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Background: Despite advances in surgery and pharmacotherapy, there remains significant residual ischemic risk after coronary artery bypass grafting surgery. Methods: In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), a multicenter, placebo-controlled, double-blind trial, statin-treated patients with controlled low-density lipoprotein cholesterol and mild to moderate hypertriglyceridemia were randomized to 4 g daily of icosapent ethyl or placebo. They experienced a 25% reduction in risk of a primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina) and a 26% reduction in risk of a key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) when compared with placebo. The current analysis reports on the subgroup of patients from the trial with a history of coronary artery bypass grafting. Results: Of the 8179 patients randomized in REDUCE-IT, a total of 1837 (22.5%) had a history of coronary artery bypass grafting, with 897 patients randomized to icosapent ethyl and 940 to placebo. Baseline characteristics were similar between treatment groups. Randomization to icosapent ethyl was associated with a significant reduction in the primary end point (hazard ratio [HR], 0.76 [95% CI, 0.63–0.92]; P =0.004), in the key secondary end point (HR, 0.69 [95% CI, 0.56–0.87]; P =0.001), and in total (first plus subsequent or recurrent) ischemic events (rate ratio, 0.64 [95% CI, 0.50–0.81]; P =0.0002) compared with placebo. This yielded an absolute risk reduction of 6.2% (95% CI, 2.3%–10.2%) in first events, with a number needed to treat of 16 (95% CI, 10–44) during a median follow-up time of 4.8 years. Safety findings were similar to the overall study: beyond an increased rate of atrial fibrillation/flutter requiring hospitalization for at least 24 hours (5.0% vs 3.1%; P =0.03) and a nonsignificant increase in bleeding, occurrences of adverse events were comparable between groups. Conclusions: In REDUCE-IT patients with a history of coronary artery bypass grafting, treatment with icosapent ethyl was associated with significant reductions in first and recurrent ischemic events. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01492361.

Background The vaginal microbiota (VMB) are the set of microorganisms residing in the human vagina. During pregnancy, their composition is Lactobacillus-dominant in most Caucasian women. Previous studies suggest that the VMB of women with African ancestry is more likely to be non-Lactobacillus dominant (dysbiotic) compared to other populations, and possibly relate to the high incidence of pregnancy complications, such as preterm birth. This work reviewed the literature on VMB composition in pregnant women from sub-Saharan Africa. Methods A search was conducted in PubMed and Embase databases following PRISMA guidelines. Observational and intervention studies analysing VMB communities from sub-Saharan African pregnant women using molecular techniques were included. Results Ten studies performed in seven sub-Saharan African countries were identified. They independently showed that Lactobacillus-dominant VMB (particularly L. iners or L. crispatus) or VMB containing Lactobacilli are the most prevalent, followed by a more diverse anaerobe-dominant VMB, in the studied populations. The majority of pregnant women with a sexually-transmitted infection had a Lactobacillus-dominant VMB, but with a significantly higher presence of anaerobic species. Conclusion In agreement with studies performed in other populations, Lactobacillus species are the most prevalent VMB species during pregnancy in sub-Saharan African women. The frequency of diverse anaerobe-dominant VMB is high in these populations. In Africa, studies on VMB in pregnancy are scant, heterogeneous in methodology, and knowledge remains limited. More insights on VMB composition and their possible sequalae among these populations is needed.

Background: Traumatic cardiac arrest (TCA) is a severe and life-threatening situation that mandates urgent action. Outcomes after on-scene treatment of TCA in the Netherlands are currently unknown. The aim of the current study was to investigate the rate of survival to discharge in patients who suffered from traumatic cardiac arrest and who were subsequently treated on-scene by the Dutch Helicopter Emergency Medical Services (HEMS). Methods: A retrospective cohort study was performed including patients ≥ 18 years with TCA for which the Dutch HEMS were dispatched between January 1 st 2014 and December 31 st 2018. Patients with TCA after hanging, submersion, conflagration or electrocution were excluded. The primary outcome measure was survival to discharge after prehospital TCA. Secondary outcome measures were return of spontaneous circulation (ROSC) on-scene and neurological status at hospital discharge. Results: Nine-hundred-fifteen patients with confirmed TCA were included. ROSC was achieved on-scene in 261 patients (28.5%). Thirty-six (3.9%) patients survived to hospital discharge of which 17 (47.2%) had a good neurological outcome. Age < 70 years (0.7% vs. 5.2%; p=0.041) and a shockable rhythm on first ECG (OR 0.65 95%CI 0.02-0.28; p

ObjectivesMacrolide resistance in Mycoplasma genitalium is emerging globally. There is paucity of data from sub-Saharan Africa where syndromic management is used to treat sexually transmitted infections (STIs). We conducted a molecular epidemiological study to determine the prevalence of azithromycin resistance and epidemic diversity of M. genitalium infections in South Africa.MethodsWe analysed 90 M. genitalium-positive specimens that had been collected consecutively from men and women (50% symptomatic) from geographically diverse communities across the northern part of South Africa between 2015 and 2019. Melting curve analysis followed by targeted sequencing of the 23S rRNA gene was performed to detect azithromycin resistance. Molecular typing was done through single nucleotide polymorphism (SNP) analysis of the MG191 gene and short tandem repeats (STR) assessment of the MG309 gene. An overview of all published M. genitalium sequence types was generated and novel sequence types identified in this study were allocated numbers accordingly.ResultsAzithromycin resistance was detected in 1/90 M. genitalium-positive specimens (1.1%; 95% CI 0% to 3.3%) as conferred by A2071G mutation; this strain also harboured a C234T mutation in the parC gene with wild type gyrA gene. SNP typing and STR assessment was successful in 38/90 specimens (42%) and showed a genetically diverse epidemic, without geographic clustering, with eight novel sequence types identified.ConclusionThis is the first study that determines resistance in M. genitalium infection since introduction of azithromycin in the syndromic management regimen for STIs in South Africa in 2015. Despite a well-established epidemic, azithromycin-resistant M. genitalium infection is still uncommon in the public healthcare sector. However, it has the potential to undermine the effectiveness of syndromic management. Introduction of molecular diagnostics and continuous surveillance are warranted for early detection emergence of resistance.

This study explored the possibility of a common health-related stigma reduction intervention among people living with HIV, leprosy, schizophrenia and diabetes in Indonesia by assessing their perspectives towards others with the same (within group) and different health conditions (across groups), and willingness to participate in such a program. This mixed-methods study was conducted in West Java, Indonesia between March and June 2018. Eighty participants completed a survey with social distance scale (SDS), while 12 focus group discussion were conducted. Participants with HIV, leprosy and diabetes reported lower within-group SDS scores (4.14 ± 3.65; 4.25 ± 3.95; 7.23 ± 5.31, respectively) while those with schizophrenia reported the highest within-group SDS score (7.76 ± 4.63). Participants with diabetes reported a twofold higher across-group SDS score towards people with the other three health conditions (p < 0.05). The qualitative findings showed that the perception of participants towards one another was shaped by knowledge, understanding and relatedness to the experience of living with health-related stigma. Overall, participants supported the idea of a common stigma reduction intervention for different health conditions, but recommended step-wise implementation of such interventions. Accordingly, this study recommends piloting a common stigma reduction intervention with special focus on fostering understanding, awareness and empathy between people living with different health conditions.

Syphilis and HIV infection may coexist in the same individual. Ocular syphilis and/or neurosyphilis may develop at any stage of coinfection, with a stronger association between ocular and neurosyphilis in individuals living with HIV, than in HIV-uninfected individuals. The diagnosis of ocular syphilis in HIV-infected and -uninfected patients remains with some controversy due to unspecific clinical manifestations and limited diagnostic tests. Penicillin is the mainstay of treatment of ocular syphilis, but alternative options are warranted. This review describes the epidemiology, pathophysiology, and clinical manifestations, as well as the diagnostic and therapeutic challenges posed by ocular syphilis against the background of HIV coinfection.

Purpose: Overview of the evolving epidemiology of human immunodeficiency virus (HIV)-related ocular disease over time. Method: Narrative review. Results: HIV enhances susceptibility to opportunistic eye infections, has direct pathogenic effects, and places patients at risk of immune recovery inflammatory syndromes in previously infected eyes after starting highly-active antiretroviral therapy (HAART). Widespread availability of HAART has resulted in a decrease of infectious ocular conditions such as cytomegalovirus retinitis, toxoplasmic retinitis, squamous cell carcinoma of the conjunctiva, and microvascular retinopathy. However, large coexisting burdens of tuberculosis, herpesvirus infection and syphilis (among others) continue to contribute to the burden of ocular disease, especially in low-resource settings. Growing risks of cataract, retinopathy and retinal nerve fiber thinning can affect patients with chronic HIV on HAART; thought due to chronic inflammation and immune activation. Conclusion: The changing epidemic of ocular disease in HIV-infected patients warrants close monitoring and identification of interventions that can help reduce the imminent burden of disease.

PurposeTo determine the role of18F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET)/computed tomography (CT) in children with fever of unknown origin (FUO).MethodsThis retrospective single-center study included 110 children (0–18 years) with FUO who underwent FDG-PET/CT between 2010 and 2019. The diagnostic value of FDG-PET/CT for identifying cause of fever was calculated, treatment modifications after FDG-PET/CT were assessed, and logistic regression analyses were performed to identify clinical and biochemical factors associated with FDG-PET/CT outcome.ResultsIn 53 out of 110 patients (48%), FDG-PET/CT identified a (true positive) cause of fever. Endocarditis (11%), systemic juvenile idiopathic arthritis (5%), and inflammatory bowel disorder (5%) were the most common causes of FUO. In 42 patients (38%), no cause of fever was found on FDG-PET/CT. In 58 out of 110 patients (53%), treatment modifications were made after FDG-PET/CT. FDG-PET/CT achieved a sensitivity of 85.5%, specificity of 79.2%, positive predictive value of 84.1%, and negative predictive value of 80.9%. On multivariate logistic regression, C-reactive protein was positively associated with finding a true positive focus of fever on FDG-PET/CT (OR = 1.01 (95% CI 1.00–1.02) per mg/L increase in CRP), while leukocyte count was negatively associated with finding a true positive focus of fever (OR = 0.91 (95% CI 0.85–0.97) per 109leukocytes/L increase).ConclusionFDG-PET/CT is a valuable diagnostic tool in the evaluation of children with FUO, since it may detect a true underlying cause in almost half (48%) of all cases where none was found otherwise. It allows full-body evaluation in patients without disease-specific symptoms on one examination. CRP and leukocyte count were significantly associated with FDG-PET/CT results, which may contribute to a priori assessment on the outcome of FDG-PET/CT. Future research could be aimed at evaluating more patient-specific factors to prospectively estimate the added value of FDG-PET/CT in children with FUO.

Health-related stigma causes a negative impact on the lives of affected people and undermines the effectiveness of public health programs. This study aimedto explore experiences and consequences of stigma among people affected by four health conditions relevant in Indonesia– HIV (Human ImmunodeficiencyVirus), leprosy, schizophrenia and diabetes. In this qualitative study 40 people affected by the four health conditions in Jakarta and West Java, Indonesia–,were interviewed between March and June 2018. Data were analyzed thematically by following an integrative inductive-deductive approach. The experiencesand consequences of people with stigma were similar, but such experience were more severe among people affected by HIV, leprosy, and schizophrenia.Those with diabetes either experienced no or less severe stigma. The participants revealed that they experienced enacted stigma in healthcare, employment,and social interactions in the structural and interpersonal levels. They also experience the stigma in the form of internalized and anticipated stigma at an individual level. Incidences of human rights violations were evident. Social, behavioral, psychological, and medical consequences were also reported.

ObjectiveSTIs during pregnancy increase adverse pregnancy and birth outcomes and may increase HIV risk. STI syndromic management is standard of care in South Africa. Our study evaluated the prevalence and incidence of STIs in pregnant women and the associated risk factors.MethodsWe combined data from two prospective observational studies of pregnant women enrolled while attending their first antenatal clinic (ANC) visit in Tshwane District and Cape Town. Women ≥18 years were tested at first ANC visit and at their first postpartum visit for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis using Xpert assays (Cepheid, USA). We evaluated the prevalence and incidence of STI and the associated risk factors using multivariable regression models.ResultsWe enrolled 669 pregnant women, 64% (n=427) from Tshwane District and 36% (n=242) from Cape Town; 80% (n=534) were women living with HIV (WLHIV) and 20% (n=135) without HIV. At enrolment, 37% (n=250) were diagnosed with at least one STI, of which 76% (n=190) were asymptomatic. STI prevalence was 40% (n=213) in WLHIV and 27% (n=37) in women without HIV (p=0.01). Baseline STI infection was associated with younger age (OR=0.95 per year, 95% CI 0.92 to 0.98), higher gestational age (adjusted OR (aOR)=1.03 per week, 95% CI 1.00 to 1.05), single relationship status (aOR=1.53, 95% CI 1.09 to 2.15) and HIV status (aOR=1.86, 95% CI 1.17 to 2.95). Of 419 participants with no STI at baseline, 21 had an incident STI during follow-up, with a mean follow-up time of 140 days. The incidence rate of STI during pregnancy and early post partum was 15 infections per 100 women-years (95% CI 9 to 23). Younger age was associated with STI incidence.ConclusionOur study shows high prevalence and incidence of STIs in pregnancy, especially in WLHIV, demonstrating the need for STI screening in ANC to prevent adverse pregnancy and birth outcomes. Most STI cases were asymptomatic and would have gone untreated with syndromic management. Aetiological STI screening is urgently needed to reduce the burden of STIs in pregnancy.

ObjectiveMycoplasma genitalium (MG) is a sexually transmitted organism associated with cervicitis and pelvic inflammatory disease in women and has been shown to increase the risk of HIV acquisition and transmission. Little is known about the prevalence and incidence of MG in pregnant women. Our study sought to evaluate the prevalence and incidence of MG infection in HIV-infected and HIV-uninfected pregnant women.MethodsWe conducted a cohort study of 197 women ≥18 years receiving antenatal care in South Africa from November 2017 to February 2019. We over-recruited HIV-infected pregnant women to compare MG by HIV infection status. Self-collected vaginal swabs, performed at the first antenatal visit, third trimester and within 1 week post partum, were tested for MG using the Aptima assay (Hologic, USA). We report on the prevalence and incidence of MG and used multivariable logistic regression to describe correlates of MG and adverse pregnancy and birth outcomes (preterm delivery, miscarriage and vertical HIV transmission), adjusting for maternal age and HIV infection status.ResultsAt first antenatal visit, the median age was 29 years (IQR=24–34) and the gestational age was 19 weeks (IQR=14–23); 47% of women enrolled in the study were HIV-infected. MG prevalence was 24% (95% CI 16% to 34%, n=22) in HIV-infected and 12% (95% CI 6.8% to 20%, n=13) in HIV-uninfected pregnant women. MG incidence during pregnancy and early post partum was 4.7 infections per 100 woman-years (95% CI 1.2 to 12.9) or 3.9 per 1000 woman-months (95% CI 1.0 to 10.7). Adjusting for maternal age, HIV-infected women had over three times the odds of being infected with MG (adjusted OR=3.09, 95% CI 1.36 to 7.06).ConclusionWe found a high prevalence and incidence of MG in pregnant women. Younger maternal age and HIV infection were associated with MG infection in pregnancy. Further research into birth outcomes of women infected with MG, including vertical transmission of HIV infection, is needed.

Einsatz- und Katastrophenszenarien stellen westliche Gesundheitssysteme vor neue Herausforderungen. In der Praxis zeigen sich dabei Parallelen der zivilen Katastrophenmedizin und militarischen Einsatzmedizin, was eine Integration dieser Inhalte bereits in das Medizinstudium sinnvoll erscheinen lasst. Wie ist die Einstellung von Medizinstudierenden zur Ausbildung in der Einsatz- und Katastrophenmedizin (EKM) im Studium, und bestehen hierbei Unterschiede in Abhangigkeit vom Besuch eines fakultativen EKM-Lehrangebots? Im Rahmen einer Vorlesungsreihe zum Thema EKM erfolgte eine anonyme Evaluation unter den Studierenden (Gruppe 1) mit 20 Fragen zu ihrer Einstellung bezuglich der Thematik. Als Vergleichsgruppe (Gruppe 2) dienten Studierende, die die Vorlesungsreihe nicht besucht hatten. Die statistische Auswertung erfolgte deskriptiv sowie mittels Student’s t‑Test. Die Fragebogen wurden von 152 Studierenden vollstandig ausgefullt (Gruppe 1: n = 78, Gruppe 2: n = 74). Nur 10 Studierende aus Gruppe 1 und keiner aus Gruppe 2 fuhlten sich ausreichend in EKM ausgebildet. Medizinstudierende beider Gruppen sahen das Themengebiet EKM als nichtangemessen im Curriculum reprasentiert an (Gruppe 1: 64 %, Gruppe 2: 66 %) und befurworteten eine verstarkte Integration in das Studium (Gruppe 1: 72 %, Gruppe 2: 54 %, p = 0,001) sowie das Erstellen von digitalen Lehrmedien in dem Fach EKM (Gruppe 1: 73 %, Gruppe 2: 72 %). Die Befragten wunschten eine starkere Integration von Inhalten der EKM in das Curriculum. Trotz statistisch signifikanter Unterschiede in den Antworten beider Gruppen zeigten die Teilnehmer gruppenunabhangig ein groses Interesse fur die EKM. Beide Gruppen befurworten zudem E‑Learning-Angebote in der EKM. Dies sollte fur Fakultaten und Fachgesellschaften zum Anlass genommen werden, um die universitare Lehre in diesem Bereich starker zu fordern.

To determine the unmet need for care and barriers for consulting sexually transmitted infection (STI) services at six primary healthcare (PHC) facilities in rural South Africa.Cross-sectional study using three community-based strategies to mobilise adult individuals with STI-associated symptoms to access care. Participants were mobilised through clinic posters and referral by community healthcare workers (CHWs) and traditional leaders after training. Men with male urethritis syndrome and women with vaginal discharge syndrome were mobilised to visit participating PHC facilities on two designated days when an expert team visited the facility. Questionnaires were completed and HIV rapid tests offered. The minimal unmet need for care of individuals with STI-associated symptoms was calculated by dividing the number of cases over the adult catchment population of each PHC facility.We successfully mobilised 177 symptomatic individuals: 134 (76%) women and 43 (24%) men. The estimated minimal unmet need for STI care was 1:364 (95% CI 1:350-1:380) individuals in this region; the rate was higher in village than township facilities, and among women. Mobilisation through clinic posters (57%) and by CHWs (23%) was most successful. Three-quarters of individuals (132/177) reported symptoms that had been present for30 days; 49% (87/177) had symptoms6 months. In addition, we identified 14 individuals with untreated HIV infection amounting to a 7% HIV testing yield. Lack of awareness of symptoms (34%), and disappointment in care due to persistent (23%) or recurrent (15%) symptoms after previous treatment, or disappointment with health services in general during previous visit(s) for any reason (10%) was the most common reasons for not consulting health care.We demonstrate a high unmet need for care of individuals with STI-associated symptoms in rural South Africa that requires urgent attention. A multidisciplinary approach that creates service demand through community awareness and information provision by healthcare workers combined with strengthening the quality of STI services is required to improve reproductive health and prevent complications of untreated STIs in this population.Déterminer les besoins non satisfaits en matière de soins et les obstacles à la consultation des services pour IST dans six établissements de soins de santé primaires (SSP) en milieu rural en Afrique du Sud. MÉTHODES: Etude transversale utilisant trois stratégies communautaires pour mobiliser les individus adultes présentant des symptômes associés aux IST afin qu'ils puissent accéder aux soins. Les participants ont été mobilisés à travers des affiches dans les cliniques et sur recommandation des agents de santé communautaires (ASC) et des chefs traditionnels après une formation. Les hommes atteints du syndrome d'urétrite masculin et les femmes atteintes du syndrome de pertes vaginales ont été mobilisés à visiter les établissements de SSP participants, au cours de deux jours choisis lorsqu'une équipe d'experts était présente dans l’établissement. Des questionnaires ont été remplis et des tests de dépistage rapides du VIH ont été proposés. Le besoin minimal non satisfait de soins pour les personnes présentant des symptômes associés aux IST a été calculé en divisant le nombre de cas par la population adulte de la zone de chaque établissement de SSP. RÉSULTATS: Nous avons réussi à mobiliser 177 personnes symptomatiques: 134 (76%) femmes et 43 (24%) hommes. Le besoin minimal non satisfait en matière de soins IST était de 1:364 (IC95%: 1:350 - 1:380) individus dans cette région; le taux était plus élevé dans les villages que dans les installations des bidonvilles et chez les femmes. La mobilisation par le biais d'affiches de cliniques (57%) et par les ASC (23%) a eu le plus de succès. Les trois quarts des personnes (132/177) ont signalé des symptômes présents depuis30 jours; 49% (87/177) présentaient des symptômes6 mois. En outre, nous avons identifié 14 personnes présentant une infection par le VIH, non traitée, ce qui représente un rendement de dépistage du VIH de 7%. Le manque de prise de conscience des symptômes (34%) et la déception avec les soins en raison de symptômes persistants (23%) ou récurrents (15%) après un traitement précédent, ou la déception avec les services de santé en général lors de visites précédentes pour une raison quelconque (10 %) étaient les raisons les plus courantes de ne pas consulter les soins de santé.Dans les zones rurales d'Afrique du Sud, nous démontrons un besoin élevé de soins non satisfaits pour les personnes présentant des symptômes associés aux IST et nécessitant une attention urgente. Une approche multidisciplinaire qui crée une demande de services par le biais de la sensibilisation de la communauté et de la fourniture d'informations par les agents de santé, associée au renforcement de la qualité des services IST, est nécessaire pour améliorer la santé reproductive et prévenir les complications des IST non traitées dans cette population.

Background The Trauma History Questionnaire (THQ) is one of the most widely used traumatic event inventories, but its lack of validation makes it unsuitable for the millions of homeless people with severe mental illness in India, who are particularly vulnerable to trauma exposure. Aims To translate and culturally adapt the THQ for use in a population of homeless people with severe mental illness in Tamil Nadu, India. Method We used Herdman et al's model of cultural equivalence to conduct an in-depth qualitative assessment of the cultural validity of the THQ. Following several translations, conceptual, item, semantic and operational equivalence of the THQ was assessed through four focus groups with user-survivors (n = 20) and two focus groups with mental health professionals (n = 11). Results Several adaptations, including the addition of 18 items about relationships, homelessness and mental illness, were necessary to improve cultural validity. Three items, such as rape, were removed for reasons of irrelevance or cultural insensitivity. Items like ‘adultery’ and ‘mental illness’ were reworded to ‘extramarital affair’ and ‘mental health problem’, respectively, to capture the cultural nuances of the Tamil language. Findings revealed a divergence in views on tool acceptability between user-survivors, who felt empowered to voice their experiences, and mental health professionals, who were concerned for patient well-being. Providing a sense of pride and autonomy, user-survivors preferred self-administration, whereas mental health professionals preferred rater administration. Conclusions Culture significantly affects what types of events are considered traumatic, highlighting the importance of cultural validation of instruments for use in novel populations and settings.

Background:There is a lack of research on technical assistance (TA) interventions in low- and middle-income countries. Variation in local contexts requires tailor-made approaches to TA that are structured and replicable across intervention sites whilst retaining the flexibility to adapt to local contexts. We developed a systematic process of TA using multidisciplinary roving teams to provide support across the various elements comprising local HIV services. Objectives:To examine the effectiveness of targeting specific HIV and TB programme indicators for improvement using roving teams. Method:We conducted a cluster-randomised stepped-wedge evaluation of a TA support package focussing on clinical, managerial and pharmacy services in the Mopani district of the Limpopo province, South Africa (SA). Three roving teams delivered the intervention. Seventeen primary and community healthcare centres that had 400–600 patients on antiretroviral therapy (ART) were selected for inclusion. The TA package was implemented for six consecutive months across facilities until all had received the same level of support. Data were collected from the relevant health management information systems for 11 routine indicators. Results:The mean proportion of PLWH screened for tuberculosis (TB) at ART initiation increased from 85.2% to 87.2% (P= 0.65). Rates of retention in care improved, with the mean proportion of patients retained in care at three months post-ART initiation increasing from 79.9% to 87.4% (P< 0.001) and from 70.3% to 77.7% (P< 0.01) after six months. Finally, the mean proportion of patients with TB who completed their treatment increased from 80.6% to 82.1% (P= 0.75). Conclusion:Tailored TA interventions in SA using a standardised structure and process led to a significant improvement in retention-in-care rates and to non-significant improvements in the proportion of PLWH screened for TB and of those who completed their treatment.

BackgroundThe United States of America has the highest global number of COVID-19 cases and deaths, which may be due in part to delays and inconsistencies in implementing public health and social measures (PHSMs).ObjectiveIn this descriptive analysis, we analyzed the epidemiological evidence for the impact of PHSMs on COVID-19 transmission in the United States and compared these data to those for 10 other countries of varying income levels, population sizes, and geographies.MethodsWe compared PHSM implementation timing and stringency against COVID-19 daily case counts in the United States and against those in Canada, China, Ethiopia, Japan, Kazakhstan, New Zealand, Singapore, South Korea, Vietnam, and Zimbabwe from January 1 to November 25, 2020. We descriptively analyzed the impact of border closures, contact tracing, household confinement, mandated face masks, quarantine and isolation, school closures, limited gatherings, and states of emergency on COVID-19 case counts. We also compared the relationship between global socioeconomic indicators and national pandemic trajectories across the 11 countries. PHSMs and case count data were derived from various surveillance systems, including the Health Intervention Tracking for COVID-19 database, the World Health Organization PHSM database, and the European Centre for Disease Prevention and Control.ResultsImplementing a specific package of 4 PHSMs (quarantine and isolation, school closures, household confinement, and the limiting of social gatherings) early and stringently was observed to coincide with lower case counts and transmission durations in Vietnam, Zimbabwe, New Zealand, South Korea, Ethiopia, and Kazakhstan. In contrast, the United States implemented few PHSMs stringently or early and did not use this successful package. Across the 11 countries, national income positively correlated (r=0.624) with cumulative COVID-19 incidence.ConclusionsOur findings suggest that early implementation, consistent execution, adequate duration, and high adherence to PHSMs represent key factors of reducing the spread of COVID-19. Although national income may be related to COVID-19 progression, a country’s wealth appears to be less important in controlling the pandemic and more important in taking rapid, centralized, and consistent public health action.

Macrolide resistance in Mycoplasma genitalium infection is emerging worldwide and is largely driven by use of azithromycin in STI treatment. South Africa has used azithromycin in its syndromic management regimen of male urethritis and vaginal discharge since 2015, but prevalence of macrolide resistance in M. genitalium remains largely unknown. This study determined azithromycin resistance in M. genitalium in remnant vulvovaginal specimens that had been obtained from pregnant women in Cape Town, South Africa, between November 2017 and February 2019.1 In brief, vulvovaginal swabs were self-collected at participants’ first antenatal care (ANC), third trimester ANC and postnatal care visits. In-facility GeneXpert testing (Cepheid, Sunnyvale, California) for Chlamydia trachomatis , Neisseria gonorrhoeae and Trichomonas vaginalis was done, followed by treatment if indicated. The Aptima Vaginal Swab Specimen Collection Kit (Hologic, San Diego, California) was used to collect a …

Provision of high-quality care and ensuring retention of children on antiretroviral therapy (ART) are essential to reduce human immunodeficiency virus (HIV)-associated morbidity and mortality. Virological non-suppression (≥1000 viral copies/ml) is an indication of suboptimal HIV care and support. This retrospective cohort study included ART-naïve children who initiated first-line ART between July 2015 and August 2017 in Johannesburg and rural Mopani district. Of 2739 children started on ART, 29.5% (807/2739) were lost to care at the point of analysis in August 2018. Among retained children, overall virological non-suppression was 30.2% (469/1554). Virological non-suppression was associated with higher loss to care 30.3% (229/755) compared with suppressed children (9.7%, 136/1399, P < 0.001). Receiving treatment in Mopani was associated with virological non-suppression in children under 5 years (adjusted odds ratio (aOR) 1.7 (95% confidence interval (CI) 1.1–2.4), 5–9 years (aOR 1.8 (1.1–3.0)) and 10–14 years (aOR 1.9 (1.2–2.8)). Virological non-suppression was associated with lower CD4 count in children 5–9 years (aOR 2.1 (1.1–4.1)) and 10–14 years (aOR 2.1 (1.2–3.8)). Additional factors included a shorter time on ART (

Background: Previous studies have described the association between dysbiosis of the vaginal microbiota (VMB) and related dysbiotic conditions, such as bacterial vaginosis (BV) and aerobic vaginitis (AV), and various adverse pregnancy outcomes. There is limited overview of this association from countries in sub-Saharan Africa (SSA), which bear a disproportionally high burden of both vaginal dysbiotic conditions and adverse pregnancy outcomes. This systematic review assesses the evidence on the association between VMB dysbiosis, BV, and AV, and late adverse pregnancy outcomes in women living in SSA.Methods: The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guidelines were followed. Three databases [PubMed, Embase (Ovid), and Cochrane] were used to retrieve observational and intervention studies conducted in SSA that associated VMB dysbiosis, BV, or AV and preterm birth/labor/delivery, preterm rupture of membranes (PROM), low birthweight, small for gestational age, intrauterine growth restriction, intrauterine infection, intrauterine (fetal) death, stillbirth, perinatal death, or perinatal mortality.Results: Twelve studies out of 693 search records from five SSA countries were included. One study identified a positive association between VMB dysbiosis and low birthweight. Despite considerable differences in study design and outcome reporting, studies reported an association between BV and preterm birth (7/9), low birthweight (2/6), PROM (2/4), intrauterine infections (1/1), and small for gestational age (1/1). None of the retrieved studies found an association between BV and pregnancy loss (5/5) or intrauterine growth retardation (1/1). At least two studies support the association between BV and PROM, low birthweight, and preterm birth in Nigerian pregnant women. No reports were identified investigating the association between AV and late adverse pregnancy outcomes in SSA.Conclusion: Two of the included studies from SSA support the association between BV and PROM. The remaining studies show discrepancies in supporting an association between BV and preterm birth or low birthweight. None of the studies found an association between BV and pregnancy loss. As for the role of VMB dysbiosis, BV, and AV during pregnancy among SSA women, additional research is needed. These results provide useful evidence for prevention efforts to decrease vaginal dysbiosis and its contribution to adverse pregnancy outcomes in SSA.

Introduction: This study looked at the effect of post-exposure prophylaxis (PEP) with single-dose rifampicin (SDR) and the education given along with SDR-PEP on stakeholders’ perception regarding leprosy. It is a side study of the Leprosy Postexposure Prophylaxis (LPEP) Program. Methods: The study was done in LPEP implementation areas in India, Nepal and Indonesia. A before and after survey design was used, with qualitative and quantitative data collection methods. This paper presents the quantitative results. In each country 100 interviews were held with representatives of leprosy patients, contacts and community members, before and 1-1.5 years after starting the LPEP Program. Three tools were used: a knowledge, attitudes and practices questionnaire, EMIC community stigma scale and social distance scale (SDS). Results: The most notable effect at follow-up was increased knowledge regarding leprosy in all stakeholder groups, especially leprosy patients. A positive effect was seen on how people think about persons affected by leprosy, reflected by the lower SDS scores in the contact groups in India and Nepal. No negative effects were found on people’s perception and reported behaviour. Participants did express or perceive reluctance to disclose a person’s leprosy status, but this did not negatively affect willingness to participate in the LPEP Program. Conclusion: This study showed that implementation of SDR-PEP and accompanied education led to increased knowledge on leprosy among patients, contacts and community members and it had no negative effect on perception. SDR-PEP implementation provides an opportunity for health education, including messages to help reduce stigmatisation of persons affected by leprosy.

Objective To measure the frequencies of sexually transmitted infections (STIs) and adverse pregnancy outcomes among women receiving either aetiological testing or syndromic management for STIs. Design Non‐randomised prospective cohort study. Setting Primary healthcare facilities in Tshwane, South Africa. Population HIV‐infected pregnant women attending antenatal care services. Methods Participants were enrolled to receive aetiological testing using Xpert® CT/NG and Xpert® TV assays or standard syndromic management. Outcome data were collected at the postnatal care visit (≤30 days from delivery) and from maternity records. Enrolment gestational age‐adjusted relative risk (aRR) was calculated. Main outcome measures STI prevalence at postnatal visit, and frequency of adverse pregnancy outcomes (preterm birth, low birthweight). Results We enrolled 841 women. The prevalence of any STI at baseline was 40%; Chlamydia trachomatis 30%, Neisseria gonorrhoeae 5.6%, Trichomonas vaginalis 20%. The prevalence of STIs at postnatal care was lower among those receiving aetiological testing compared with those receiving syndromic management (14% versus 23%; aRR 0.61; 95% CI 0.35–1.05). No difference was observed between study groups for frequency of preterm birth (23% versus 23%; aRR 1.2, 95% CI 0.81–1.8) and low birth weight (15% versus 13%; aRR 1.1, 95% CI 0.66–1.7). Conclusions Aetiological testing provides an effective intervention to reduce the high burden of STIs in pregnant women in South Africa; however, the optimal implementation strategy remains to be determined. Tweetable abstract Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy., Tweetable abstract Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy.

Background Ensuring the current public health workforce has appropriate competencies to fulfill essential public health functions is challenging in many low- and middle-income countries. The absence of an agreed set of core competencies to provide a basis for developing and assessing knowledge, skills, abilities, and attitudes contributes to this challenge. This study aims to identify the requisite core competencies for practicing health professionals in mid-level supervisory and program management roles to effectively perform their public health responsibilities in the resource-poor setting of Uttar Pradesh (UP), India. Methods We used a multi-step, interactive Delphi technique to develop an agreed set of public health competencies. A narrative review of core competency frameworks and key informant interviews with human resources for health experts in India were conducted to prepare an initial list of 40 competency statements in eight domains. We then organized a day-long workshop with 22 Indian public health experts and government officials, who added to and modified the initial list. A revised list of 54 competency statements was rated on a 5-point Likert scale. Aggregate statement scores were shared with the participants, who discussed the findings. Finally, the revised list was returned to participants for an additional round of ratings. The Wilcoxon matched-pairs signed-rank test was used to identify stability between steps, and consensus was defined using the percent agreement criterion. Results Stability between the first and second Delphi scoring steps was reached in 46 of the 54 statements. By the end of the second Delphi scoring step, consensus was reached on 48 competency statements across eight domains: public health sciences, assessment and analysis, policy and program management, financial management and budgeting, partnerships and collaboration, social and cultural determinants, communication, and leadership. Conclusions This study produced a consensus set of core competencies and domains in public health that can be used to assess competencies of public health professionals and revise or develop new training programs to address desired competencies. Findings can also be used to support workforce development by informing competency-based job descriptions for recruitment and performance management in the Indian context, and potentially can be adapted for use in resource-poor settings globally.

BackgroundHealth-related stigma is a complex phenomenon, the experience of which intersects with those of other adversities arising from a diversity of social inequalities and oppressive identities like gender, sexuality, and poverty – a concept called “intersectionality”. Understanding this intersectionality between health-related stigma and other forms of social marginalization can provide a fuller and more comprehensive picture of stigma associated with health conditions. The main objective of this paper is to build upon the concept of intersectionality in health-related stigma by exploring the convergence of experiences of stigma and other adversities across the intersections of health and other forms of social oppressions among people living with stigmatized health conditions in Indonesia.MethodsThis qualitative study interviewed 40 people affected by either of four stigmatizing health conditions (HIV, leprosy, schizophrenia, and diabetes) in Jakarta and West Java, Indonesia between March and June 2018. Data was analyzed thematically using an integrative inductive-deductive framework approach.ResultsThe main intersectional inequalities identified by the participants were gender and socioeconomic status (n = 21), followed by religion (n = 13), age (n = 11), co-morbidity (n = 9), disability (n = 6), and sexuality (n = 4). Based on these inequalities/identities, the participants reported of experiencing oppression because of prevailing social norms, systems, and policies (macro-level), exclusion and discrimination from societal actors (meso-level), and self-shame and stigma (micro-level). While religion and age posed adversities that negatively affected participants in macro and meso levels, they helped mitigate the negative experiences of stigma in micro level by improving self-acceptance and self-confidence.ConclusionThis study uncovered how the experience of health-related stigma intersects with other oppressions originating from the various social inequalities in an individual’s life. The findings highlight the importance of acknowledging and understanding the multi-dimensional aspect of lives of people living with stigmatized health conditions, and warrant integrated multi-level and cross-cutting stigma reduction interventions to address the intersectional oppressions they experience.

Contains fulltext : 225968.pdf (Publisher’s version ) (Closed access) Immunosuppression in IgA nephropathy (IgAN) should be reserved for patients at high-risk of disease progression, which KDIGO guidelines determine based solely on proteinuria 1g or more/day. To investigate if treatment decisions can be more accurately accomplished using individualized risk from the International IgAN Prediction Tool, we simulated allocation of a hypothetical immunosuppression therapy in an international cohort of adults with IgAN. Two decision rules for treatment were applied based on proteinuria of 1g or more/day or predicted risk from the Prediction Tool above a threshold probability. An appropriate decision was defined as immunosuppression allocated to patients experiencing the primary outcome (50% decline in eGFR or ESKD) and withheld otherwise. The net benefit and net reduction in treatment are the proportion of patients appropriately allocated to receive or withhold immunosuppression, adjusted for the harm from inappropriate decisions, calculated for all threshold probabilities from 0-100%. Of 3299 patients followed for 5.1 years, 522 (15.8%) experienced the primary outcome. Treatment allocation based solely on proteinuria of 1g or more/day had a negative net benefit (was harmful) because immunosuppression was increasingly allocated to patients without progressive disease. Compared to using proteinuria, treatment allocation using the Prediction Tool had a larger net benefit up to 23.4% (95% confidence interval 21.5-25.2%) and a larger net reduction in treatment up to 35.1% (32.3-37.8%). Thus, allocation of immunosuppression to high-risk patients with IgAN can be substantially improved using the Prediction Tool compared to using proteinuria.

Circulating blood glucocorticoid levels are dynamic and responsive to stimuli that impact autonomic function. In the brain stem, vagal afferent terminals release the excitatory neurotransmitter glutamate to neurons in the nucleus of the solitary tract (NTS). Vagal afferents integrate direct visceral signals and circulating hormones with ongoing NTS activity to control autonomic function and behavior. Here, we investigated the effects of corticosterone (CORT) on glutamate signaling in the NTS using patch-clamp electrophysiology on brain stem slices containing the NTS and central afferent terminals from male C57BL/6 mice. We found that CORT rapidly decreased both action potential-evoked and spontaneous glutamate signaling. The effects of CORT were phenocopied by dexamethasone and blocked by mifepristone, consistent with glucocorticoid receptor (GR)-mediated signaling. While mRNA for GR was present in both the NTS and vagal afferent neurons, selective intracellular quenching of G protein signaling in postsynaptic NTS neurons eliminated the effects of CORT. We then investigated the contribution of retrograde endocannabinoid signaling, which has been reported to transduce nongenomic GR effects. Pharmacological or genetic elimination of the cannabinoid type 1 receptor signaling blocked CORT suppression of glutamate release. Together, our results detail a mechanism, whereby the NTS integrates endocrine CORT signals with fast neurotransmission to control autonomic reflex pathways.

This systematic review examines and consolidates existing evidence on stigma associated with the top four non-communicable diseases (NCDs)—cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes—and its impact on the lives of people affected. We conducted a systematic literature search in PubMed, PsycINFO, JSTOR, Science Direct, and Web of Science for original research in English that explored health-related stigma among people living with either of the four NCDs. A three-step integrative synthesis of data was conducted. Twenty-six articles (qualitative = 15; quantitative = 11) were selected, with most (n = 15) related to cancers, followed by diabetes (n = 7), chronic respiratory diseases (n = 3), and cardiovascular diseases (n = 1). Blame, shame, and fear were the main causes of stigma, the origin and nature of which differed according to the disease-specific features. The manifestations (enacted and felt stigma) and consequences (social, behavioral, psychological, and medical) of stigma across NCDs were similar. Inconsistencies existed in the conceptualization of stigma processes. To fill this gap, we developed an NCD-related stigma framework. People living with NCDs can experience stigma, which can negatively impact their health, management of their disease, and quality of life. The new framework can help in improving the understanding of the processes and experiences of stigma related to NCDs.

Aim To review the current literature and publications to assess the clinical features, recommended investigations and treatment for ocular tuberculosis in HIV infected patients. Methods Literature review. Results The human immunodeficiency virus (HIV) epidemic affects as many as 37.9 million people. Mycobacterium tuberculosis infection is common in HIV infection and is a leading cause of death and morbidity. Common clinical presentations include anterior uveitis (granulomatous or otherwise), choroidal granulomas/tubercles, chorioretinitis, subretinal abscess, panophthalmitis, retinal detachment and vasculitis. The majority of clinical findings were in the posterior segment, appeared primarily infective (tubercles/chorioretinitis/abscess) and were largely seen in the context of pulmonary tuberculosis or disseminated disease. Current investigational patterns include corroborative tests such as tuberculin skin test or Interferon-gamma release assay. Systemic testing includes Computed Tomography, MRI or PET/CT scans. Newer Molecular techniques such as GeneXpert MTB/RIF assay and Line Probe assays (LPA) are increasingly important. Apart from standard ocular anti-inflammatory protocols, anti-tubercular treatment as per the clinical staging (latent or active) needs to be initiated. Initiation of anti-retroviral therapy (ART) is important and can be started soon after ATT. Conclusions Ocular manifestations within this group are distinct and unique investigational and therapeutic approaches are needed.

Background: Great strides have been made in decreasing paediatric human immunodeficiency virus (HIV) infections, especially in sub-Saharan Africa. In South Africa, new paediatric HIV infections decreased by 84% between 2009 and 2015. This achievement is a result of a strong political will and the rapid evolution of the country’s prevention of mother-to-child transmission (PMTCT) guidelines. Objectives: In this paper we report on the implementation of a large PMTCT programme in Soweto, South Africa. Methods: We reviewed routinely collected PMTCT data from 13 healthcare facilities, for the period 2002–2015. Antiretroviral therapy (ART) coverage among pregnant women living with HIV (PWLHIV) and the mother-to-child transmission (MTCT) rate at early infant diagnosis were evaluated. Results: In total, 360 751 pregnant women attended the facilities during the review period, and the HIV prevalence remained high throughout at around 30%. The proportion of PWLHIV presenting with a known HIV status increased from 14.3% in 2009 when the indicator was first collected to 45% in 2015, p < 0.001. In 2006, less than 10% of the PWLHIV were initiated on ART, increasing to 88% by 2011. The MTCT rate decreased from 6.9% in 2007 to under 1% from 2013 to 2015, p < 0.001. Conclusion: The achievements in decreasing paediatric HIV infections have been hailed as one of the greatest public health achievements of our times. While there are inherent limitations with using routinely collected aggregate data, the Soweto data reflect progress made in the implementation of PMTCT programmes in South Africa. Progress with PMTCT has, however, not been accompanied by a decline in HIV prevalence among pregnant women.

BackgroundEnsuring the public health workforce has appropriate competencies to fulfill essential public health functions is a challenge in many low- and middle-income countries. The absence of an agreed set of core competencies to provide a basis for developing and assessing knowledge, skills, abilities, and attitudes contributes to this challenge. In Uttar Pradesh, India, where most staff are trained as clinicians, this study is aimed at identifying the requisite core competencies for health professionals in mid-level supervisory and program management roles to effectively perform their public health responsibilities.MethodsWe used a multi-step, interactive Delphi technique to develop an agreed set of public health competencies. A narrative review of core competency frameworks and key informant interviews with human resources for health experts in India were conducted to prepare an initial list of 40 competency statements in eight domains. We then organized a day-long workshop bringing together 22 public health experts and government officials from India, who added to and modified the initial list. After this, a revised list of 54 competency statements was rated on a 5-point Likert scale, with 1 as “not at all important” to 5 as “absolutely essential”. Aggregate statement scores were shared with the participants, who discussed the findings. Finally, the same list was returned to participants for an additional round of ratings. Stability between scores at different steps was identified using the Wilcoxon matched-pairs signed-rank test. Consensus was defined using the percent agreement criterion.ResultsStability between the first and second Delphi scoring steps was reached in 46 of the 54 statements presented to participants. By the end of the second Delphi scoring step, consensus was reached on 48 competency statements across eight domains: public health sciences, assessment and analysis, policy and program management, financial management and budgeting, partnerships and collaboration, social and cultural determinants, communication, and leadership.ConclusionsThis study produced a consensus set of core competencies and domains in public health that can be used to review current training practices, assess competencies of public health professionals, and revise or develop new training programs to address desired competencies in Uttar Pradesh. Findings from this study can also be used to support workforce development by informing competency-based job descriptions for recruitment and performance management and adapted for use elsewhere.

Introduction: The purpose of this study is to investigate the impact of post-exposure prophylaxis (PEP) and the education given along with PEP on knowledge about leprosy and the attitudes and reported behaviour towards people affected by leprosy. This study is a sub-study of the Leprosy Post-Exposure Prophylaxis (LPEP) programme. Methods: Seventy-two semi-structured interviews and five Focus Group Discussions (FGDs) were conducted in India, Nepal and Indonesia. The study population consisted of i) index patients, ii) contacts, iii) community members and iv) health professionals. The participants were selected purposively. A team of four social scientists analysed the data using a thematic analysis. Results: The participants in this study were mostly positive and sometimes very positive about the possibility to prevent leprosy in close contacts through a single dose of rifampicin. Most respondents reported that there were no changes in their views towards leprosy or people affected by leprosy after the intervention. The study revealed that the incorrect health information that was retained and the wish of some people affected to conceal the illness poses challenges for a PEP programme. Conclusion: The LPEP programme was perceived positively and no negative effects were reported. In this analysis, PEP did not appear to have an effect on the way leprosy or people affected by leprosy were perceived. More research is needed on providing health information that is accurate and understandable for contacts, and on approaches in which disclosure of the index patient is not required.

This study from South Africa highlights the importance of rectal Trichomonas vaginalis infection as a sexually transmitted infection among men who have sex with men (MSM). We report seven MSM presenting with rectal T. vaginalis infection. Two men presented with symptoms of proctitis; 5/7 had urethral coinfection with T. vaginalis. Rectal T. vaginalis infection should be considered in MSM in areas where genital infection is endemic.

Summary Implementation research is important in global health because it addresses the challenges of the know–do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.

Background Sexual behaviors in human immunodeficiency virus (HIV)-infected pregnant women in South Africa are not well understood. Methods Human immunodeficiency virus-infected pregnant women were recruited into a prospective cohort at first antenatal care visit. Sociodemographic information and self-collected vulvovaginal swab samples were collected from participants. Vulvovaginal swab samples were tested for Chlamydia trachomatis, Neisseria gonorrhoea, and Trichomonas vaginalis using GeneXpert. We investigated sexual behaviors, alcohol use, factors associated with condomless sex during pregnancy, and prevalent sexually transmitted infection (STI) among our cohort. We report descriptive, univariate and multivariable logistic regression results of sexual behaviors and alcohol use, factors associated with condomless sex at last sex, and having any STI during pregnancy adjusting for a priori confounders. Results We recruited and enrolled 430 HIV-infected pregnant women. Median age was 30 years; median gestational age was 20 weeks. Eighty-nine percent of women reported sex during pregnancy. At last sex, 68% reported condomless sex; 18% reported having more than 1 sex partner in the past 12 months. Adjusting for age, income and relationship status, condom use at last sex was associated with prior knowledge of HIV status (adjusted odds ratio [aOR], 2.46; 95% confidence interval [CI], 1.54-3.92) and being in a concordant HIV-positive (aOR, 3.17; 95% CI, 1.84-5.50), or serodiscordant relationship (aOR, 6.50; 95% CI, 3.59-11.80). The prevalence of any STI was 41% (95% CI, 36%-45%). Adjusting for mothers' age and employment, odds of having an STI increased if the woman reported alcohol use during pregnancy (aOR, 1.96; 95% CI, 1.06-3.64) or if the father of the child was a non-cohabiting or casual partner (aOR, 1.42; 95% CI, 0.97-2.03). Conclusions Almost all HIV-infected pregnant women were sexually active during pregnancy and most women reported condomless sex at last sex. Condom use was associated with knowledge of serostatus and/or partner's serostatus before first antenatal care visit. Factors associated with having STIs included: alcohol use during pregnancy and father of child being a non-cohabiting partner.

HIV testing services are the critical first step to enrolling people into HIV treatment and being an important aspect of HIV prevention efforts.1 However, South African men have consistently been found to test for HIV at lower rates than women.2–4 Data from the 2017 National HIV Prevalence, Incidence, Behavior and Communication Survey, for example, indicate that 78% of HIV-positive men and 89% of HIV-positive women know their HIV status.5 Orr et al4 found in focus group discussions that men reported lower levels of participation in HIV testing for 3 main reasons: fear of damaging their reputations and losing their sense of masculine pride; fear of the potential for community rejection; and fear of a loss of emotional control resulting from the psychological burden of knowing one was HIV-positive. There is therefore a clear need to develop interventions that increase HCT uptake among South African men if the UNAIDS 90-90-90 targets for the HIV program are to be met by 2020.3 One under-researched means of improving men's access to HCT is through involving religious leaders (RLs) in promoting HIV testing in their congregations and communities. Church involvement in the response to the HIV epidemic in southern Africa has tended to be on prevention messaging, counseling, and support and care for those infected and affected by the disease.6,7 There is little evidence of individual churches or congregations directly participating in implementing HTS. Some evidence exists of the potential role of churches in encouraging member to test for HIV; Eriksson et al8 found that youth in faith communities that receive higher levels of education on HIV prevention are more likely to test for HIV. In Philadelphia in the United States, Stewart et al examined the feasibility of conducting HIV testing at churches and found that churches provide a “trust and culturally responsive venue for HIV testing and linkage to care.”9 Similarly, Ezeanolue et al found that a culturally adapted church-based intervention focusing on PMTCT uptake in Nigeria successfully increased HIV testing during pregnancy. In Tanzania, educating RLs about male circumcision resulted in a much higher uptake of services.10 Churches, therefore, seem to provide a potentially useful platform for increasing access to HTS and HIV prevention services. Given that 86% of South Africans report Christianity as their religious affiliation, with 52% reporting at least weekly attendance of religious services and ceremonies, this potential needs to be explored.11 This article explores the role of a 3-phase intervention conducted as partnership between Anova Health Institute and the International Network of Religious Leaders Living with or Affected by HIV and AIDS (INERELA+) with churches and RLs in Limpopo Province, South Africa, in increasing HTS uptake and linkage to care among male church members.

Disclosing to a child that s/he is living with HIV is necessary to promote adherence to treatment and improve health outcomes. Facilitating disclosure between caregivers and children remains a challenge for health workers. Understanding how health workers are involved in and perceive the disclosure process is integral to engaging with such challenges. We held group discussions with and surveyed 73 physicians, nurses, and counselors across 16 randomly selected facilities in two rural South African health districts, exploring their experiences of supporting disclosure between caregivers and children. Ninety percent of those surveyed agreed that children should be informed of their HIV status. Differences between categories of health workers regarding training, involvement in the disclosure process, and perceived responsibility for disclosure support led to inconsistent disclosure practices within facilities. Disclosure-strengthening interventions must consider the composition of the health worker team and the role that each category of health worker performs in their local settings.

Item does not contain fulltext OBJECTIVE: In the prehospital setting, the Nijmegen and Rotterdam helicopter emergency medical services administer packed red blood cells to critically ill or injured pediatric patients. Blood is given on scene or during transport and is derived from nearby hospitals. We summarize our experience with prehospital blood use in pediatric patients. METHODS: The databases from both the Nijmegen and Rotterdam helicopter emergency medical services were reviewed for all pediatric (< 18 years) patients who received packed red blood cells on scene or during transport to the hospital. RESULTS: Between 2007 and 2015, 10 pediatric patients out of approximately 2,400 pediatric patients received blood in the prehospital setting. The median Injury Severity Score was 41. Seven hospitals delivered blood in the prehospital setting at the scene. All patients were in hypovolemic shock. Two patients died. Two patients were believed to be unexpected survivors; 1 was predicted by the Trauma and Injury Severity Score, and a second unexpected survivor was a neonate who was in hypovolemic shock and cardiopulmonary arrest. CONCLUSION: The incidence of prehospital use of blood in injured or critically ill children is low. This intervention presented a potential to limit acid-base disturbance, low hemoglobin levels, and coagulopathy in this group. We believe this cohort also contains 2 unexpected survivors. 4 p.

Responsiveness of physicians (ROPs) reflects the social actions by physicians to meet the legitimate expectations of health care users. Responsiveness is important since it improves understanding and care seeking by users, as well as fostering trust in health systems rather than replicating discrimination and entrenching inequality. Given widespread public and private sector health care provision in Bangladesh, we undertook a mixed-methods study comparing responsiveness of public and private physicians in rural Bangladesh. The study included in-depth interviews with physicians (n = 12, seven public, five private) and patients (n = 7, three male, four female); focus group discussions with users (four sessions, two male and two female); and observations in consultation rooms of public and private sector physicians (1 week in each setting). This was followed by structured observation of patient consultations with 195 public and 198 private physicians using the ROPs Scale, consisting of five domains (Friendliness; Respecting; Informing and guiding; Gaining trust; and Financial sensitivity). Qualitative data were analysed by framework analysis and quantitative data were analyzed using two-sample t-test, multiple linear regression, multivariate analysis of variance, and descriptive discriminant analyses. The mean responsiveness score of public sector physicians was statistically different from private sector physicians: -0.29 vs 0.29, i.e. a difference of - 0.58 (P-value < 0.01; 95% CI - 0.77, -0.39) on a normalized scale. Despite relatively higher level of responsiveness of private sector, according to qualitative findings, neither of the sectors performed optimally. Private physicians scored higher in Friendliness, Respecting and Informing and guiding; while public sector physicians scored higher in other domains. 'Respecting' domain was found as the most important. Unlike findings from other studies in Bangladesh, instead of seeing one sector as better than the other, this study identified areas of responsiveness where each sector needs improvements.

Purpose The purpose of this paper is to demonstrate how public health and systems science methods can be combined to examine the structure and behavior of Afghanistan’s routine childhood immunization system to identify the pathways through which health system readiness to deliver vaccination services may extend beyond immunization outcomes. Design/methodology/approach Using findings from an ecological study of Afghanistan’s immunization system and a literature review on immunization program delivery, the routine immunization system was mapped using causal loop diagrams. Next, a stock-and-flow diagram was developed and translated to a system dynamics (SD) model for a system-confirmatory exercise. Data are from annual health facility assessments and two cross-sectional household surveys. SD model results were compared with measured readiness and service outcomes to confirm system structure. Findings Readiness and demand-side components were associated with improved immunization coverage. The routine immunization system was mapped using four interlinking readiness subsystems. In the SD model, health worker capacity and demand-side factors significantly affected maternal health service coverage. System readiness components affected their future measures mostly negatively, which may indicate that the reinforcing feedback drives current system-structured behavior. Originality/value The models developed herein are useful to explore the potential impact of candidate interventions on service outcomes. This paper documents the process through which public health and systems investigators can collaboratively develop models that represent the feedback-driven behavior of health systems. Such models allow for more realistically addressing health policy and systems-level research questions.

Objective To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions. Design Cross-sectional study. Setting Thirty-three provinces in Afghanistan. Participants Observation of 3072 sick child visits selected by systematic random sampling. Main outcome measure(s) A 10 point IMCI assessment index. Results One hundred and thirty-one (4.3%) of the 3072 sick child visits involved no IMCI-related complaints. The mean assessment index for all sick child visits was 4.81 (SD 2.41). Visits involving any IMCI-related complaint were associated with a 1.02 point higher mean assessment index than those without IMCI-related complaints (95% CI, 0.52-1.53; P < 0.001). After adjusting for relevant covariates including patient age, caretaker gender, provider type, provider gender, provider IMCI training status and IMCI guideline availability, we found that children with IMCI-related presenting complaints had a significantly better quality of IMCI screening, than those without IMCI presenting complaints (by 0.75 points; 95% CI, 0.25-1.26; P = 0.003). Conclusions Our study indicates that children with non-IMCI presenting complaints are at greater risk of suboptimal screening compared to children with IMCI-related presenting complaints. The premise of IMCI is to routinely screen all children for conditions responsible for the major burden of childhood disease in countries like Afghanistan. The study illustrates an important finding that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination to ensure that all children receive routine screening for common IMCI conditions.

Over seven million persons in the United States are supervised by the criminal justice system, including many who have co-occurring mental and substance use disorders (CODs). This population is at high risk for recidivism and presents numerous challenges to those working in the justice system.To provide a contemporary review of the existing research and examine key issues and evidence-based treatment and supervision practices related to CODs in the justice system.We reviewed COD research involving offenders that has been conducted over the past 20 years and provide an analysis of key findings.Several empirically supported frameworks are available to guide services for offenders who have CODs, including Integrated Dual Disorders Treatment (IDDT), the Risk-Need-Responsivity (RNR) model, and Cognitive-Behavioral Therapy (CBT). Evidence-based services include integrated assessment that addresses both sets of disorders and the risk for criminal recidivism. Although several evidence-based COD interventions have been implemented at different points in the justice system, there remains a significant gap in services for offenders who have CODs. Existing program models include Crisis Intervention Teams (CIT), day reporting centers, specialized community supervision teams, pre- and post-booking diversion programs, and treatment-based courts (e.g., drug courts, mental health courts, COD dockets). Jail-based COD treatment programs provide stabilization of acute symptoms, medication consultation, and triage to community services, while longer-term prison COD programs feature Modified Therapeutic Communities (MTCs).Despite the availability of multiple evidence-based interventions that have been implemented across diverse justice system settings, these services are not sufficiently used to address the scope of treatment and supervision needs among offenders with CODs.

Demographic changes, with substantial increase in life expectancy, ask for solid knowledge about how pain perception might be altered by aging. Although psychophysical studies on age-related changes in pain perception have been conducted over more than 70 years, meta-analyses are still missing. The present meta-analysis aimed to quantify evidence on age-related changes in pain perception, indexed by pain thresholds and pain tolerance thresholds in young and older healthy adults. After searching PubMed, Google Scholar and PsycINFO using state-of-art screening (PRISMA-criteria), 31 studies on pain threshold and 9 studies assessing pain tolerance threshold were identified. Pain threshold increases with age, which is indicated by a large effect size. This age-related change increases the wider the age-gap between groups; and is especially prominent when heat is used and when stimuli are applied to the head. In contrast, pain tolerance thresholds did not show substantial age-related changes. Thus, after many years of investigating age-related changes in pain perception, we only have firm evidence that aging reduces pain sensitivity for lower pain intensities. (C) 2017 Elsevier Ltd. All rights reserved.

Objectives: People affected by leprosy are often stigmatised, but stigma is rarely quantified and the effectiveness of interventions is often not evaluated. The SARI Project aimed to test and evaluate three interventions: counselling (involving peer counsellors), socio-economic development (SED) and contact between community members and affected people. Results: This study used a controlled trial design in which pairs of the stigmareduction interventions were randomly allocated to sub-districts in Cirebon District, Indonesia. The study sample consisted of one cohort of people affected by leprosy (on treatment or treated) and two independent samples of community members. The latter were selected through purposive sampling. Three scales (e.g. SARI Stigma Scale, Participation scale) were applied among leprosy-affected people and two scales (e.g. Social Distance Scale) were used among community members pre- and post-intervention. Among affected people (n = 237), significant differences in reduction of stigma and participation restrictions were found in all intervention areas and an improvement in quality of life in some intervention areas. Social distance and social stigma significantly reduced among community members (n = 213 and 375) in the two intervention areas where the contact intervention was implemented. Two of the five instruments indicated changes in the control area, but the changes in the intervention areas were much larger. Conclusion: The SARI Project has demonstrated that a measurable reduction in leprosy-related stigma can be achieved, both at community level and among people affected by leprosy, using reproducible interventions that can be adapted to different settings and target groups.

Introduction The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators. Methods This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework. Results There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P p = 0.02). The qualitative findings suggest that strengthening of citizens’ demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders. Conclusions and recommendations The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.

Background: Penetrating injury can encompass a large spectrum of injuries dependent on the penetrating object, the location of entry, and the trajectory of the object through the human body. Therefore, the management of penetrating injuries can be challenging and often requires rapid assessment and intervention. No universal definition of penetrating injury exists in the literature and little is known about the demographics and outcome of penetrating injury in the Netherlands. Objective: A research was carried out to ascertain the size and outcome of penetrating injuries in two level-one trauma centers in the Netherlands. Methods: Using the trauma registry of the Radboud University Medical Center in Nijmegen and VU University Medical Center in Amsterdam, all patients with penetrating injury were identified who were admitted to these level 1 trauma centers in the period between January 1, 2009, and January 1, 2014. Penetrating injury was defined as an injury that caused disruption of the body surface and extended into the underlying tissue or into a body cavity. Data concerning age, gender, mechanism of injury, Glasgow Coma Scale, number of injuries, type of injury, and Injury Severity Score were collected and analyzed. Patient results were stratified by Injury Severity Score. Results: In total, 354 patients were identified, making up around 2% of all admitted trauma patients 3.1% (VU Medical Center) and 1.6% (Radboud Medical Center). Patients were overwhelmingly male (83.1%) and median age was 36 years (range = 1–88 years). Most injuries were caused by stabbings (51.1%) followed by shootings (26.3%). Admission to the intensive care unit occurred in 41.1% of all patients. Median stay in the intensive care unit was 5.1 days (range = 1–96 days) and median total hospital stay was 8 days (range = 1–95 days). Mortality among these patients was 7.1%, ranging from 0% among patients with Injury Severity Score 1–8 to 100% in patients with Injury Severity Score > 34. High mortality figures were associated with injuries caused by firearms (19.4%), injuries to the head (27.9%), and alleged assaults (10.9%). Differences in demographics between the two centers were not significant. Conclusion: Penetrating injury is a relative rare occurrence in the Netherlands compared with other countries. It is associated with high mortality and substantial hospital costs. The incidence of penetrating injuries is higher in metropolitan areas than in rural areas. A universal definition of penetrating trauma should be agreed upon in order to ensure that future studies remain free of bias, and also to ensure that data remain homogeneous.

A progressive decline in maximum heart rate (mHR) is a fundamental aspect of aging in humans and other mammals. This decrease in mHR is independent of gender, fitness, and lifestyle, affecting in equal measure women and men, athletes and couch potatoes, spinach eaters and fast food enthusiasts. Importantly, the decline in mHR is the major determinant of the age-dependent decline in aerobic capacity that ultimately limits functional independence for many older individuals. The gradual reduction in mHR with age reflects a slowing of the intrinsic pacemaker activity of the sinoatrial node of the heart, which results from electrical remodeling of individual pacemaker cells along with structural remodeling and a blunted β-adrenergic response. In this review, we summarize current evidence about the tissue, cellular, and molecular mechanisms that underlie the reduction in pacemaker activity with age and highlight key areas for future work.

Background Depression is one of the most common and serious diseases worldwide: According to WHO, more than 300 million people worldwide were affected by depression in 2015. In this group, the suicide rate is about 20 times higher than the population average. In Germany, around 10,000 people take their lives each year, many of them suffering from depression. The Institute for Quality and Efficiency in Health Care commissioned the Department of Health Care Management at the Berlin University of Technology to conduct a Health Technology Assessment on whether non-drug interventions influence coping with suicidal crises in unipolar depression. Methods A systematic search of primary studies and systematic reviews (e.g., in MEDLINE, PSYCINFO) was performed to assess the benefit of ambulatory crisis intervention programmes or psychosocial interventions compared to another non-drug treatment, drug treatment, inpatient treatment or no treatment/waiting list in adult suicidal patients with unipolar depression regarding patient-relevant outcomes (e.g., suicide attempts, suicidal ideation, depression). Results The search yielded a total of 4,159 hits. After two rounds of screening for relevance and removing duplicates, 4 studies remained for inclusion in the qualitative and quantitative analysis. The studies present RCTs assessing the effects of cognitive behavioural therapy (CBT) of the 2. and 3. wave - all short-term programmes focussing on suicidality. Results indicate a benefit of CBT compared to standard treatment, depending on the outcome, on the “wave” and on the time of follow up assessment. Conclusions There is some evidence on benefits of CBT for adult patients with suicidal crises in unipolar depression. However, the quality of the included RCTs is weak and evidence on benefits of other non-drug interventions in outpatient care is missing. Further research is needed to identify effective interventions, especially for the vulnerable weeks immediately after suicide attempt. Key messages Short term cognitive behavioural therapy with suicidal prevention elements may influence coping with suicidal crises in unipolar depression positively. Further research is needed to identify effective interventions for the vulnerable weeks immediately after suicide attempt.

Background Neisseria gonorrhoeae drug resistance has emerged worldwide. There is limited data about the situation in South Africa where syndromic management is used for sexually transmitted infections (STIs). We investigated the antimicrobial resistance profile of Neisseria gonorrhoeae infections in high-risk men. Methods We conducted a cross-sectional study at three primary healthcare facilities in Johannesburg, South Africa. We recruited: (a) men with persistent or recurrent discharge following recent treatment, and b) men-who-have sex with men (MSM) presenting with urethral discharge. Urethral swab and urine were obtained for culture of Neisseria gonorrhoeae on New York city medium followed by drug susceptibility testing using E-test with minimum inhibitory concentration (MIC) as per EUCAST guidelines. Molecular diagnostics for STIs were performed using the TIB MOLBIOL Lightmix Kit 480 HT CT/NG assay and real-time PCR assays for Trichomonas vaginalis and Mycoplasma genitalium. Results We recruited 48 men of which 30 (63%) had persistent or recurrent discharge and 18 (37%) were MSM. Urine PCR was positive for Neisseria gonorrhoeae in 36 men (75%); Chlamydia trachomatis was detected in 9 (19%), Mycoplasma genitalium in 13 (27%) and Trichomonas vaginalis in 6 (13%). Gonococcal cultures were positive for 25/36 men (69%) with Neisseria gonorrhoeae detected molecularly. Isolates showed resistance to ciprofloxacin in 60%, penicillin 32% and tetracycline 60%. Reduced susceptibility to azithromycin was identified in 11/25 (44%) isolates: 5 were resistant (MIC range 1–8 µg/ml) and another 6 showed intermediate resistance. All MIC values for the cephalosporins and spectinomycin were within the susceptible range. Conclusion The observed high rate of azithromycin resistance in Neisseria gonorrhoeae infection in our high-risk population is of great concern as it effectively results in monotherapy. These findings add to the debate on the best regimen choice for syndromic management, and emphasize that the introduction of diagnostics is a priority in our setting. Disclosure No significant relationships.

Introduction: Extrapulmonary tuberculosis (TB) causes a significant burden of disease worldwide, especially among HIV-infected individuals and those with other immunosuppressive conditions. Cutaneous TB is an important manifestation of extrapulmonary TB but is uncommonly reported in South Africa despite the high burden of HIV and TB co-infection. There is a paucity of published data on clinical presentation and outcome of cutaneous TB in this context. Raising awareness of this condition among clinicians is imperative to improve early diagnosis and optimise treatment outcomes. Patient presentation: In this series, we present three cases of cutaneous TB, two adults and one child, referred to a tertiary hospital from two primary healthcare centres and from a general practitioner. We demonstrate that the clinical presentation is diverse, ranging from papular lesions to abscesses, and that concordant pulmonary TB may be present. Management: In particular, we show the importance of performing diagnostic procedures (e.g. aspiration) in individuals presenting with an abscess that does not respond to broad spectrum antimicrobial treatment, particularly in those with advanced immunosuppression. Outcome and conclusion: The outcome of our three patients was poor, highlighting the need for earlier diagnosis in this WHO Stage 4 condition and intensive management of clinical cases. Keywords: HIV-medicine; Retro-Viral Disease; Mycobacteria; Tuberculosis; Multidrug Resistance; Cutaneous Tuberculosis; Cutaneous Disease; immunocompromised.