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Rice Hull Ash (RHA) was converted to amorphous silica gel using a modified version of published literature procedures. The gels were characterized by a comparison of their CPMAS [29] Si NMR and Scanning Electron Microscopy (SEM) images with commercial silica gels. The resulting gels were silanized with a 7.5:1 mixture of methyltrichlorosilane and chloropropyltrichlorosilane and then reacted with poly(allylamine) (PAA) to produce the silica polyamine composite (SPC) BP-1. The BP-1 was then further modified with pyridine-2-carboxaldehyde to form the copper selective SPC, CuSELECT. This procedure follows that used to produce the commercialized version of these composite materials from commercially available amorphous silica gels. The composites were characterized by solid state NMR techniques, elemental analysis, SEM, porosimetry, and metal ion capacity and selectivity. The overall goal of the project was to determine the feasibility of using RHA to make SPC. The observed strengths and weaknesses of this approach are discussed.

Over the past ten years research at the University of Montana in collaboration with Purity Systems Inc, both located in Missoula, Montana, has resulted in a novel class of chelator materials composed of amorphous, nanoporous silica gels and modified polyamines. These materials offer some distinct advantages over conventional polystyrene based resins especially for applications in the mining industry. This paper will report on the relationship between polymer structure and metal selectivity, the relationship between chelator structure and metal selectivity and further comparisons with polystyrene analogs.

Abstract Introduction In 2018, the Malawi Ministry of Health adopted the recommendation to switch first-line antiretroviral therapy (ART) from an efavirenz (EFV)-based to a dolutegravir (DTG)-based regimen. Little is known about patients’ experience during this transition. We conducted a qualitative study to explore DTG-related counselling challenges among providers of HIV care and factors influencing regimen switching or non-switching among women living with HIV in Lilongwe, Malawi. Methods Between February-July 2020, we recruited participants who took part in DTG counselling on reasons to switch, side effects, and benefits from two government health facilities providing HIV care: Area 18 health centre and Bwaila district hospital in Lilongwe, Malawi. We purposively sampled and interviewed 8 women living with HIV who remained on an EFV-based regimen after counselling, 10 women who switched to a DTG-based regimen, and 10 HIV care providers who provided counselling about ART switching. In-depth interviews were used to explore patient’s perceptions of DTG, factors affecting the decision to switch, and both patient and provider experience with counselling. Interview data was coded for themes using inductive and deductive codes. Interviews were conducted until thematic saturation was achieved. Data matrices were used for analysis and thematic extraction. Results Most women in both groups were well versed on DTG’s potential side effects and felt well counselled on the benefits of switching, such as quicker viral load suppression. Many women associated DTG with birth defects and expressed concern. However, the primary reason for not switching was concern with how the new medication would be tolerated, especially when they were satisfied with their current regimen. Almost all providers expressed difficulty providing DTG counselling. Primary reasons included feeling inadequately trained and/or not having resources to use during counselling, such as diagrams or brochures. Conclusion DTG counselling was well accepted by women; however, some felt that their concerns were not fully addressed. Providers reflected this sentiment in that they did not feel adequately trained or well-equipped to provide adequate counselling. Training on counselling for new ART regimens should be intensified and utilize patient-centered educational materials to address the concerns raised by both patients and health care providers.

Angioleiomyoma is a benign soft tissue tumor arising from vascular smooth muscle and most commonly presents in the lower extremities. We report a case of a 52-year-old right-hand dominant woman who presented with a 2-year history of intermittent, nonradiating left wrist pain, which she described as achy in nature without numbness or tingling. A focused physical examination revealed no edema, no obvious skin changes; there was tenderness over the volar-radial aspect of the left wrist, with an underlying firm, mobile, and palpable soft tissue mass. There was no prior history of trauma or surgery to the affected area. Ultrasound (US) examination demonstrated a 0.6 × 0.6 × 0.4 cm well-defined, oval, hypoechoic soft tissue mass within the volar radial soft tissues of the left wrist. The lesion abutted the radial artery without signs of calcification or necrosis. Color Doppler showed little to no vascularity within the mass nor radial artery thrombosis. Histological analysis revealed an angioleiomyoma arising from the radial artery wall. A case presentation like this would most commonly be due to a volar ganglion cyst; however, it is important to consider other soft tissue masses in differential diagnosis, such as angioleiomyoma, as treatment varies significantly.

Abstract Background Enfortumab vedotin (EV) is an antibody‐drug conjugate showing significant overall survival (OS) benefit versus chemotherapy for patients with previously treated locally advanced or metastatic urothelial carcinoma (la/mUC) in EV‐301. This subgroup analysis was conducted to further analyze the efficacy and safety in a Japanese population. Methods In the open‐label, phase 3 EV‐301 trial, patients with la/mUC were randomized 1:1 to EV 1.25 mg/kg on Days 1, 8, and 15 for 28‐day cycles or investigator‐preselected standard chemotherapy (SC; docetaxel or paclitaxel for patients in Japan) on Day 1 of each 21‐day cycle. Primary endpoint was OS and secondary efficacy endpoints included progression‐free survival (PFS) and overall response rate (ORR). Safety/tolerability was also evaluated. Results As of the July 15, 2020 cut‐off date for the interim analysis, the Japanese subgroup included 86 patients (EV: n = 36; SC: n = 50). Median OS was 15.18 months for EV and 10.55 months for SC (HR: 0.437 [95% CI: 0.209, 0.914]). Median PFS was 6.47 months for EV and 5.39 months for SC (HR: 0.464 [95% CI: 0.258, 0.835]). Confirmed ORR was 34.4% for EV and 21.3% for SC. A higher proportion of patients receiving SC versus EV had treatment‐related adverse events (TRAEs; 97.9% vs. 91.7%, respectively), including grade ≥ 3 TRAEs (75.0% vs. 63.9%). Conclusions This subgroup analysis confirmed that EV, with consistent efficacy and safety/tolerability in the EV‐301 Japanese subgroup and overall study population, represents an important treatment option for previously treated patients with la/mUC.

Bladder cancer can often exhibit genomic and morphological heterogeneity. Here, the authors use genomics analysis to show lineage plasticity of bladder cancers with squamous differentiation, and identify key transcription factors related to this morphological and immune heterogeneity.

Data regarding response to SARS-CoV-2 immunization in pediatric patients with predominantly antibody deficiency (PAD) is limited. We evaluated SARS-CoV-2 immunization response by anti-SARS-CoV-2-spike antibody level in 15 pediatric PAD patients. These data were compared to a published cohort of adult PAD patients (n=62) previously analyzed following SARS-CoV-2 immunization at our single center institution. We evaluated demographics, clinical characteristics, immunophenotype, infection history, and past medication use by chart review. Following a two-dose monovalent initial series SARS-CoV-2 immunization, mean anti-SARS-CoV-2-spike antibody levels were significantly higher in pediatric PAD patients compared to adult PAD patients (2,890.7 vs. 140.1 U/mL; p

Abstract Introduction Despite widespread success in reducing vertical HIV transmission, most antenatal care (ANC) programmes in eastern and southern Africa have not emphasized primary prevention of maternal HIV acquisition during pregnancy and lactation/breastfeeding. We hypothesized that combination HIV prevention interventions initiated alongside ANC could substantially reduce maternal HIV incidence. Methods We constructed a multi‐state model describing male‐to‐female HIV transmission in steady heterosexual partnerships during pregnancy and lactation/breastfeeding, with initial conditions based on population distribution estimates for Malawi and Zambia in 2020. We modelled individual and joint increases in three HIV prevention strategies at or soon after ANC initiation: (1) HIV testing of male partners, resulting in HIV diagnosis and less condomless sex among those with previously undiagnosed HIV; (2) initiation (or re‐initiation) of suppressive antiretroviral therapy (ART) for male partners with diagnosed but unsuppressed HIV; and (3) adherent pre‐exposure prophylaxis (PrEP) for HIV‐negative female ANC patients with HIV‐diagnosed or unknown‐status male partners. We estimated the percentage of within‐couple, male‐to‐female HIV transmissions that could be averted during pregnancy and lactation/breastfeeding with these strategies, relative to base‐case conditions in which 45% of undiagnosed male partners become newly HIV diagnosed via testing, 75% of male partners with diagnosed but unsuppressed HIV initiate/re‐initiate ART and 0% of female ANC patients start PrEP. Results Increasing uptake of any single strategy by 20 percentage points above base‐case levels averted 10%−11% of maternal HIV acquisitions during pregnancy and lactation/breastfeeding in the model. Joint uptake increases of 20 percentage points in two interventions averted an estimated 19%−23% of transmissions, and with a 20‐percentage‐point increase in uptake of all three interventions, 29% were averted. Strategies achieving 95% male testing, 90% male ART initiation/re‐initiation and 40% female PrEP use reduced incident infections by 45%. Conclusions Combination HIV prevention strategies provided alongside ANC and sustained through the post‐partum period could substantially reduce maternal HIV incidence during pregnancy and lactation/breastfeeding in eastern and southern Africa.

Abstract Introduction Couple HIV testing and counselling (CHTC) is associated with measurable benefits for HIV prevention and treatment. However, the uptake remains limited in much of sub‐Saharan Africa, despite an expanded range of strategies designed to promote access. Methods Following PRIMSA guidelines, we conducted a systematic review to characterize CHTC uptake strategies. Five databases were searched. Full‐text articles were included if they were: conducted in sub‐Saharan Africa during the study period (1980–2019), targeted heterosexual couples, reported at least one strategy to promote CHTC and provided a quantifiable measure of CHTC uptake. After the initial and full‐text screening, key features of the studies were abstracted and synthesized. Results Of the 6188 unique records found in our search, 365 underwent full‐text review with 29 distinct studies included and synthesized. Most studies recruited couples through antenatal care (n = 11) or community venues (n = 8) and used provider‐based HIV testing (n = 25). The primary demand creation strategies included home‐based CHTC (n = 7); integration of CHTC into clinical settings (n = 4); distribution of HIV self‐testing kits (n = 4); verbal or written invitations (n = 4); community recruiters (n = 3); partner tracing (n = 2); relationship counselling (n = 2); financial incentives (n = 1); group education with CHTC coupons (n = 1); and HIV testing at other community venues (n = 1). CHTC uptake ranged from negligible to nearly universal. Discussion We thematically categorized a diverse range of strategies with varying levels of intensity and resources used across sub‐Saharan Africa to promote CHTC. Offering CHTC within couples’ homes was the most common approach, followed by the integration of CHTC into clinical settings. Due to heterogeneity in study characteristics, we were unable to compare the effectiveness across studies, but several trends were observed, including the high prevalence of CHTC promotion strategies in antenatal settings and the promising effects of home‐based CHTC, distribution of HIV self‐tests and integration of CHTC into routine health services. Since 2019, an updated literature search found that combining partner notification and secondary distribution of HIV self‐test kits may be an additionally effective CHTC strategy. Conclusions There are many effective, feasible and scalable approaches to promote CHTC that should be considered by national programmes according to local needs, cultural context and available resources.

The 24-h activity cycle (24HAC) is a new paradigm for studying activity behaviors in relation to health outcomes. This approach inherently captures the interrelatedness of the daily time spent in physical activity (PA), sedentary behavior (SB), and sleep. We describe three popular approaches for modeling outcome associations with the 24HAC exposure. We apply these approaches to assess an association with a cognitive outcome in a cohort of older adults, discuss statistical challenges, and provide guidance on interpretation and selecting an appropriate approach. We compare the use of the isotemporal substitution model (ISM), compositional data analysis (CoDA), and latent profile analysis (LPA) to analyze 24HAC. We illustrate each method by exploring cross-sectional associations with cognition in 1,034 older adults (Mean age = 77; Age range = 65–100; 55.8% female; 90% White) who were part of the Adult Changes in Thought (ACT) Activity Monitoring (ACT-AM) sub-study. PA and SB were assessed with thigh-worn activPAL accelerometers for 7-days. For each method, we fit a multivariable regression model to examine the cross-sectional association between the 24HAC and Cognitive Abilities Screening Instrument item response theory (CASI-IRT) score, adjusting for baseline characteristics. We highlight differences in assumptions and the scientific questions addressable by each approach. ISM is easiest to apply and interpret; however, the typical ISM assumes a linear association. CoDA uses an isometric log-ratio transformation to directly model the compositional exposure but can be more challenging to apply and interpret. LPA can serve as an exploratory analysis tool to classify individuals into groups with similar time-use patterns. Inference on associations of latent profiles with health outcomes need to account for the uncertainty of the LPA classifications, which is often ignored. Analyses using the three methods did not suggest that less time spent on SB and more in PA was associated with better cognitive function. The three standard analytical approaches for 24HAC each have advantages and limitations, and selection of the most appropriate method should be guided by the scientific questions of interest and applicability of each model’s assumptions. Further research is needed into the health implications of the distinct 24HAC patterns identified in this cohort.

Immune checkpoint blockade therapy is successful in a high proportion of cancer patients, but others remain unresponsive. Authors here show that therapeutic success might be predictable in metastatic bladder cancer by longitudinal analysis of the early neoantigen-specific CD8 T cell response in peripheral blood.

This study explored the experiences of pregnant women who received two intervention models for increasing uptake of male partner HIV testing in antenatal settings. As part of a randomised trial, we interviewed twenty participants who received partner notification services only while 22 received the partner notification plus HIV self-testing. Thematic analysis was used to analyse the data. Partner notification services helped to initiate discussions of HIV testing with partners, influence partners to undergo testing, and encouraged disclosure of HIV status. Some women experienced difficulties engaging partners due to fear of their partner's reaction. Some partners were unable to test due to time constraints. The partner notification plus HIV self-testing intervention, stimulated discussion about HIV testing; facilitated testing for men at their convenience; addressed privacy/confidentiality, and stigma concerns; and provided the opportunity to disclose HIV status. Some women feared disclosure and retribution in case of discordance results. There were also challenges with men making follow-ups for confirmatory HIV tests. The addition of HIV self-test kits to partner notification services can expand HIV testing services to male partners, including those of HIV-negative women. Additional efforts are needed to link men to appropriate HIV prevention, care, and treatment services.

Crowdsourcing is an interactive process that has a group of individuals attempt to solve all or part of a problem and then share solutions with the public. Crowdsourcing is increasingly used to enhance training through developing learning materials and promoting mentorship. This scoping review aims to assess the literature on crowdsourcing for training in public health. We searched five medical and public health research databases using terms related to crowdsourcing and training. For this review, the concept of crowdsourcing included open calls, designathons, and other activities. We used a PRISMA checklist for scoping reviews. Each full-text was assessed by two independent reviewers. We identified 4,071 citations, and 74 studies were included in the scoping review. This included one study in a low-income country, 15 studies in middle-income countries, 35 studies in high-income countries, and 11 studies conducted in multiple countries of varying income levels (the country income level for 12 studies could not be ascertained). Nine studies used open calls, 35 used a hackathon, designathon or other "a-thon" event, and 30 used other crowdsourcing methods, such as citizen science programs and online creation platforms. In terms of crowdsourcing purpose, studies used crowdsourcing to educate participants (20 studies), develop learning materials (17 studies), enhance mentorship (13 studies) and identify trainees (9 studies). Fifteen studies used crowdsourcing for more than one training purpose. Thirty-four studies were done in-person, 31 were conducted virtually and nine used both meeting options for their crowdsourcing events. Seventeen studies generated open access materials. Our review found that crowdsourcing has been increasingly used to support public health training. This participatory approach can be a useful tool for training in a variety of settings and populations. Future research should investigate the impact of crowdsourcing on training outcomes.

Background Oncolytic virus V937 showed activity and safety with intratumoral administration. This phase 1 study evaluated intravenous V937±pembrolizumab in patients with advanced solid tumors.Methods Patients had advanced non-small cell lung cancer (NSCLC), urothelial cancer, metastatic castration-resistant prostate cancer, or melanoma in part A (V937 monotherapy), and metastatic NSCLC or urothelial cancer in part B (V937+pembrolizumab). Prior immunotherapy was permitted >28 days before study treatment. Patients received intravenous V937 on days 1, 3, and 5 (also on day 8 in part B) of the first 21-day cycle and on day 1 of subsequent cycles for eight cycles. Three ascending dose-escalation cohorts were studied. Dose-escalation proceeded if no dose-limiting toxicities (DLTs) occurred in cycle 1 of the previous cohort. In part B, patients also received pembrolizumab 200 mg every 3 weeks from day 8 for 2 years; dose-expansion occurred at the highest-dose cohort. Serial biopsies were performed.Results No DLTs occurred in parts A (n=18) or B (n=85). Grade 3–5 treatment-related adverse events (AEs) were not observed in part A and were experienced by 10 (12%) patients in part B. The most frequent treatment-related AEs (any grade) in part B were fatigue (36%), pruritus (18%), myalgia (14%), diarrhea (13%), pyrexia (13%), influenza-like illness (12%), and nausea (12%). At the highest tested dose, median intratumoral V937 concentrations were 117,631 copies/mL on day 8, cycle 1 in part A (n=6) and below the detection limit for most patients (86% (19/22)) on day 15, cycle 1 in part B. Objective response rates were 6% (part A), 9% in the NSCLC dose-expansion cohort (n=43), and 20% in the urothelial cancer dose-expansion cohort (n=35).Conclusions Intravenous V937+pembrolizumab had a manageable safety profile. Although V937 was detected in tumor tissue, in NSCLC and urothelial cancer, efficacy was not greater than that observed in previous studies with pembrolizumab monotherapy.Trial registration number NCT02043665.

Abstract Background Clients must recall information from contraceptive counseling sessions to properly use their chosen method. Client recall in community-based settings is challenging given the public nature of these events and the presence of many potential distractions. Understanding the factors that influence client recall during community-based distribution events can guide future training of providers to improve proper use of contraceptive methods and client satisfaction. Methods This cross-sectional study employed a convenience sample of 957 women ages 15–49 old who sought contraceptive services from community-based contraceptive distribution events in Kinshasa, Democratic Republic of the Congo, known as Lelo PF. Recall scores were developed by matching direct observations with client exit interviews. The association between recall and client characteristics, provider characteristics and an index for the quality of the provider-client interaction were tested using multivariate linear regression. Results The average recall score was 67.6%. Recall scores were higher among clients who accepted methods with simpler administration procedures, such as CycleBeads (81.3%), compared to methods requiring more medically advanced administration procedures, such as DMPA-SC (56.6%) and Implanon-NXT (62.1%). This relationship held even after controlling for amount of information each client received. Status as a first-time user was associated with a 5.8 percentage point decrease in recall score (p = 0.002). Time since the provider’s initial family planning training and clients’ perception of the provider-client interaction were associated with higher client recall scores. Conclusion Results of this study suggest that to improve client recall at Lelo PF events, future provider training should focus on how to deliver clear, specific information to clients, making sure clients feel at ease during the counseling session, and treating clients with respect. First-time family planning users and clients who select methods with more medically advanced administration procedures may require extra attention during the consultation to ensure they are able understand and remember the information. Results suggest that providers who have been offering services longer may be more effective in conveying information in a way that clients can remember. Program managers should consider requesting input from experienced providers to improve training sessions.

Abstract Background Youth are at high risk for HIV, but are often left out of designing interventions, including those focused on adolescents. We organized a designathon for Nigerian youth to develop HIV self-testing (HIVST) strategies for potential implementation in their local communities. A designathon is a problem-focused event where participants work together over a short period to create and present solutions to a judging panel. Methods We organized a 72-h designathon for youth (14–24 years old) in Nigeria to design strategies to increase youth HIVST uptake. Proposals included details about HIVST kit service delivery, method of distribution, promotional strategy, and youth audience. Teams pitched their proposals to a diverse seven-member judging panel who scored proposals based on desirability, feasibility, potential impact and teamwork. We examined participants’ socio-demographic characteristics and summarized themes from their HIVST proposals. Results Forty-two youth on 13 teams participated in the designathon. The median team size was 3 participants (IQR: 2–4). The median age was 22.5 years (IQR: 21–24), 66.7% were male, 47.4% completed tertiary education, and 50% lived in Lagos State. Themes from proposals included HIVST integration with other health services, digital marketing and distribution approaches, and engaging students. Judges identified seven teams with exceptional HIVST proposals and five teams were supported for further training. Conclusions The designathon provided a structured method for incorporating youth ideas into HIV service delivery. This approach could differentiate HIV services to be more youth-friendly in Nigeria and other settings.

Abstract Background Research supports that moderate-to-vigorous intensity physical activity (MVPA) is key to prolonged health and function. Among older adults, substantial changes to MVPA may be infeasible, thus a growing literature suggests a shift in focus to whole-day activity patterns. Methods With data from 795 older adults aged 65–100 in the Adult Changes in Thought Activity Monitoring study, we used linear regression to estimate associations between ActiGraph and activPAL measured activity patterns – including light intensity physical activity, steps, standing, and sedentary behaviors – and physical function as measured by a short Performance-based Physical Function (sPPF) score (range 0–12), a composite score based on three standardized physical performance tasks: gait speed, timed chair stands, and grip strength. We examined whether relationships persisted when controlling for MVPA or differed across age, gender, or quartiles of MVPA. Results In models unadjusted for MVPA, a 1-standard deviation (SD) increment of daily sitting (1.9 h more), mean sitting bout duration (8 min longer average), or time spent in sedentary activity (1.6 h more) was associated with ~ 0.3–0.4 points lower mean sPPF score (all p

Metastatic primary cutaneous extramammary Paget disease (EMPD) is a rare clinical entity with a 5-year survival

Abstract Background Immune checkpoint blockade has made a significant impact on the clinical outcomes of patients with metastatic urothelial carcinoma (UC). However, evidence for this approach in patients with non‐UC of the urinary tract is limited. Methods This was a phase II open‐label study of durvalumab 1500 mg and tremelimumab 75 mg every 4 weeks for four cycles followed by durvalumab 1500 mg every 4 weeks. Eligible patients had metastatic non‐UC with ECOG PS 0–1 regardless of prior therapy (except small cell carcinoma who were pretreated). The primary endpoint was overall response rate per RECIST v1.1. A Simon's minimax two‐stage design was employed, with 13 patients planned for stage one. Pre‐treatment tumors underwent PD‐L1 staining and next‐generation sequencing. Results Thirteen patients were treated, including seven small cell carcinoma, three squamous cell carcinoma, and three adenocarcinoma. Eleven patients had visceral metastases. No responses were observed; 11 patients had PD and 2 patients had SD. Median PFS was 1.8 months (95% CI, 1.25‐not reached [NR]) with a median follow‐up of 7.38 months (range, 5.23–21.99 months). Median OS was 6.97 months (95% CI, 4.34‐NR). One patient's tumor was PD‐L1 positive and all sequenced tumors (n = 8) were microsatellite stable. Grades 3–4 treatment‐related adverse events occurred in 38.4% of patients. Conclusions In a poor prognosis cohort of patients with non‐UC, durvalumab and tremelimumab lacked clinical activity while demonstrating a manageable safety profile.

Older adults have higher sedentary behavior (SB), lower physical activity, and are particularly susceptible to negative impacts from the COVID-19 pandemic and associated public health restrictions. Pandemic impacts to SB and health, particularly via objective assessment, are not well documented in the literature. Here we described differences in SB, physical activity, and blood pressure (BP) for older adults before and during the pandemic. Baseline thigh-worn activPAL accelerometer and BP measurements from 95 participants enrolled in a SB intervention trial pre-pandemic were compared to 60 enrolled post-pandemic. We used linear regression models adjusted for demographic and health factors to estimate differences in sample means of SB measures and BP. The post-COVID sample was older (age 67 vs. 70), more female (60% vs. 72%), and included more individuals of color (21% vs. 32%). In fully adjusted models, systolic BP was statistically significantly higher in the post-COVID group (6.8, 95% CI: [0.3,13.3]). After adjustment, activPAL-measured and self-reported activity were non-significant but trended towards greater total sitting (0.4 hours [−0.3, 1.1]), fewer daily steps (−270 [−1078, 538]), and greater self-reported TV time (0.4 hours, [-0.3, 1.1]) post-COVID. Future analyses are warranted to better quantify these impacts and guide clinical care and future interventions.

Introduction Long-term care engagement of women on antiretroviral therapy (ART) is essential to effective HIV public health measures. We sought to explore factors associated with a history of HIV treatment interruption among pregnant women living with HIV presenting to an antenatal clinic in Lilongwe, Malawi. Methods We performed a cross-sectional study of pregnant women living with HIV who had a history of ART interruption presenting for antenatal care. Women were categorized as either retained in HIV treatment or reinitiating care after loss-to-follow up (LTFU). To understand factors associated with treatment interruption, we surveyed socio-demographic and partner relationship characteristics. Crude and adjusted prevalence ratios (aPR) for factors associated with ART interruption were estimated using modified Poisson regression with robust variance. We additionally present patients’ reasons for ART interruption. Results We enrolled 541 pregnant women living with HIV (391 retained and 150 reinitiating). The median age was 30 years (interquartile range (IQR): 25–34). Factors associated with a history of LTFU were age Conclusions Interventions that simplify the ART clinic transfer process, facilitate partner disclosure, and provide counseling about the importance of lifelong ART beyond pregnancy and breastfeeding should be further evaluated for improving retention in ART treatment of women living with HIV in Malawi.

BackgroundDespite the global expansion of HIV self-testing (HIVST), many research studies still rely on self-reported outcomes. New HIVST verification methods are needed, especially in resource-limited settings. ObjectiveThis study aims to evaluate the user experience of a mobile health (mHealth) app to enhance HIVST result reporting and verification. MethodsSemistructured, in-depth interviews were used to evaluate the user experience of the 4 Youth By Youth mHealth photo verification app for HIVST. We used a think-aloud approach, and participants performed usability tasks and completed a qualitative exit interview. The app included HIV educational resources, step-by-step video instructions for performing HIVST, a 20-minute timer, a guide on interpreting results with linkages to care, an offline version, and a photo verification system. Demographic characteristics were reported by using descriptive statistics. Qualitative data were analyzed by using thematic analysis. ResultsA total of 19 users—12 women and 7 men—with a mean age of 22 years, participated in the study. The users completed the usability tasks and successfully uploaded a photo of their test results by using the app without assistance. Four main themes were identified in the data. First, in terms of user-friendly design, the participants noted the user-friendly features of the offline version and the app’s low data use. However, some wanted the app to work in the background when using their mobile phone, and the font used should be more youth friendly. Second, in terms of ease of use, participants remarked that the app’s self-explanatory nature and instructions that guided them on how to use the app enhanced its use. Third, in terms of a user’s privacy, many participants reinforced the importance of privacy settings and tools that protect confidentiality among users. Finally, in terms of linkage to care, participants noted that the app’s linkage to care features were useful, particularly in relation to referrals to trained counselors upon the completion of the test. All the participants noted that the app provided a convenient and private means of verifying the HIV test results. ConclusionsOur findings demonstrated the importance of engaging end users in the development phase of health technology innovations that serve youth. Clinical trials are needed to determine the efficacy of using an mHealth app to verify HIVST results among young people.

Study Region: Lake Urmia, Iran. Study focus: There is widespread interest in restoring drying saline lakes. At Iran’s hypersaline Lake Urmia, managers have sought a uniform target lake level of 1274.1 m above sea level to lower salinity below 263 g L−1 and recover Artemia to sufficient densities to support flamingos. We suggest that addressing a broader range of objectives will allow more flexibility for managing the lake. We define eight restoration objectives to lower salinity, sustain Artemia and flamingo populations, separate islands from each other and the mainland, reduce lakebed dust, maintain commercially valuable ions, and improve recreational access from resort beaches. We use 40 years of experimental, field, satellite, and model data to relate each objective to lake level. We describe variations through time and associated uncertainties for meeting each objective. New hydrological insights: We show that:1) Lake variations prevent setting a precise target restoration level; 2) The current target may not sufficiently lower salinity to recover Artemia to sufficient densities to support flamingos; 3) Restoration objectives do not converge to a single lake level; tradeoffs are murky; 4) Lake Urmia managers should focus on multiple ecosystem services and track how they are met as lake level varies over time; and 5) As information about the lake improves, managers should adapt their management strategies to meet the most attainable objectives.

Introduction To realise the expected gains from prevention of mother-to-child HIV transmission initiatives, adherence to preventative and therapeutic antiretroviral regimens is critical and interventions deployable in busy programmatic settings with a high HIV burden are needed. Based on formative research, we developed an approach that integrates patient-centred counselling and engagement of an adherence supporter for pregnant and breastfeeding women initiating HIV treatment (ie, antiretroviral therapy (ART)) or biomedical HIV prevention (ie, pre-exposure prophylaxis (PrEP)).Methods Tonse Pamodzi 2 is a pilot study designed to provide acceptability, fidelity and clinical outcomes data on a set of behavioural interventions for adherence support. The study comprises two parallel randomised trials, enrolling HIV-positive pregnant women initiating ART (Trial 1, n=100) and HIV-negative pregnant women with risk of HIV acquisition and willing to initiate PrEP (Trial 2, n=200). Within each trial, participants are randomised 1:1 to either the intervention or control group. The Tonse Pamodzi adherence intervention comprises patient-centred counselling (adapted Integrated Next Step Counseling(iNSC)) and external adherence support tailored to the clinical context (ie, for ART or PrEP). Participants randomly assigned to the control group receive standard counselling based on local HIV guidelines. Participants are followed for 6 months. To assess intervention acceptability, we will employ a mixed method approach to describe participant engagement, satisfaction, and discussion content. We will audit and score recorded counselling sessions to evaluate the implementation fidelity of iNSC sessions. We will also assess clinical outcomes at 3 and 6 months for both Trial 1 (retention in care and viral suppression of HIV) and Trial 2 (retention in care, and plasma and intracellular tenofovir drug concentrations).Ethics and dissemination The study protocol was approved by the Malawi National Health Science Research Committee (19/05/2334) and the University of North Carolina at Chapel Hill Institutional Review Board (19-1060).Trial registration number NCT04330989.

Introduction: Older adults, who already have higher levels of social isolation, loneliness, and sedentary behavior, are particularly susceptible to negative impacts from social distancing mandates meant to control the spread of COVID-19. We sought to explore the physical, mental, and social health impacts of the pandemic on older adults and their coping techniques.Materials and Methods: We conducted 25 semi-structured interviews with a sub-sample of participants in an ongoing sedentary behavior reduction intervention. Interviews were recorded and transcribed, and iterative coding was used to extract key themes.Results: Most participants reported an increase in sedentary behavior due to limitations on leaving their home and increased free time to pursue seated hobbies (e.g., reading, knitting, tv). However, many participants also reported increased levels of intentional physical activity and exercise, particularly outdoors or online. Participants also reported high levels of stress and a large decrease in in-person social connection. Virtual connection with others through phone and video was commonly used to stay connected with friends and family, engage in community groups and activities, and cope with stress and social isolation. Maintenance of a positive attitude and perspective gained from past hardships was also an important coping strategy for many participants.Discussion: The COVID-19 pandemic and associated social distancing measures have impacted older adults' perceived levels of activity, stress, and social isolation, but many leveraged technology and prior life experiences to cope. These themes could inform future interventions for older adults dealing with chronic stress and isolation.

BackgroundOral Pre-Exposure Prophylaxis (PrEP) is an effective HIV prevention strategy for adherent users. Adolescent girls and young women (AGYW) in sub-Saharan Africa may particularly benefit from PrEP because of the disproportionate burden of HIV in this group. Understanding potential users' perceptions of and interest in using PrEP is critical to promote the utilization of PrEP by individuals at risk of HIV.MethodsThis qualitative investigation of AGYW's knowledge of and interest in PrEP use was conducted in the context of Girl Power, a quasi-experimental cohort study comparing four models of service delivery at four health centers in Lilongwe, Malawi. We conducted individual in-depth interviews (IDIs) with 40 HIV-negative AGYW ages 15-24 years old six months after enrolment in the parent study. An explanation of PrEP was provided to participants. Interview topics included participants' prior knowledge of, interest in, concerns about, and delivery preferences for PrEP. Analysis consisted of structural coding of interview transcripts corresponding to interview topics, summary of responses within these topics, and identification and description of emerging themes within each topic.ResultsNone of the AGYW had knowledge of PrEP prior to the IDIs, but once explained, a majority expressed an interest in using it due to inconsistencies in condom use, condom use errors, their own or their partners' concurrent sexual partnerships, and rape. Most AGYW hoped that PrEP would be available in youth-friendly sections of health centers for easy access and youth-friendly counselling. They suggested that discrete packaging of PrEP would be needed to ensure user privacy. Concerns about relationship destabilization and accusations of promiscuity were raised as potential barriers to use.ConclusionGeneral interest in PrEP among AGYW was high. Discrete packaging and access to youth-friendly PrEP delivery modalities may facilitate the utilization of PrEP as a prevention strategy among sexually active AGYW. Attention to potential negative reactions from partners and community members to PrEP use will be needed when introducing PrEP to this population.