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A sizable portion of youth (ages 13–24) living with HIV in the United States have unsuppressed viral load. The AIDS Interventions (ATN) 152 study [evaluating the Triggered Escalating Real-Time Adherence (TERA) intervention] baseline data were examined to identify correlates of high viremia (>5000 copies/mL) and self-reported adherence, which can help in planning of differentiated services for viremic youth. Depression, HIV-stigma, and cannabis use were common in this sample of 87 youth. Almost half (48%) had high viremia, which associated with enacted stigma, moderate- to high-risk alcohol use, mental health diagnosis, and age ≥21. Self-reported adherence was related to viral load and associated with mental and physical health functioning, depression, social support, self-confident decision-making, total and internalized stigma, adherence motivation, and report of a missed a care visit in the past 6 months. Mental health emerged as a common correlate of viral load and adherence. Clinical Trial Registration number: NCT03292432.

Uptake of pre-exposure prophylaxis (PrEP) has dramatically increased but remains well below the estimated number of individuals who could benefit from PrEP in the United States, and uptake remains limited among young men who have sex with men (YMSM) and MSM of color. Reasons for not adopting PrEP as a prevention strategy among those at elevated risk for HIV is an important area of inquiry that could advise efforts to better position PrEP as an active part of prevention programs. As part of a mixed methods study investigating experiences with repeat HIV testing, we identified main themes emerging from in-depth interview data pertaining to reasons why YMSM report not using PrEP, among YMSM with frequent access to HIV testing services. Themes from 14 in-depth interviews with predominantly Latino MSM for not using PrEP included perceived burden of daily dosing, feeling that risk was not high enough to warrant PrEP, and beliefs that PrEP would have severe adverse events affecting the kidneys and bones. Less prominent but noteworthy themes included stigma as a PrEP user, social or provider influence on decisions not to use PrEP, and preference for current prevention strategy. No differences in PrEP discourse were noted across those at different levels of HIV risk. Results suggest that efforts are needed to engage communities and individuals around PrEP-related education, facilitate risk evaluation, and reduce PrEP stigma. New formulations and nondaily regimens may also be of particular interest to YMSM who may perceive daily PrEP regimens as highly burdensome.

BACKGROUND: Microneedle patch (MNP) technology is designed to simplify the process of vaccine administration; however, depending on its characteristics, MNP technology may provide additional benefits beyond the point-of-use, particularly for vaccine supply chains. METHODS: Using the HERMES modeling software, we examined replacing four routine vaccines – Measles-containing vaccine (MCV), Tetanus toxoid (TT), Rotavirus (Rota) and Pentavalent (Penta) – with MNP versions in the routine vaccine supply chains of Benin, Bihar (India), and Mozambique. RESULTS: Replacing MCV with an MNP (5 cm(3)-per-dose, 2-month thermostability, current single-dose price-per-dose) improved MCV availability by 13%, 1% and 6% in Benin, Bihar and Mozambique, respectively, and total vaccine availability by 1% in Benin and Mozambique, while increasing the total cost per dose administered by $0.07 in Benin, $0.56 in Bihar and $0.11 in Mozambique. Replacing TT with an MNP improved TT and total vaccine availability (3% and

Government partnerships are essential for many health solutions to sustain impact at scale, particularly in low-resource settings where strengthening health systems is critical for Universal Health Coverage. Many non-governmental organizations (NGOs) and funders ultimately want solutions to be integrated into public health systems by transitioning solution ownership, management and/or operation to government. However, NGOs and their government partners have limited guidance on how to effectively determine when a solution is ready to transition in a way that will maintain impact long term. To address this need, VillageReach developed the Transition Readiness Assessment (TRA) based on our transition to government theoretical framework. The framework was developed to define both factors related to a solution, as well as external influences that affect a solution’s success. The framework identifies seven dimensions of solution readiness: the political, economic, and social context; solution design; resource availability; financial management; government strategy; government policy and regulations; and organizational management. The TRA measures those dimensions and assigns each one a readiness score. We developed the framework and TRA for VillageReach solutions, as well as to share with government partners and stakeholders. This Open Letter outlines the TRA development, details empirical examples from applying the tool on two VillageReach solutions, and presents recommendations based on our lessons learned. Stakeholders working to transition solutions to government can utilize both the TRA and our lessons.

The government of Cape Verde, an archipelagic Small Island Developing State (SIDS) off the coast of Senegal, has established a goal to achieve 100% of its electricity from renewable sources by 2025. Several islands in the archipelago have suitable wind and solar resources and nationally these compose about 25% of the electricity output. However, not all islands are equally endowed with these resources and the lack of grid connections among islands poses challenges for integrating additional variable energy generation. Integrating desalination and storage (pumped hydro or battery) could enable greater penetration of wind and solar energy. Ocean thermal energy conversion (OTEC) is an emerging technology that could be suitable for Cape Verde. Microgrids and self-generation could prove to be more cost effective than grid connections outside of the large cities. Achieving the 100% renewable energy goal would require a US$1 billion investment. Cape Verde has a variety of resources that can contribute to achieving its 100% renewable electricity goal but combining them in manageable and cost-effective way remains a challenge. The options, opportunities, and challenges encountered by Cape Verde are applicable to other countries, especially small island developing states and archipelagos around the world.

A well-functioning supply chain is a critical component of the health system to ensure high-quality medicines and health products are available when and where they are needed. However, because supply chains are complex systems, strong, competent leaders are needed to drive continuous improvement efforts. This paper documents the learnings from a supply chain leadership intervention in the Democratic Republic of Congo (DRC), which aimed to build leadership capacity in a cross-tier group of central/provincial/district-level leaders. The intervention, called the Leadership in Supply Chain Initiative, used an experiential learning curriculum to train 19 ‘champions’ in Equateur Province, DRC. Based on self-assessments and key informant interviews, participants reported that the intervention increased their ability to lead change in the supply chain. In particular, participants and stakeholders noted that empowering district managers as leaders in the supply chain was important to improve supply chain performance, since they oversee service delivery points and are responsible for operationalising changes in the supply chain. Moreover, this intervention adds to evidence that leadership capacity is most effectively gained through experiential learning coupled with mentorship and coaching. Additional research is needed to determine the optimal duration of leadership building interventions and to better understand how supply chain leaders can be supported and mentored within the public health system.

Background Poor access to essential medicines is common in many low- and middle-income countries, partly due to an insufficient and inadequately trained workforce to manage the medicines supply chain. We conducted a prospective impact evaluation of the training and deployment of pharmacy assistants (PAs) to rural health centers in Malawi. Methods A quasi-experimental design was used to compare access to medicines in two districts where newly trained PAs were deployed to health centers (intervention) and two districts with no trained PAs at health centers (comparison). A baseline household survey and two annual post-intervention household surveys were conducted. We studied children under five years with a history of fever, cough and difficulty in breathing, and diarrhea in the previous two weeks. We collected data on access to antimalarials, antibiotics and oral rehydration salts (ORS) during the childrens’ symptomatic periods. We used difference-in-differences regression models to estimate the impact of PA training and deployment on access to medicines. Results We included 3974 children across the three rounds of annual surveys: 1840 (46%) in the districts with PAs deployed at health centers and 2096 (53%) in districts with no PAs deployed at health centers. Approximately 80% of children had a fever, nearly 30% had a cough, and 43% had diarrhea in the previous two weeks. In the first year of the program, the presence of a PA led to a significant 74% increase in the odds of access to any antimalarial, and a significant 49% increase in the odds of access to artemisinin combination therapies. This effect was restricted to the first year post-intervention. There was no effect of presence of a PA on access to antibiotics or ORS. Conclusion The training and deployment of pharmacy assistants to rural health centers in Malawi increased access to antimalarial medications over the first year, but the effect was attenuated over the second year. Pharmacy assistants training and deployment demonstrated no impact on access to antibiotics for pneumonia or oral rehydration salts for diarrhea.

Mobile SMS health messages had higher successful delivery and led to higher intended or actual behavior change among subscribers than voice messages. Providing multiple delivery modalities led to greater overall access., Objective: To determine the difference in delivery success of health messages delivered through pushed SMS, pushed voice messages sent to personal phones, and voice messages retrieved from a community phone (“retrieved voice messaging”), as well as the difference in quality of the user experience. Methods: We analyzed the project's electronic monitoring data between September 2011 and June 2013, including demographics, enrollment data, and messages sent and successfully delivered. We also collected and analyzed information from quarterly phone-based surveys with users to assess quality of the user experience, including acceptability, comprehension, new information learned, and reported behavior change. Results: More than half of subscribers enrolled in the retrieved voice messaging service while nearly one-third enrolled in the pushed SMS service and less than 10% in pushed voice messaging. Message delivery success was highest among pushed SMS subscribers and lowest among retrieved voice subscribers. Overall, 99% of survey respondents reported trusting messages they received, and about 75% of respondents recalled the last message they received and learned something new. Almost 75% of respondents reported that they had already changed or intended to change their behavior based on received messages. Intended or actual behavior change was significantly higher among pushed SMS enrollees than among pushed or retrieved voice messaging enrollees (P = .01). Conclusion: All message modalities led to high levels of satisfaction, comprehension, and new information learned. Due to lower cost, higher delivery success, and higher levels of intended or actual behavior change, SMS is the preferred delivery modality. However, the majority of users included in this study did not have access to a personal phone, and retrieved voice messages provided an opportunity to access a population that otherwise could not be served. Providing multiple methods by which users could access the service was crucial in extending reach beyond literate personal phone owners.

Background Internationally, non-urgent presentations are increasing the pressure on Emergency Department (ED) staff and resources. This systematic review aims to identify the impact of alternative emergency care pathways on ED presentations – specifically GP cooperatives and walk-in clinics. Methods Based on a structured PICO enquiry with either walk-in clinic or GP cooperative as the intervention, a search was made for peer-reviewed publications in English, between 2000 and 2014. Medline plus, OVID, PubMed, and Google Scholar were searched. The Critical Appraisal Skills Program (CASP) guidelines were used to assess study quality and data was extracted using an adapted JBI Qualitative Assessment and Review Instrument (QARI). Subsequent reporting followed the PRISMA guideline. Results Eleven high quality quantitative studies met the inclusion criteria. Walk-in clinics do have the potential to reduce non-urgent emergency department presentations, however evidence of this effect is low. GP cooperatives offer an alternative care stream for patients presenting to the ED and do significantly reduce local ED attendances. Community members need to be made aware of these options in order to make informed treatment choices. Conclusion GP cooperatives in particular do have the potential to reduce ED workload. Further research is required to uncover recent trends and patient outcomes for walk-in clinics and GP cooperatives.

Objective To determine whether women with low-grade serous ovarian cancer (LGSOC) have personal and family histories of breast and ovarian cancer that are less suggestive of Hereditary Breast and Ovarian Cancer (HBOC), as compared to women with high-grade serous ovarian cancer (HGSOC). Methods A single institution, case-control retrospective review of medical records was conducted. Personal demographics, personal cancer history, and family history of breast and ovarian cancer of women with LGSOC were collected and compared to controls with HGSOC, which is known to be associated with HBOC. Results 195 cases of LGSOC and 386 controls with HGSOC were included in the analysis. Women with LGSOC were significantly less likely to have a first- or second-degree relative with breast or ovarian cancer ( p =0.0016). Additionally, when the personal and family histories were quantified using the AMyriad BRC mutation prevalence tables, women with LGSOC had lower scores indicative of a less suggestive family history for HBOC ( p =0.027). Conclusions In this study, women with LGSOC had family histories that were less suggestive of HBOC compared to women with HGSOC, especially when the degree of relatedness of affected relatives was taken into account. By beginning to determine if LGSOC is part of the tumor spectrum seen in HBOC, this study is an important step towards refining hereditary cancer risk assessment for women with ovarian cancer.

Background Malawi, like many low-income countries, is facing a severe health worker shortage. A potential stop-gap solution to this crisis is improving the efficiency of health center operations. Given the lack of research on center efficiency in rural health centers in Malawi, we conducted a study to identify deficiencies in center organization and barriers to patient flow. Methods We performed a time-motion survey at a rural health center in Ntaja, Malawi over a period of 1 week. We used a standardized questionnaire to collect information on the amount of time a patient spent with each health worker, the number of center staff that attended to each patient, and the total time spent at the center. Additionally, at the end of the visit, we conducted an exit survey to collect demographic information and data on perception of quality of care with the center visit for all patients. Results A total of 1018 patients were seen over the five-day study. The average total time spent at the center by the patients was 123 min (2–366 min). Adults had an average total time spent at the center of 111 min (2–366 min) and children 134 min (7–365 min). Patient waiting time (PWT) was higher in the early morning hours ranging from 157 min (between 06:00 and 08:00) to 53 min (between 14:00 and 16:00). Health worker contact time (HCT) was higher for adults (2.3 min) than children (1.7 min). Shorter wait times were associated with higher perceptions of quality of service. Conclusion Despite shortages in health workers and funds, opportunities are available to increase efficiency in rural health centers. By removing bottlenecks to increase the productivity of health workers, centers in low-income countries can treat more patients and improve service quality. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-2144-x) contains supplementary material, which is available to authorized users.

Background Access to essential medicines is core to saving lives and improving health outcomes of people worldwide, particularly in the low- and middle-income countries. Having a trained pharmacy workforce to manage the supply chain and safely dispense medicines is critical to ensuring timely access to quality pharmaceuticals and improving child health outcomes. Methods/Design This study measures the impact of an innovative pharmacy assistant training program in the low-income country of Malawi on access to medicines and health outcomes. We employ a cluster quasi-experimental design with pre-and post-samples and decision analytic modeling to examine access to and the use of medicines for malaria, pneumonia, and diarrhea for children less than 5 years of age. Two intervention districts, with newly trained and deployed pharmacy assistants, and two usual care comparison districts, matched on socio-economic, geographic, and health-care utilization indicators, were selected for the study. A baseline household survey was conducted in March 2014, prior to the deployment of pharmacy assistants to the intervention district health centers. Follow-up surveys are planned at 12- and 24-months post-deployment. In addition, interviews are planned with caregivers, and time-motion studies will be conducted with health-care providers at the health centers to estimate costs and resources use. Discussion This impact evaluation is designed to provide data on the effects of a novel pharmacy assistant program on pharmaceutical systems performance, and morbidity and mortality for the most common causes of death for children under five. The results of this study should contribute to policy decisions about whether and how to scale up the health systems strengthening workforce development program to have the greatest impact on the supply chain and health outcomes in Malawi.

Background: Malaria rapid diagnostic tests (RDTs) are particularly useful in low-resource settings where follow-through on traditional laboratory diagnosis is challenging or lacking. The availability of these tests depends on supply chain processes within the distribution system. In Mozambique, stock-outs of malaria RDTs are fairly common at health facilities. A longitudinal cross-sectional study was conducted to evaluate drivers of stock shortages in the Cabo Delgado province. Methods: Data were collected from purposively sampled health facilities, using monthly cross-sectional surveys between October 2011 and May 2012. Estimates of lost consumption (consumption not met due to stock-outs) served as the primary quantitative indicator of stock shortages. This is a better measure of the magnitude of stock-outs than binary indicators that only measure frequency of stock-outs at a given facility. Using a case study based methodology, distribution system characteristics were qualitatively analysed to examine causes of stock-outs at the provincial, district and health centre levels. Results: 15 health facilities were surveyed over 120 time points. Stock-out patterns varied by data source; average monthly proportions of 59%, 17% and 17% of health centres reported a stock-out on stock cards, laboratory and pharmacy forms, respectively. Estimates of lost consumption percentage were significantly high; ranging from 0% to 149%; with a weighted average of 78%. Each ten-unit increase in monthly-observed consumption was associated with a nine-unit increase in lost consumption percentage indicating that higher rates of stock-outs occurred at higher levels of observed consumption. Causes of stock-outs included inaccurate tracking of lost consumption, insufficient sophistication in inventory management and replenishment, and poor process compliance by facility workers, all arguably stemming from inadequate attention to the design and implementation of the distribution system. Conclusions: Substantially high levels of RDT stock-outs were found in Cabo Delgado. Study findings point to a supply chain with a commendable degree of sophistication. However, insufficient attention paid to system design and implementation resulted in deteriorating performance in areas of increased need. In such settings fast moving commodities like malaria RDTs can call attention to supply chain vulnerabilities, the findings from which can be used to address other slower moving health commodities.

We describe our experiences integrating ODK Scan into the community health worker (CHW) supply chain in Mozambique. ODK Scan is a mobile application that uses computer vision techniques to digitize data from paper forms. The application automatically classifies machine-readable data types, like bubbles and checkboxes, and assists users with the manual entry of handwritten text and numbers. We designed an intervention that uses paper forms in conjunction with ODK Scan to monitor CHW usage of essential health commodities, finding that the application is capable of providing supervisors and stakeholders with important information regarding health commodity availability in the field. Specifically, we (1) detail our experiences integrating ODK Scan into the health worker supply chain in Mozambique, with particular emphasis on the critical (and often under-reported) role of practitioners; (2) evaluate the impact of the technology at multiple levels of the information hierarchy, providing quantitative and qualitative data that exposes the benefits, challenges and limitations of the technology; and (3) share lessons learned and provide actionable guidance to researchers and practitioners interested in ODK Scan or other systems that bridge the gap between paper-based and digital data collection.

The evidence base to support the growing field of mHealth is relatively nascent, with most studies lacking the level of rigor needed to inform scale up of interventions. This paper investigates the impact of a maternal, newborn and child health (MNCH) mHealth project in Malawi, comparing the intention-to-treat (ITT) and the treatment on the treated (TOT) estimates, and discussing the implications for future evaluations. Services offered included a toll-free case management hotline and mobile messaging service for women and children. The evaluation methods included a quasi-experimental pre-test post-test design, consisting of cross-sectional household surveys. A total of 4,230 women were interviewed in the intervention area and 2,463 in the control site. While the intervention did not have any ITT effects of the MNCH outcomes studied, there were large TOT effects. Rigorous evaluation designs can be successfully applied to mHealth pilot projects, helping to understand what works and what does not.

The aim of this paper was to investigate the impact of a toll-free hotline and mobile messaging service on care-seeking behaviors. Due to the low uptake of the services, the treatment on the treated estimate is used. For maternal health, the intervention had a strong, positive impact on antenatal care initiation and skilled birth attendance. No effect was observed for postnatal check-ups, receiving the recommended four antenatal care visits and vitamin A uptake. A negative effect was observed on tetanus toxoid coverage. For child health, no change was seen in child immunization, and a significant decrease was observed for care-seeking for children with fever. Different factors are associated with care-seeking, which may explain in part the variations seen across care-seeking behaviors and possible influence of exogenous factors. Introduction of mHealth services for demand generation require attention to local health systems to ensure adequate supply and quality are available.

Background VillageReach, in partnership with the Malawi Ministry of Health, the Malawi College of Health Sciences and the University of Washington Global Medicines Program, is addressing key barriers to medicines availability by implementing a new approach to training, deployment, and support of an enhanced pharmacy assistant cadre. Key aspects of the program include curriculum redesign to include more content to enhance skills in supply chain management and an extensive practicum component at public health facilities.

Objectives To catalogue patients with DSD and to assess the concordance of genotype and phenotype with sex assignment at birth compared to sex assignment before and following assessment by a Gender Medicine Team (GMT) at one institution, as an initial step in formulating standardized guidelines for management of these conditions. Design After obtaining IRB approval, a retrospective chart review was conducted patients seen in the Gender Medicine Clinic (GMC) between 2006–2009 at Texas Children’s Hospital (TCH), Houston, Texas. McNemar’s test and Kappa agreement provided associations of various factors with sex assignment at birth prior to GMT assessment and after GMT assessment. Participants Forty-seven patients seen in the GMC with confirmed DSD. Results Forty-seven patients met the inclusion criteria. The mean age of the patients at the time of GMT evaluation was 9.1+/−6.1 years; 61.7% had male karyotype, and 38.3% had female karyotype; 51.1% had a male external phenotype, 42.6% had a female external phenotype, and 6.4% had phenotypic ambiguity. Sex assignment was concordant with genotype and phenotype in 63.8% and 86.4%, respectively of cases at the time of birth and in 76.6% and 97.7%, respectively, of cases after assessment by GMT. Conclusion Long-term outcomes are needed to establish standardized practice guidelines for decision-making.

a malignancy should always be considered. We present three cases of genital malignancies presenting as vaginal bleeding occurring in infancy, childhood, and pubescence. Case 1: A 7 month old infant was initially seen in a primary care clinic with a three day history of blood in her diapers. An evaluation for urinary tract infection was negative and renal ultrasound showed no structural abnormalities. Multiple episodes of bleeding occurred over the next month. Pelvic ultrasound and vaginoscopy revealed a 2 centimeter friable vaginal mass consistent with a yolk sack tumor. Case 2: A 7 year old followed for congenital absence of the right kidney was noted to have new onset hematuria on urinanalysis. Due to an unclear etiology of the bleeding, a workup for precocious puberty was preformed and was negative. Pelvic ultrasound revealed an ill defined endometrial stripe with normal ovaries. Subsequent vaginoscopy and biopsy revealed clear cell carcinoma of the vagina. Case 3: A 13 year old presented with probable anovulatory estrogen withdrawal bleeding and severe anemia. She was treated on different occasions with an oral contraceptive pill taper, daily norethindrone acetate, and intravenous estrogen with minimal response. Pelvic ultrasound revealed a large clot in the uterine cavity. Patient underwent vaginoscopy with dilation and curettage. Findings at time of surgery and subsequent histology revealed a neuroendocrine tumor of the cervix. Comments: Vaginal bleeding in infancy or childhood is more alarming to a physician than abnormal menstruation in an adolescent. Despite the high incidence of menstrual irregularities in adolescents, continued symptoms should also trigger further investigation. These cases validate the necessity of complete evaluation of the genital tract when a premenarchal or adolescent child presents with vaginal bleeding. Malignancy ranks low on the list of differential diagnoses and is rare in this age group. However, there may be dire consequences to delayed diagnosis and therefore, a timely and thorough evaluation with vaginoscopy by a pediatric gynecologist is recommended.