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BackgroundScalable PTSD screening strategies must be brief, accurate and capable of administration by a non-specialized workforce.MethodsWe used PTSD as determined by the structured clinical interview as our gold standard and considered predictors sets of (a) Posttraumatic Stress Checklist-5 (PCL-5), (b) Primary Care PTSD Screen for the DSM-5 (PC-PTSD) and, (c) PCL-5 and PC-PTSD questions to identify the optimal items for PTSD screening for public sector settings in Kenya. A logistic regression model using LASSO was fit by minimizing the average squared error in the validation data. Area under the receiver operating characteristic curve (AUROC) measured discrimination performance.ResultsPenalized regression analysis suggested a screening tool that sums the Likert scale values of two PCL-5 questions—intrusive thoughts of the stressful experience (#1) and insomnia (#21). This had an AUROC of 0.85 (using hold-out test data) for predicting PTSD as evaluated by the MINI, which outperformed the PC-PTSD. The AUROC was similar in subgroups defined by age, sex, and number of categories of trauma experienced (all AUROCs>0.83) except those with no trauma history- AUROC was 0.78.ConclusionIn some East African settings, a 2-item PTSD screening tool may outperform longer screeners and is easily scaled by a non-specialist workforce.

In Kenya, approximately one in five girls aged 15-19 years old are pregnant or already a mother. Adolescent girls and young women experience significant mental health vulnerabilities during the pregnancy and postpartum periods, leading to poor antenatal and postnatal care attendance and inferior infant and maternal health outcomes. Pregnant adolescents often experience stigma and disenfranchisement due to their pregnancy status and at the same time lack access to mental health support within health settings, schools, religious institutions, and communities. This paper presents the results of qualitative interviews embedded within the human-centered design (HCD) process used to adapt the Helping Adolescents Thrive (HAT) program for Kenyan peripartum adolescents including young fathers. This qualitative study used two phases. First, a HAT advisory group participated in a series of four workshops to help identify and articulate mental health promotion needs and deepened the team's understanding of youth-centered thinking. Second, qualitative interviews were conducted with 39 pregnant and parenting adolescents to understand their perspectives on mental health prevention and promotion. Pregnant and parenting adolescents articulated different needs including poor support, stigma, and psychological disturbances. Parenting adolescents reported disturbed relationships, managing motherhood, poor health, and social empowerment. Participants highlighted sources of stress including economic challenges, fear of delivery, strained relationships, rejection, and stigma. Participants described psychological disturbances such as feeling stressed, worthless, withdrawn, and suicidal. Coping mechanisms reported by participants included engaging in domestic activities, hobbies, and social networking. Peers, family and spirituality were identified as important sources of support, as well as school integration, livelihoods, support groups and mentorships. Findings from this study can be used to strengthen and adapt HAT program, policy and practice for mental health prevention and promotion for pregnant and parenting adolescents.

Summary: Background: Mental and substance use disorders are a major public health concern globally, with high rates of disability, morbidity, and mortality associated with these. In low- and middle-income countries, such as Kenya, mental health is often given low priority, and resources for the prevention and treatment of mental and substance use disorders are limited. Adolescence and young adulthood are critical periods for the development of mental and substance use disorders, with many disorders emerging during this time. In Kenya, the burden and risk factors of mental and substance use disorders among adolescents and young adults is not well understood. Methods: The data used in this study were obtained from the Global Burden of Disease (GBD) Study 2019. We selected the data on the number of mental and substance use disorders among adolescents and young adults in Kenya from the GBD results tool. The data were extracted by mental health (MH) condition, by age group and by sex. We used descriptive statistical methods to summarise and present the data. Specifically, we calculated the disability-adjusted life-years (DALYs) rates, risk factors of mental and substance use disorders by age group and sex. Findings: In 2019, among 10–24-year-olds in Kenya, mental disorders ranked as the second leading cause of disability, following unintentional injuries, and accounted for 248,936 [95% uncertainty interval 175,033; 341,680] DALYs or 9.4% of 2,656,546 total DALYs. Substance use disorders accounted 15,022 [9948; 20,710] DALYs. Depressive, anxiety, and conduct disorders accounted for the most DALYs of mental disorders accounting for 3.1%, 2.3% and 1.7% of the total DALYs, respectively. The main risk factors for incident DALYs in 10–24-year-olds were bullying and victimization (66.5%). Childhood sexual abuse accounted for 13.7% of the DALYs, lead exposure accounted for 8.5% of the DALYs, intimate partner violence accounted for 11.3% of the DALYs (2%) with all victims being females, and illicit drug use accounted for (52.7%) of DALYs. Interpretation: Improved surveillance of mental health and substance use burden at national and county levels is needed. Focus on timely screening and intervention for idiopathic developmental intellectual disability, conduct disorder, and substance use disorder in young boys and depression, anxiety, and eating disorders in young girls and women is critically needed. Funding: MK is funded by FIC/NIMH K43 TW 010716 and R33MH124149-03. The publication was made possible by funding from the Gates Foundation.

Abstract Growing high-yielding varieties is crucial for successful crop production and maximizing farmers’ net returns. One such example is IR05N221, locally referred to as Komboka rice variety, which was released in Kenya in 2013. On the one hand, Komboka can bridge the gap in rice imports since yields of existing rice varieties do not meet the increasing rice consumption levels of the Kenyan population. On the other hand, it has taken about seven years for Komboka to be appreciated by farmers, necessitating the need to understand farmer preferences when it comes to adopting a new improved variety. We used a mixed-method study approach by combining quantitative and qualitative data collected regionally and locally in both rainfed and irrigated ecologies. When compared to most of the other rice varieties under evaluation, Komboka was high-yielding, early-maturing, and had moderate tolerance to diseases in both rainfed and irrigated ecologies. However, farmers at the regional level ranked Komboka either at the same or lower rank in terms of sensory attributes. At the local level, farmers predominantly grew older and more aromatic Basmati 370 rice variety for sale, as it fetched them more money, with preferences for both men and women rice farmers being the same. Despite Komboka being a high-yielding variety, Mwea rice farmers’ perceptions and preferences for this improved variety were low. While Komboka was equally aromatic, the lack of a ready market dissuaded these farmers from widely preferring the new Komboka variety. We provide prerequisite information that can support the commercialization and promotion of the Komboka variety. We also show that widespread favourable perception of new varieties hinges on matching preferences between breeders’ efforts for improved rice productivity with farmers’ needs for market competitiveness in these new varieties.

Coffee is an important commodity for Kenya, where production is steadily declining, despite a global rise in demand. Of the various constraints affecting production, plant-parasitic nematodes are a significant, but often overlooked, threat. As a perennial crop, treating plantations once infected with nematodes becomes difficult. The current study evaluated the drenching application of two biocontrol agents, Trichoderma asperellum and Purpureocillium lilacinum, for their nematode control efficacy, as well as their impact on the soil nematode community structure on mature, established coffee trees in Kenya. Seven Arabica coffee field trials were conducted over two years on trees of various ages. All the fields were heavily infested with Meloidogyne hapla, the first report of the species on coffee in Kenya. Both fungal biocontrol agents were detected endophytically infecting roots and recovered from soil but not until six months after initial applications. The population densities of M. hapla had significantly declined in roots of treated trees 12 months after the initial application, although soil nematode density data were similar across treatments. Based upon the maturity index and the Shannon index, treatment with T. asperellum led to improved soil health conditions and enrichment of diversity in the microbial community. Application of P. lilacinum, in particular, led to an increased abundance of fungivorous nematodes, especially Aphelenchus spp., for which P. lilacinum would appear to be a preferred food source. The soils in the trials were all stressed and denuded, however, which likely delayed the impact of such treatments or detection of any differences between treatments using indices, such as the functional metabolic footprint, over the period of study. A longer period of study would therefore likely provide a better indication of treatment benefits. The current study positively demonstrates, however, the potential for using biologically based options for the environmentally and climate-smart management of nematode threats in a sustainable manner on established, mature coffee plantations.

Background Health providers' perceived sense of knowledge, competency, and self-efficacy to support the needs of their patients contributes to optimal patient health outcomes. With regards to mental health service delivery in Kenya, this area needs further exploration. Guided by the e-health technology acceptance mode, the needs and preferences of health care providers around mental health training for clinical management and their ability to intervene in peripartum adolescent mental health care are explored. We probed how well-equipped service providers are, their engagement with technology to learn and offer services. The health care provider's technology use preferences were also explored. Method Guided by a human-centered design-focused qualitative inquiry we interviewed 20 specialists around their needs, perspectives, and preferences for digitized mental health screening and intervention. Mean age was 44.2 years, (range of 32–58 years), 25% (5) males and 75% (15) females. After a written consenting process, the online interviews (30−45 min) were conducted in April 2021, once personal information was de-identified interviews were transcribed and coded. Thematic analysis was used and we combined rapid appraisal of Google Jamboard online storyboards to do individual human-centered design personas alongside. Results Our participants were well-exposed to digital technologies. Prohibitive costs of data bundles, lack of funds for consistent online engagement, high workload, and instability of access to appropriate gadgets were found to be barriers to e-health training. Emerging opportunities were well-identified adolescent mental health service and intervention needs, willingness to take online courses offered on learning platforms, and wish for these to be disseminated through diverse social media. Other recommendations were the need to have a user-friendly interface such as data-light engaging and practical materials including animations, short, group-based learning. Conclusion Understanding contextual factors that influence perceived usefulness and ease of use of the remote/digital components would be critical for e-training development and its uptake.

Abstract Background Addressing adolescent pregnancies associated health burden demands new ways of organizing maternal and child mental health services to meet multiple needs of this group. There is a need to strengthen integration of sustainable evidence-based mental health interventions in primary health care settings for pregnant adolescents. The proposed study is guided by implementation science frameworks with key objective of implementing a pilot trial testing a full IPT-G version along with IPT-G mini version under the mhGAP/IPT-G service framework and to study feasibility of the integrated mhGAP/IPT-G adolescent peripartum depression care delivery model and estimate if a low cost and compressed version of IPT-G intervention would result in similar size of effect on mental health and family functioning as the Full IPT-G. There are two sub- studies embedded which are: 1) To identify multi-level system implementation barriers and strategies guided by the Consolidated Framework for Implementation Research (CFIR) to enhance perinatal mhGAP-depression care and evidence-based intervention integration (i.e., group interpersonal psychotherapy; IPT-G) for pregnant adolescents in primary care contexts; 2) To use findings from aim 1 and observational data from Maternal and Child Health (MCH) clinics that run within primary health care facilities to develop a mental health implementation workflow plan that has buy-in from key stakeholders, as well as to develop a modified protocol and implementation training manual for building health facility staff’s capacity in implementing the integrated mhGAP/IPT-G depression care. Methods For the primary objective of studying feasibility of the integrated mhGAP/IPT-G depression care in MCH service context for adolescent perinatal depression, we will recruit 90 pregnant adolescents to a three-arm pilot intervention (unmasked) trial study (IPT-G Full, IPT-G Mini, and wait-list control in the context of mhGAP care). Pregnant adolescents ages 13–18, in their 1st-2nd trimester with a depression score of 13 and above on EPDS would be recruited. Proctor’s implementation evaluation model will be used. Feasibility and acceptability of the intervention implementation and size of effects on mental health and family functioning will be estimated using mixed method data collection from caregivers of adolescents, adolescents, and health care providers. In the two sub-studies, stakeholders representing diverse perspectives will be recruited and focus group discussions data will be gathered. For aim 2, to build capacity for mhGAP-approach of adolescent depression care and research, the implementation-capacity training manual will be applied to train 20 providers, 12 IPT-G implementers/health workers and 16 Kenyan researchers. Acceptability and appropriateness of the training approach will be assessed. Additional feedback related to co-located service delivery model, task-shifting and task-sharing approach of IPT-G delivery will be gathered for further manual improvement. Discussion This intervention and service design are in line with policy priority of Government of Kenya, Kenya Vision 2030, World Health Organization, and UN Sustainable Development Goals that focus on improving capacity of mental health service systems to reduce maternal, child, adolescent health and mental health disparities in LMICs. Successfully carrying out this study in Kenya will provide an evidence-based intervention service development and implementation model for adolescents in other Sub-Saharan African (SSA) countries. The study is funded by FIC/NIH under K43 grant.

Abstract Background Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Methods/design We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale –up. Discussion The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information – a critical gap for addressing a leading global cause of disability. Trial registration ClinicalTrials.gov NCT03466346, registered March 15, 2018.

Background: How can we fast-track the global agenda of integrated mental healthcare in low- and middle-income countries (LMICs) such as Kenya? This is a question that has become increasingly important for individuals with lived experiences, policymakers, mental health advocates and health care providers at the local and international levels.Discussion: This narrative synthesis and perspective piece encompasses an overview of mental health care competencies, best practices and capacity building needed to fast track patient responsive services. In that vein we also review key policy developments like UHC to make a case for fast-tracking our four-step framework.Results: While there is an increasingly global impetus for integrated mental healthcare, there is a lack of clarity around what patient-responsive mental healthcare services should look like and how to measure and improve provider readiness appropriately. Here, our collaborative team of local and international experts proposes a simple four-step approach to integrating responsive mental healthcare in Kenya. Our recommended framework prioritizes a clear understanding and demonstration of multidimensional skills by the provider. The four steps are (1) provider sensitization, (2) continuous supervision, (3) continuous professional training, and (4) leadership empowerment.Conclusion: Our proposed framework can provide pointers to embracing patient-centered and provider empowerment focused quality of care improvements. Though elements of our proposed framework are well-known, it has not been sufficiently intertwined and therefore not been integrated. We think in the current times our integrated framework offers an opportunity to “building back better” mental health for all.

Abstract Introduction Models estimate that the disability burden from mental disorders in Sub-Saharan Africa (SSA) will more than double in the next 40 years. Similar to HIV, mental disorders are stigmatized in many SSA settings and addressing them requires community engagement and long-term treatment. Yet, in contrast to HIV, the public mental healthcare cascade has not been sustained, despite robust data on scalable strategies. We draw on findings from our International AIDS Society (IAS) 2020 virtual workshop and make recommendations for next steps in the scale up of the SSA public mental healthcare continuum. Discussion Early HIV surveillance and care cascade targets are discussed as important strategies for HIV response in SSA that should be adopted for mental health. Advocacy, including engagement with civil society, and targeted economic arguments to policymakers, are reviewed in the context of HIV success in SSA. Parallel opportunities for mental disorders are identified. Learning from HIV, communication of strategies that advance mental health care needs in SSA must be prioritized for broad global audiences. Conclusions The COVID-19 pandemic is setting off a colossal escalation of global mental health care needs, well-publicized across scientific, media, policymaker, and civil society domains. The pandemic highlights disparities in healthcare access and reinvigorates the push for universal coverage. Learning from HIV strategies, we must seize this historical moment to improve the public mental health care cascade in SSA and capitalize on the powerful alliances ready to be forged. As noted by Ambassador Goosby in our AIDS 2020 workshop, ‘The time is now’.

Résumé : Dans cet article, il est question d’évaluer la déforestation dans la périphérie Ouest de la réserve de Biosphère du Dja à travers les techniques de Télédétection et de Système d’Information Géographique. Pour cela, 08 images Landsat de date différentes (2011 à 2018) ont été utilisées pour produire les cartes d’occupation du sol, à travers la méthode de classification supervisée et l’algorithme « maximum likelihood ». Les classes d’occupation de sol retenues pour cette classification sont : forêt dense, forêt dégradée, zone de culture, zone marécageuse, zone d’habitation, sol nu et eau. L’analyse des changements a été faite avec la technique de « change detection ». Les résultats de cette étude ont montré que la déforestation a été importante pendant la période d’étude (2011 – 2018). Les surfaces forestières se sont principalement transformées en zone de culture, marécage, forêt dégradée, sol nu. Le taux de déforestation observé est de 6,8% et dénote une importante baisse du couvert forestier dense. L’étude a montré des tendances de déforestation dans cette périphérie. Elle a permis d’observer que les zones tendancieuses sont concentrées principalement autour de certaines activités anthropiques présentes dans cette zone (la plantation agricole SUDCAM, le barrage de Mekin, les lieux habités). Mots-clés : Déforestation, Changement climatique, forêt, tendances de déforestation, images satellites

Oil palm plantations have expanded rapidly. Estimating either positive effects on the economy, or negative effects on the environment, requires accurate maps. In this paper, three classification algorithms (Support Vector Machine (SVM), Decision Tree and K-Means) were explored to map oil palm plantations in Cameroon, using PALSAR 50 m Orthorectified Mosaic images and differently sized training samples. SVM had the ideal performance with overall accuracy ranging from 86% to 92% and a Kappa coefficient from 0.76 to 0.85, depending upon the training sample size (ranging from 20 to 500 pixels per class). The advantage of SVM was more obvious when the training sample size was smaller. K-Means required the user’s intervention, and thus, the accuracy depended on the level of his/her expertise and experience. For large-scale mapping of oil palm plantations, the Decision Tree algorithm outperformed both SVM and K-Means in terms of speed and performance. In addition, the decision threshold values of Decision Tree for a large training sample size agrees with the results from previous studies, which implies the possible universality of the decision threshold. If it can be verified, the Decision Tree algorithm will be an easy and robust methodology for mapping oil palm plantations.

BACKGROUND:SSG&PM over 17 days is recommended as first line treatment for visceral leishmaniasis in eastern Africa, but is painful and requires hospitalization. Combination regimens including AmBisome and miltefosine are safe and effective in India, but there are no published data from trials of combination therapies including these drugs from Africa. METHODS:A phase II open-label, non-comparative randomized trial was conducted in Sudan and Kenya to evaluate the efficacy and safety of three treatment regimens: 10 mg/kg single dose AmBisome plus 10 days of SSG (20 mg/kg/day), 10 mg/kg single dose AmBisome plus 10 days of miltefosine (2.5mg/kg/day) and miltefosine alone (2.5 mg/kg/day for 28 days). The primary endpoint was initial parasitological cure at Day 28, and secondary endpoints included definitive cure at Day 210, and pharmacokinetic (miltefosine) and pharmacodynamic assessments. RESULTS:In sequential analyses with 49-51 patients per arm, initial cure was 85% (95% CI: 73-92) in all arms. At D210, definitive cure was 87% (95% CI: 77-97) for AmBisome + SSG, 77% (95% CI 64-90) for AmBisome + miltefosine and 72% (95% CI 60-85) for miltefosine alone, with lower efficacy in younger patients, who weigh less. Miltefosine pharmacokinetic data indicated under-exposure in children compared to adults. CONCLUSION:No major safety concerns were identified, but point estimates of definitive cure were less than 90% for each regimen so none will be evaluated in Phase III trials in their current form. Allometric dosing of miltefosine in children needs to be evaluated. TRIAL REGISTRATION:The study was registered with ClinicalTrials.gov, number NCT01067443.

BACKGROUND: Visceral leishmaniasis (VL) is a systemic parasitic disease that is fatal unless treated. In Kenya, national VL guidelines rely on microscopic examination of spleen aspirate to confirm diagnosis. As this procedure is invasive, it cannot be safely implemented in peripheral health structures, where non-invasive, accurate, easy to use diagnostic tests are needed. METHODOLOGY: We evaluated the sensitivity, specificity and predictive values of two rapid diagnostic tests (RDT), DiaMed IT LEISH and Signal-KA, among consecutive patients with clinical suspicion of VL in two treatment centres located in Baringo and North Pokot District, Rift Valley province, Kenya. Microscopic examination of spleen aspirate was the reference diagnostic standard. Patients were prospectively recruited between May 2010 and July 2011. PRINCIPAL FINDINGS: Of 251 eligible patients, 219 patients were analyzed, including 131 VL and 88 non-VL patients. The median age of VL patients was 16 years with predominance of males (66%). None of the tested VL patients were co-infected with HIV. Sensitivity and specificity of the DiaMed IT LEISH were 89.3% (95%CI: 82.7-94%) and 89.8% (95%CI: 81.5-95.2%), respectively. The Signal KA showed trends towards lower sensitivity (77.1%; 95%CI: 68.9-84%) and higher specificity (95.5%; 95%CI: 88.7-98.7%). Combining the tests did not improve the overall diagnostic performance, as all patients with a positive Signal KA were also positive with the DiaMed IT LEISH. CONCLUSION/SIGNIFICANCE: The DiaMed IT LEISH can be used to diagnose VL in Kenyan peripheral health facilities where microscopic examination of spleen aspirate or sophisticated serological techniques are not feasible. There is a crucial need for an improved RDT for VL diagnosis in East Africa.

Alternative treatments for visceral leishmaniasis (VL) are required in East Africa. Paromomycin sulphate (PM) has been shown to be efficacious for VL treatment in India.A multi-centre randomized-controlled trial (RCT) to compare efficacy and safety of PM (20 mg/kg/day for 21 days) and PM plus sodium stibogluconate (SSG) combination (PM, 15 mg/kg/day and SSG, 20 mg/kg/day for 17 days) with SSG (20 mg/kg/day for 30 days) for treatment of VL in East Africa. Patients aged 4-60 years with parasitologically confirmed VL were enrolled, excluding patients with contraindications. Primary and secondary efficacy outcomes were parasite clearance at 6-months follow-up and end of treatment, respectively. Safety was assessed mainly using adverse event (AE) data.The PM versus SSG comparison enrolled 205 patients per arm with primary efficacy data available for 198 and 200 patients respectively. The SSG & PM versus SSG comparison enrolled 381 and 386 patients per arm respectively, with primary efficacy data available for 359 patients per arm. In Intention-to-Treat complete-case analyses, the efficacy of PM was significantly lower than SSG (84.3% versus 94.1%, difference = 9.7%, 95% confidence interval, CI: 3.6 to 15.7%, p = 0.002). The efficacy of SSG & PM was comparable to SSG (91.4% versus 93.9%, difference = 2.5%, 95% CI: -1.3 to 6.3%, p = 0.198). End of treatment efficacy results were very similar. There were no apparent differences in the safety profile of the three treatment regimens.The 17 day SSG & PM combination treatment had a good safety profile and was similar in efficacy to the standard 30 day SSG treatment, suggesting suitability for VL treatment in East Africa.www.clinicaltrials.govNCT00255567.

Visceral leishmaniasis (VL) is a major health problem in developing countries. The untreated disease is fatal, available treatment is expensive and often toxic, and drug resistance is increasing. Improved treatment options are needed. Paromomycin was shown to be an efficacious first-line treatment with low toxicity in India.This was a 3-arm multicentre, open-label, randomized, controlled clinical trial to compare three treatment regimens for VL in East Africa: paromomycin sulphate (PM) at 15 mg/kg/day for 21 days versus sodium stibogluconate (SSG) at 20 mg/kg/day for 30 days; and the combination of both dose regimens for 17 days. The primary efficacy endpoint was cure based on parasite-free tissue aspirates taken 6 months after treatment.Overall, 135 patients per arm were enrolled at five centres in Sudan (2 sites), Kenya (1) and Ethiopia (2), when the PM arm had to be discontinued due to poor efficacy. The trial has continued with the higher dose of PM as well as the combination of PM and SSG arms. These results will be reported later. Baseline patient characteristics were similar among treatment arms. The overall cure with PM was significantly inferior to that with SSG (63.8% versus 92.2%; difference 28.5%, 95%CI 18.8% to 38.8%, p