon the condition of the tooth infection and is also dictated by the response from the patient. Permanent filling are only done when patients are completely devoid of any pain or infection.
Q) Is root canal therapy / root canal treatment procedure painful?
A) Root Canal Therapy / Root Canal Treatment do not cause pain; in fact it relieves it.
Q) How long does the root canal therapy / root canal treatment takes?
A) Decay of the teeth (cavities) if left untreated, generally progress and gradually destroy a significant portion of the tooth before reaching the 'pulp' of the tooth. The pulp of the tooth is a thin soft tissue present in the tooth canals consisting of mainly nerves and blood vessels. Once this infection reaches the pulp it gives rise to a common 'dental pain'.


The story is set in the near future, in a corrupt city called Moebius, where the gap between rich and poor is growing bigger and bigger.
The heroine is a 'Hunter', someone who has chosen to oppose the criminals who have sullied their hands with illegal deeds and have gained money as a result. Hunters work for 'Bountia', an organization that takes assignments to catch criminals in the city for rewards. Armen Noir is the heroine's codename in Bountia, and her real name is Naska. The thing is, despite her being an A class hunter, she cannot kill anybody. She rose to A rank because she has been able to defeat her enemies well without having to kill them.


text:
Vita

Nata a Newcastle-under-Lyme, nella contea dello Staffordshire, Vera era la figlia di una benestante famiglia che possedeva delle industrie cartiere ad Hanley e a Cheddleton. A 18 mesi la sua famiglia si trasferì a Macclesfield, nello Cheshire, e a 11 anni si trasferisce di nuovo, a Buxton, nello Derbyshire. All'età di tredici anni frequenta il collegio di S. Monica a Kingswood, nel Surrey. Successivamente studia letteratura al Somerville College di Oxford dove Vera conosce, grazie alle amicizie universitarie di suo fratello Edward, il grande amore della sua vita, Ronald Leighton. Dopo un anno, nell'estate del 1915, lascia gli studi per arruolarsi come infermiera nella V.A.D. (Voluntary Aid Detachment) durante la prima guerra mondiale. Guerra che coinvolse il fratello e il fidanzato, entrambi arruolatisi come volontari nell'esercito britannico: il primo si unì al Reggimento Sherwood Foresters, il secondo al Reggimento Worcestershire.

Durante la Grande Guerra, il suo fidanzato Roland, altri due intimi amici, Victor Richardson e Geoffrey Thurlow e suo fratello Edward, rimangono uccisi. Le loro lettere le daranno lo spunto per scrivere il libro Letters from a Lost Generation.

Tornata ad Oxford dopo la guerra, Vera trovò delle difficoltà di adattamento alla vita tra la generazione del dopoguerra. Fu in questo periodo che incontrò Winifred Holtby, con la quale sviluppò una stretta amicizia. Il legame durò fino alla morte della Holtby, avvenuta nel 1935.

Nel 1925 sposa George Catlin, politologo e filosofo. Il loro figlio, John Brittain-Catlin, nato nel 1927, diventerà artista, pittore, uomo d'affari e sarà l'autore dell'autobiografia Family Quartet, pubblicata nel 1987. La loro figlia, Shirley Williams, nata nel 1930, divenne invece ministro.

Opere
Il primo romanzo pubblicato da Vera fu The Dark Tide (1923). Nel 1933 pubblica Testament of Youth a cui farà seguito, nel 1940, Testament of Friendship e Testament of Experience nel 1957. Molti dei suoi romanzi si basano su esperienze reali e persone reali. A questo proposito il romanzo Honourable Estate (1936) è più di un libro di memorie.

La sua vocazione al pacifismo viene alla ribalta durante la seconda guerra mondiale, quando scrive le Letters to Peacelovers. Venne però accusata quando nel 1944 scrisse Massacre by Bombing dove si lamentava a proposito dei bombardamenti a tappeto sulle città tedesche.

Nel novembre 1966 cadde in una strada male illuminata di Londra. Le lesioni che ne riportò furono causa di un forte declino fisico che le impedi' anche di continuare a scrivere.

La morte

La scrittrice visitò spesso il cimitero militare inglese situato a Louvencourt, in Francia, dove si trova la tomba del fidanzato Roland.

Quando morì a Wimbledon il 29 marzo 1970, la sua volontà fu che le sue ceneri fossero disperse sulla tomba del fratello Edward sull'Altopiano di Asiago, in Italia - "... per quasi 50 anni gran parte del mio cuore è rimasto in quel cimitero del paese italiano" disse. Sua figlia ha onorato questa richiesta nel settembre del 1970.

Note

Bibliografia
 Alessandro Gualtieri, La Grande Guerra delle Donne, Mattioli 1885, Milano

Voci correlate
Cheryl Campbell
Barenthal
Cimiteri di guerra dell'Altopiano dei Sette Comuni

Altri progetti

Collegamenti esterni

Brittain
Brittain

redpajama_set_name: RedPajamaWikipedia


text:
U.S. Sugar Policy
Sugar's Coast-to-Coast Reach
Meet America's Sugar Producers
Sugar Sustainably
Foreign Subsidies Threaten U.S. Farms and Jobs
Idaho Grower Trailblazes Industry-Changing Technology
July 22, 2019 /in People, Products, Sugar Sustainably /by ASA
Duane Grant never set out to be an agricultural pioneer. He just wanted to continue the family farm and make his dad proud.
Grant grew up on his father Douglas's farm in Southern Idaho and contributed from an early age, eventually joining the operation full-time after high school.
Since he joined the operation in 1980, he has become the CEO of Grant 4-D Farms and guided a more than 50-fold increase in the farm's size and production. Grant 4-D Farms grows sugarbeets, potatoes, seed potatoes, wheat, malt barley, corn, and hay on its farms in Southern Idaho and Eastern Oregon.
"Hard work and technology fueled the growth," said Grant, who is also the chairman of Amalgamated Sugar Company.
And no technology has been as revolutionary as sugarbeet seeds that are bioengineered to resist weed-killing herbicides – a process commonly called GMO. Grant credits the invention with reducing the industry's environmental footprint as well as saving countless farms from ruin.
"My family has been involved in agriculture since migrating from Scotland more than 100 years ago," Grant said. "We are now seeing the next generation working on our family farms, and it is an incredible feeling to know that thanks to advancements like biotechnology our operations can continue to contribute to the local economy and the nation's food supply."
Like many farms in his area, sugarbeets are at the heart of Grant's operation. But the crop was becoming harder and harder for families like his to produce.
"Beets are a nightmare to grow because of weeds," he explained. "Sugar farmers can go bankrupt if they can't successfully control weeds. That used to mean a rigorous regimen that required lots of money, lots of chemicals, and lots of people working long hours."
So, in the early 2000s, Grant dedicated himself to bringing the same GMO technology to sugarbeets that was benefitting corn and soybean farmers.
Numerous field trials testing genetically-modified beets were conducted on Grant's farm. He was one of the first farmers who agreed to take the leap of faith and commercially plant a GMO sugarbeet crop in 2007. And, he was deeply involved with a U.S. Department of Agriculture advisory committee charged with charting a course for the future of biotechnology.
By 2008, other sugarbeet farmers were eager to enjoy GMO's benefits, and nearly 60 percent of U.S. beet production had shifted. Just one year later, bioengineered seeds accounted for 95 percent of the nation's sugarbeet crop.
Since the introduction of GMO sugarbeet seed, Grant said per acre productivity has accelerated to the point where growers associated with Amalgamated Sugar get twice as much production from less than half the amount of inputs they did 15 years ago.
This means less spraying of herbicides; less tilling and stripping of the land, which leads to erosion; and less need for costly farm equipment that burns fossil fuels.
"When I was a kid, the valley where we grow used to turn brown from wind-blown soil erosion caused by traditional sugarbeet tillage practices." Grant said. "That doesn't happen anymore…we stay green and it's thanks to the genetically modified seed."
In fact, scientific studies show that bioengineered sugarbeets have reduced ecotoxicity and environmental risk by 92 percent and 98 percent respectively. And this technology has enabled farmers to utilize better farming practices that have cut soil-derived carbon emissions by 80%.
And with sugar prices low and stagnating, and with production costs climbing, the development of GMO sugarbeet seed also helped alleviate the economic squeeze of weed control that was crippling Grant and his neighbors.
In short, more sugarbeets are being produced on less land, and it's being done in a more economical and environmental way.
"Best of all, when the natural sugar contained in beets is extracted during the refining process, the resulting table sugar is identical to sugar from non-GMO beet or cane sugar," Grant said, "which is important to some consumers."
Grant is astonished when he sits back and thinks about how far his farm and the industry has come in just the past decade.
"It's fitting to describe the journey as a 'tough row to hoe,'" he said of the farming metaphor used to describe a challenging task. "But it's been well worth it. We've saved farms, helped families, and improved the environment by making sugar more sustainable."
Needless to say, his father would be proud.
https://sugaralliance.org/wp-content/uploads/2019/07/iStock-497143238.jpg 1414 2121 ASA https://sugaralliance.org/wp-content/uploads/2021/01/ASA_logo_COLOR_221x70.png ASA2019-07-22 07:19:372021-02-21 09:14:20Idaho Grower Trailblazes Industry-Changing Technology
Sugarbeet Co-Products Fuel Champions and Create Opportunities
And the winner of this year's Kentucky Derby is _____________.
Regardless of the name filling in the blank, chances are good that a race-day food derived from sugarbeets powered them across the finish line. That's because most Kentucky Derby participants, including Triple Crown champion American Pharoah, feast on sugarbeet pulp before heading to the starting gate.
Pulp is the tissue of the beet left over after sugar is extracted, and it's prized in equine circles as a dietary additive because it is fiber-rich, full of energy and aids digestion.
Midwest Agri-Commodities is a California-based company that sells beet pulp on behalf of four sugarbeet cooperatives in Michigan, Minnesota and North Dakota. Each year, they market 1.7 million tons of sugarbeet co-products for U.S. farmers.
"A big percentage of our business is feed, and there's a lot that goes into it," explained Andy Ford, the company's president.
Beet pulp isn't exclusively used by prized thoroughbreds. Beef cattle, dairy herds, pigs and other livestock all eat it, and you can find the pulp in many pet foods. Pulp is shipped to farms and feedlots in many forms, too, including pellets and shreds – the dried, non-pelleted form of pulp most favored by horses.
"Our entire company is rooted in sustainability – in repurposing leftovers to help sugar farmers use every part of their crop and make a little extra money during the tough times," Ford explained.
And this U.S. sustainability story stretches to the far corners of the globe.
Japan is the biggest importer, buying 190,000 to 200,000 tons of sugarbeet pulp every year for its dairy industry.
"We are the dominant supplier to Japan, and we are in the process of replicating that success elsewhere," said Ford, who was born and raised in Japan and has a background in logistics.
Europe and Northern Africa are areas where Midwest Agri-Commodities also has a strong presence. Exploring and expanding into new markets is a big company goal.
A recent collaborative effort, involving many within the U.S. sugar industry, resulted in America becoming the first country to gain import approval for sales into China. Midwest Agri-Commodities sent 70,000 tons to China's livestock sector in 2018 before ongoing trade disputes stalled further sales.
"I take pride when I market internationally in knowing that America's beet pulp quality and reputation is unmatched," Ford said.
The company often sees a premium price for its exports, and Ford said the Made-In-America brand is the reason.
"Our quality and the dependability of our delivery logistics set us apart," he said, "and it's why I'm so bullish about the future of these sustainable products."
There's good reason to be confident because, in addition to feed, Midwest Agri-Commodities and others in the sugar industry are investing in research and constantly finding new and inventive uses of sugarbeet and sugarcane waste.
Pulp is being used as mulch for mushroom production, de-sugared liquid removed from beets is used in the construction industry to make adhesives and concrete hardener, and beet juice is even being applied to roads throughout the United States, including Washington, D.C., to melt away ice and snow.
Ford thinks that's just the beginning of what's possible.
Beet byproducts are in development for things as varied as sports drinks, cosmetics, paint and even a replacement for Styrofoam containers.
"Sugar has an exceptional sustainability story to tell," he concluded. "We've been focused on it a long time, and as long as a strong U.S. sugar policy remains in place, I think we'll be supplying consumers with world-class sugar and co-products for a long time to come."
https://sugaralliance.org/wp-content/uploads/2019/09/kentuckyderby.jpg 836 1254 ASA https://sugaralliance.org/wp-content/uploads/2021/01/ASA_logo_COLOR_221x70.png ASA2019-07-22 07:15:532021-02-21 09:14:44Sugarbeet Co-Products Fuel Champions and Create Opportunities
COPYRIGHT © 2021 AMERICAN SUGAR ALLIANCE. ALL RIGHTS RESERVED.


text:
const PlotCard = require('../../plotcard');

class UneasyTruce extends PlotCard {
    setupCardAbilities(ability) {
        this.persistentEffect({
            condition: () => !this.game.isDuringChallenge(),
            match: card => card.getType() === 'faction',
            targetLocation: 'faction',
            targetController: 'any',
            effect: ability.effects.cannotGainPower()
        });

        this.forcedReaction({
            when: {
                onChallengeInitiated: event => event.challenge.attackingPlayer.faction.power > 0
            },
            handler: context => {
                let {attackingPlayer, defendingPlayer} = context.event.challenge;
                this.game.addMessage('{0} is forced by {1} to move 1 power from their faction to {2}\'s faction', attackingPlayer, this, defendingPlayer);
                this.game.movePower(attackingPlayer.faction, defendingPlayer.faction, 1);
            }
        });
    }
}

UneasyTruce.code = '11060';

module.exports = UneasyTruce;

redpajama_set_name: RedPajamaGithub


text:
Q: SQL Server Reports Builder - Week Number from Today() I am trying to create a calculated field in SQL Server Reports Builder of which the output is Week Number (e.g. 1, 12, 32, 45, etc...) and am using the following expression:
=DatePart("ww",Today())
I am getting a result of "99".  What am I doing wrong?

A: Roman Pelepei has a great Article on this.
This should do the trick.
=DatePart(DateInterval.WeekOfYear, Today())
You may have to use Now() instead of Today() but it will work all the same.

A: Try = DATEPART(WEEK,GETDATE())

redpajama_set_name: RedPajamaStackExchange


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WIMBLEDON, England (AP) — Simona Halep's Wimbledon championship lifted her from No. 7 to No. 4 in the WTA rankings on Monday, while runner-up Serena Williams moved up one spot to No. 9, her best…
Strycova wins doubles title after semifinal loss in singles
WIMBLEDON, England (AP) — Three days after losing in her first major semifinal in singles, Barbora Strycova won her first major title in doubles. Strycova and Hsieh Su-wei won the women's doubles at Wimbledon on…
Federer comes so close to 9th Wimbledon title before losing
WIMBLEDON, England (AP) — Roger Federer won more points than Novak Djokovic in the Wimbledon final. Federer was the first of the pair to come within a point of taking the championship Sunday, too. Had…
WIMBLEDON, England (AP) — For nearly five tight, tense and terrific hours, Novak Djokovic and Roger Federer traded the lead, playing on and on and on until an unprecedented fifth-set tiebreaker was required to settle…
The Latest: Djokovic beats Federer in Wimbledon final
WIMBLEDON, England (AP) — The Latest at Wimbledon (all times local): 7:08 p.m. Novak Djokovic has won his fifth Wimbledon title, beating eight-time champion Roger Federer in a fifth-set tiebreaker after saving two match points.…
Novak Djokovic wins 5th Wimbledon title, beats Roger Federer in 5th-set tiebreaker
WIMBLEDON, England (AP) — Novak Djokovic wins 5th Wimbledon title, beats Roger Federer in 5th-set tiebreaker.
The Latest: Halep says Slam losses helped her beat Williams
WIMBLEDON, England (AP) — The Latest at Wimbledon (all times local): 9:15 p.m. Simona Halep figures her past problems in Grand Slam finals allowed her to come through against Serena Williams at Wimbledon. Halep lost…
Seeking 9th Wimbledon title, Federer faces Djokovic in final
WIMBLEDON, England (AP) — If Roger Federer's going to win a record ninth championship at Wimbledon, he'll need to follow up a victory over Rafael Nadal with one over defending champion Novak Djokovic. Federer has…
Djokovic wins longest point ever recorded at Wimbledon
WIMBLEDON, England (AP) — Going by the number of strokes, it was the longest point ever recorded at Wimbledon. And for Novak Djokovic, it went a long way toward putting him into another final at…
WIMBLEDON, England (AP) — After waiting 11 years to get another shot against Rafael Nadal at Wimbledon, Roger Federer was so, so close to the finish line. One match point slipped away when Federer missed…


But in the meantime, Long has not popped the question yet, according to the actress' rep, who told E! News that Barrymore's status update on Facebook reading, "I'm engaged," means nothing.
"Not true," the rep said.
Their relationship seems just fine and dandy in the meantime, however.
A tuxedoed Long was on Barrymore's arm at both the Golden Globes and SAG Awards this month, where she scooped up wins for her role as Little Edie Beale in the HBO movie Grey Gardens.
Before Oscar watch takes over, relive some of the glamour from the 2010 Screen Actors Guild Awards in our Arrivals gallery.


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Arsenal on brink of Europa League knockout rounds
The Gunners play host to the 1991 European Cup winner Red Star Belgrade, in north London, a fortnight after Olivier Giroud's remarkable late goal secured a 1-0 win in Serbia.
02 November, 2017 21:03 IST
Arsenal is top of Group H with maximum points and simply avoiding defeat against Red Star Belgrade could be enough for it to progress to the last 32. - Getty Images
Having made a perfect start to its Europa League campaign, Arsenal can secure a place in the knockout phase with two group games to spare by beating Red Star Belgrade on Thursday.
The Gunners play host to the 1991 European Cup winner in north London a fortnight after Olivier Giroud's remarkable late goal secured a 1-0 win in Belgrade.
Having also got the better of Cologne and BATE Borisov, Arsene Wenger's side is top of Group H with maximum points and simply avoiding defeat against the Serbian league leader could be enough for it to progress to the last 32.
For a side growing in confidence after four straight wins in all competitions, another victory should not be too much to ask, even if Wenger will again rotate his squad with one eye on Sunday's Premier League clash with Manchester City.
Everton, the other English side in the competition, is in a rather less favourable position as it heads to France to take on Lyon.
Languishing in the relegation zone in the Premier League and without a permanent manager since the sacking of Ronald Koeman last week, the Toffees could be eliminated from Europe on Thursday.
Such a scenario will arise if it loses and Group E leader Atalanta avoids defeat in its game against Apollon Limassol in Cyprus.
It has been a miserable continental campaign so far for Everton, which was held at home by Apollon either side of a defeat to Atalanta and a 2-1 home loss to Lyon last month.
It has lost both games so far under caretaker manager David Unsworth, following a 2-1 reverse at Chelsea in the League Cup with a 2-0 Premier League defeat at Leicester City, but youngster Dominic Calvert-Lewin put a positive spin on things ahead of the trip to France.
"The match at Chelsea showed we have those good performances in us, then in the second half against Leicester they had a two-goal cushion but we were trying to break them down for the full 45 minutes and were the better side," he told the club's website.
"If we can keep bringing that intensity and standard of play to our performances, then we will win games."
However, unbeaten in seven and fresh from four straight wins, Lyon is in formidable form and is determined to go all the way to the final which will be held at its own Groupama Stadium.
Among the other clubs which could secure qualification for the last 32 with two games to spare on Thursday are Dynamo Kiev, Lazio and Zenit St Petersburg.
Surprise Swedish side Ostersund -- coached by Englishman Graham Potter -- will extend its run in Europe into the New Year with the right combination of results as it visits Athletic Bilbao.
Meanwhile, in the midst of a poor run of form in Serie A, AC Milan is also in a position to progress to the last 32 with a win against AEK Athens in Greece in Group D.
But it must do so without Argentina midfielder Lucas Biglia, who has been ruled out with a knee problem.
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BMW X3 Facelift Gets A Launch Date!
Home Modified Bikes This Retro Styled Honda CBR 400RR is an Agonisingly Desirable Baby Blade
This Retro Styled Honda CBR 400RR is an Agonisingly Desirable Baby Blade
November 21, 2017 | Amit Chhangani
Added in: Modified Bikes
The CBR400RR or the Baby Blade was one hell of a machine for its time. Packing in an inline-four engine setup within a compact 400cc displacement, it was a firecracker of a machine, and was properly capable of hitting 200 km/h. We once had the privilege of riding this beauty and the time we had is etched in our memories forever. So when we received this email from a youngster duo who had painstakingly recreated their own rendition of the legendary machine, replete in Rothman's livery, we were compelled to share the story with you.
Nishanth Patel
Piyush Verma
Piyush Verma a mechanical graduate, and his friend Nishanth Patel, decided to build a bike after their final semester. The duo was a part of an off road racing team which they founded and competed under the name of for 3 years at the SAE BAJA. However, when college ended and the placements started, all the companies that came in to recruit were primarily from the IT sector. Oriented towards the mechanical engineering stream, computers and software wasn't something that appealed to metal junkies. So to pursue their love for handmade motorcycles, they set out to create a custom machine.
Nishanth had a CBR 400 RR also known as the NC 29 and it came across as the perfect canvas for the platform since the original body was in bad shape owing to the negligence of the previous owner. They wanted it to have a retro look, and stand out among a sea of modern, edgy machines.
To carve out their desired shape in metal, the two friends made a cardboard template and then made the entire shape out of aluminium. All those panels, which are a prominent departure from the lines of the original, have been handmade using a flat sheet of Aluminium. The entire chassis was buffed for a mirror finish including the swing arm. The bike retains its original head lights though.
The finished custom 400RR also has a free-flow exhaust, blue racing hose pipes, custom wiring and racing brake lines. Since the bike was retro styled, Nishanth decided to go for the old school Rothman's Honda paint scheme. The paint job was carried out at Fusion Kustoms.
The duo believes that this is a one of its kind custom CBR400RR in India since it's a rare machine, and those who have it also want to maintain its original styling and livery. While it's a small beginning for the two friends, it's impressive nonetheless. We wish the two grease monkeys all the best for their future.
Check out some more images of the machine in the gallery below.
G_SupragnaK says:
Great work.. guys Nishant and Piyush


The Blue Brain project is a mammoth scientific undertaking that aims to "build a biologically detailed digital reconstruction of the rodent, and ultimately the human brain." Historically, the project has the potential to stand beside other major achievements in neuroscience and advance our understanding of the brain in giant leaps.
But, what exactly will these new discoveries tell us about minds? About humans and our experiences? This is where I think a bit of philosophy comes into play, whether anyone likes it or not. Some recent pieces illustrate this nicely.
Will You Ever Be Able to Upload Your Brain?
"Much of the current hope of reconstructing a functioning brain rests on connectomics: the ambition to construct a complete wiring diagram, or "connectome," of all the synaptic connections between neurons in the mammalian brain. Unfortunately connectomics, while an important part of basic research, falls far short of the goal of reconstructing a mind, in two ways.
Philosophers have been arguing for centuries about issues of brains, bodies, minds, and subjective experience, and as some, such as Alva Noë and Evan Thompson, have stated, modern neuroscience has rather taken for granted that understanding brains will equate to understanding minds.
So what would it mean to duplicate or upload a brain? Could we ever 'backup' a brain to the cloud like we do with a laptop, or 'update' a brain as easily as we update an iPhone to the latest iOS? What might this 'about' information capture and enable us to manipulate? Could chronic pain be simply a 'bug' that can be fixed by deleting and re-installing an app? Science Fiction has attempted to answer these questions, but I don't think any one has even the first clue as to what an answer might even look like.
In 2016, FIVE great speakers, over THREE big days will take you on an unforgettable journey into, and around, brains, bodies, minds, people and more, at ONE big EP3 event. Click on the image below for all the details and to purchase your ticket now.
Lots of juicy thoughts in that post Tim! For now, just as I am about to teach, the reminder that "information about the brain is not the same as information in the brain" is very helpful.


The IOPTWH newsletter editor produces a newsletter for members twice a year. This is distributed via the member organization delegates and friends.
Copies of all IOPTWH newsletters are available to view or download from this page.


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Home » Your Health » Hepatitis C: Symptoms, Causes, and Treatment
Hepatitis C: Symptoms, Causes, and Treatment
By: Katherine George on	Tuesday, May 7th, 2019
About 3.9 million people in the United States suffer from the hepatitis C virus (HCV), according to WebMD. Even though this disease is now curable if treated with medication, unfortunately it also exhibits very few symptoms, which means people don't realize they have it until more serious damage is done. In some cases it can take up to a few decades for any warnings to present themselves.
You've probably heard of hepatitis A and B because we have vaccines to protect ourselves from these infections. Unfortunately, there is no vaccine to protect us from hepatitis C and the virus is highly contagious, says Healthline. Researchers continue to work towards hopefully creating a vaccine.
To stop this virus from spreading and protect ourselves, we need to get better informed on the topic. This article dives into everything there is to know about hepatitis C, including the symptoms, causes, risk factors, and available treatments…
1. What is Hepatitis C?
Hepatitis C is something most of us have heard about, been warned about, and might even know someone who's contracted it, but do we really know what it is? If the answer to that question is no, then don't worry! We'll do our best to explain it here…
The Mayo Clinic writes that hepatitis C is a viral infection that is caused by the hepatitis C virus and can lead to liver inflammation, as well as more serious liver damage. It is most commonly spread through contaminated blood, but we'll get into the details of how later.
2. Chronic vs. Acute Hepatitis C
There are two types of hepatitis C: acute and chronic. The Mayo Clinic describes chronic hepatitis C as a long-term infection. Every chronic infection has an acute phase, but not every acute hepatitis C infection becomes chronic. "Some people clear HCV from their bodies after the acute phase, an outcome known as spontaneous viral clearance," writes the Mayo Clinic. "In studies of people diagnosed with acute HCV, rates of spontaneous viral clearance have varied from 14 to 50-percent."
Healthline also helps explain by defining the two on how they develop. Acute hepatitis C sets in quickly and can last a few weeks, whereas chronic hepatitis C develops slowly over a long period of time and will often not show any signs or symptoms. It's estimated by the World Health Organization (WHO) that roughly 71 million people have chronic hepatitis C.
3. Common Symptoms
Chronic hepatitis C is often described as a "silent infection" because it doesn't usually present any symptoms until the infection has become so severe that it has spread to the liver and the body begins showing signs of liver damage. Acute hepatitis C is similar in the sense that it often goes undiagnosed because it also presents no symptoms, and when they do appear, the Mayo Clinic writes that they'll show up one to three months after acquiring the infection and can last anywhere from two weeks to three months.
The Centers for Disease Control and Prevention (CDC) predicts that about 70 to 80-percent of people with hepatitis C do not experience any symptoms. This percentage does leave a small group of people who do have some mild to severe symptoms which include: "clay-colored poop, dark urine, fever, fatigue, jaundice, joint pain, loss of appetite, nausea, stomach pain," and vomiting, writes WebMD.
Healthline points out that while the symptoms of hepatitis C are the same for men and women, for some reason men are less likely to be able to fight the infection than women. In the case of men, the infection tends to stay in their body for longer and is more likely to show symptoms.
4. Genotypes
As we've already mentioned, hepatitis C is caused by the hepatitis C virus which spreads through blood contamination. The Mayo Clinic explains that in addition to being divided into acute and chronic, HCV can exist in different forms which are referred to as genotypes.
Their are six different genotypes are referred to as type 1 through 6. The source notes that the most common type in North America and Europe is type 1, but type 2 and 3 are also present in some parts of the United States and Europe, however it's less common. "Both type 1 and type 2 have also spread through much of the world, although other genotypes cause a majority of infections in the Middle East, Asia and Africa."
5. Cause: Drug Injections
Drug injections is by far the most common cause of transmitting hepatitis C. According to NHS, 90-percent of hepatitis C cases in the UK have occurred through injected drugs. In fact, the source estimates that half of the people in the UK who use needles to inject drugs will also have this disease.
"The infection can be spread by sharing needles and associated equipment. Injecting yourself with just one contaminated needle may be enough to become infected," writes the source. "It's also possible to get the infection by sharing other equipment to prepare or take drugs — such as spoons, filters, pipes, and straws — that have been contaminated with infected blood."
6. Cause: Unprotected Sex
It's always important to practice safe sex, particularly if you do not definitively know whether or not your partner has been tested. Hepatitis C can be transmitted during unprotected sex, although the NHS notes this risk is relatively low. The risk increases slightly during sex between two men, or if there are genital sores or ulcers from sexually transmitted infections, as well as if one of the people has HIV.
The best way to prevent transmitting hepatitis C through intercourse is by using protection. With long term partners, obviously protection isn't often used, so as long as each person is tested and comes back clear (or has never had any other partners) then the risk disappears.
7. Less Common Causes
Drug injections and unprotected sex are the most common causes of hepatitis C, but there are a few other potential risks. NHS lists blood donations before September 1991 and any blood transfusions and treatment abroad. Today, all donated blood is checked for the virus, but anyone who received a blood transfusion or product before this date could be at risk. Also, treatment abroad might not be held to the same standard, for example the medical equipment might not be sterilized properly.
Other potentially risk situations are sharing personal items that can be contaminated with blood like toothbrushes, scissors and razors. There's also a risk in tattooing and piercing the body if it hasn't be sterilized properly. Most parlors today are held to a high standard so this risk is low, but you should always do your due diligence when it comes to researching a credible vendor.
Hepatitis C can also be transmitted between mother and child if the mother is infected, she can pass it along to her baby. NHS notes this risk is low and only happens in about 5-percent of cases. The last cause that is listed on NHS is needle stick injury. "There's a small — approximately 1 in 30 — risk of getting hepatitis C if your skin is accidentally punctured by a needle used by someone with hepatitis C," writes the source. This risk is really only a concern for nurses, laboratory technicians, and healthcare workers.
8. What are the Risk Factors?
There are several factors that put people at an even higher risk of contracting hepatitis C. Healthline lists at risk people as those who have "received an organ transplant, clotting factor concentrates or other blood products before 1987, received hemodialysis treatment for a long period, had a blood transfusion before 1992, been born to a mother with hepatitis C, had a sexual partner who's infected with hepatitis C," or someone who has used needles that have been used before.
WebMD lists a few other risk factors like someone who's received blood from a donor who had the disease, anyone who has inhaled or injected drugs, long-term kidney dialysis, has HIV, got a tattoo or piercing with unclean equipment, have ever been in prison, has symptoms of liver disease, and lastly but also most importantly, anyone who was born between the years 1945 and 1965.
9. How It Isn't Spread…
Just like any other common virus and infection, there is a lot of misinformation that floats around, not even just on the internet, but also through word of mouth and the spreading of myths. We're here to set the record straight! We've covered the most common ways that hepatitis C is spread, so let's just clear up how it's not spread (in case that was up for debate).
Hepatitis C cannot be spread through kissing, sharing eating utensils, food, or drink, says WebMD. It also cannot be spread through sneezing, coughing, hugging, kissing, holding hands, or any casual contact. Lastly, it cannot be spread through breastfeeding unless the woman's nipples are cracked and bleeding.
10. Complications of Hepatitis C
As we previously mentioned, one of the biggest problems with hepatitis C is that if it goes untreated, it can lead to some pretty nasty complications that become life threatening. Many of the complications associated with the disease are related to the liver.
The Mayo Clinic lists three common complications — the first is scarring of the liver which is also known as cirrhosis. "After 20 to 30 years of hepatitis C infection, cirrhosis may occur. Scarring in your liver makes it difficult for your liver to function," writes the source. The second common complication is liver cancer, however this typically only affects a small number of people. The last one is liver failure which results due to advanced liver cirrhosis. This could lead to the liver failing all together.
11. Some People Can Fight Infection
Before we get into the available treatment for hepatitis C, it's important to note that note everyone needs treatment. According to Healthline, some people have strong enough immune systems that are able to fight the infection and clear it from their body. In this case, the doctor will monitor the state of your liver with regular blood tests.
12. Hepatitis C Treatment
For a long time, hepatitis was treated with weekly injections and oral medications which was good, but it wasn't practical. A lot of patients weren't able to keep up with the treatment because of their other health problems or the unbearable side effects, explains the Mayo Clinic.
Today new medicine has emerged that is game-changing. The source writes, "chronic HCV is usually curable with oral medications taken every day for two to six months." This is great news, but knowing who is infected is still a problem because many people don't realize that they are due to the lack of symptoms.
To help combat this, the U.S. Centers for Disease Control and Prevention (CDC) recommends those who are a heightened risk to receive a one-time screening blood test. The Mayo Clinic writes that the largest at risk group are people born between 1945 and 1965, "a population five times more likely to be infected than those born in other years."
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