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Abstract Background The association between HIV infection and increased cardiometabolic risk, attributed to chronic inflammation in people living with HIV (PLWH) and/or antiretroviral therapy (ART) effects, has been inconsistent. In this study, we aimed to assess the associations of HIV-related factors with hypertension (HTN) and type-2 diabetes mellitus (T2DM), and the potential mediation effects of body mass index (BMI) in the associations between ART use and HTN or T2DM in PLWH in Cameroon. Methods A cross-sectional study was conducted with 14,119 adult PLWH from Cameroon enrolled in the International epidemiology Databases to Evaluate AIDS (IeDEA) between 2016 and 2021. HTN was defined as systolic/diastolic blood pressure ≥ 140/90 mmHg and/or current use of antihypertensive medication, while T2DM was defined as fasting blood sugar ≥ 126 mg/dL and/or use of antidiabetic medications. Univariable and multivariable multinomial logistic regression analyses examined the associations of factors with HTN alone, T2DM alone, and both (HTN + T2DM). Mediation analyses were conducted to assess the potential mediation roles of BMI, while controlling for age, sex, and smoking. Results Of the 14,119 participants, 9177 (65%) were women, with a median age of 42 (25th–75th percentiles: 35–51) years. Age > 50 years was associated with HTN alone, T2DM alone, and HTN + T2DM compared to the age group 19–29 years. Men had higher odds of having HTN + T2DM. Overweight and obesity were predictors of HTN alone compared to being underweight. WHO stages II and III HIV disease were inversely associated with HTN alone compared to stage I. The odds of diabetes alone were lower with ART use. BMI partially mediated the association between ART use and hypertension, with a proportion of mediation effect of 49.6% (all p

Abstract Enhancing the arsenal of methods available to shape implementation strategies and bolster knowledge translation is imperative. Stated preference methods, including discrete choice experiments (DCE) and best-worst scaling (BWS), rooted in economics, emerge as robust, theory-driven tools for understanding and influencing the behaviors of both recipients and providers of innovation. This commentary outlines the wide-ranging application of stated preference methods across the implementation continuum, ushering in effective knowledge translation. The prospects for utilizing these methods within implementation science encompass (1) refining and tailoring intervention and implementation strategies, (2) exploring the relative importance of implementation determinants, (3) identifying critical outcomes for key decision-makers, and 4) informing policy prioritization. Operationalizing findings from stated preference research holds the potential to precisely align health products and services with the requisites of patients, providers, communities, and policymakers, thereby realizing equitable impact.

BackgroundDespite the increasing need for digital services to support geriatric mental health, the development and implementation of digital mental health care systems for older adults have been hindered by a lack of studies involving socially vulnerable older adult users and their caregivers in natural living environments. ObjectiveThis study aims to determine whether digital sensing data on heart rate variability, sleep quality, and physical activity can predict same-day or next-day depressive symptoms among socially vulnerable older adults in their everyday living environments. In addition, this study tested the feasibility of a digital mental health monitoring platform designed to inform older adult users and their community caregivers about day-to-day changes in the health status of older adults. MethodsA single-arm, nonrandomized living lab pilot study was conducted with socially vulnerable older adults (n=25), their community caregivers (n=16), and a managerial social worker over a 6-week period during and after the COVID-19 pandemic. Depressive symptoms were assessed daily using the 9-item Patient Health Questionnaire via scripted verbal conversations with a mobile chatbot. Digital biomarkers for depression, including heart rate variability, sleep, and physical activity, were measured using a wearable sensor (Fitbit Sense) that was worn continuously, except during charging times. Daily individualized feedback, using traffic signal signs, on the health status of older adult users regarding stress, sleep, physical activity, and health emergency status was displayed on a mobile app for the users and on a web application for their community caregivers. Multilevel modeling was used to examine whether the digital biomarkers predicted same-day or next-day depressive symptoms. Study staff conducted pre- and postsurveys in person at the homes of older adult users to monitor changes in depressive symptoms, sleep quality, and system usability. ResultsAmong the 31 older adult participants, 25 provided data for the living lab and 24 provided data for the pre-post test analysis. The multilevel modeling results showed that increases in daily sleep fragmentation (P=.003) and sleep efficiency (P=.001) compared with one’s average were associated with an increased risk of daily depressive symptoms in older adults. The pre-post test results indicated improvements in depressive symptoms (P=.048) and sleep quality (P=.02), but not in the system usability (P=.18). ConclusionsThe findings suggest that wearable sensors assessing sleep quality may be utilized to predict daily fluctuations in depressive symptoms among socially vulnerable older adults. The results also imply that receiving individualized health feedback and sharing it with community caregivers may help improve the mental health of older adults. However, additional in-person training may be necessary to enhance usability. Trial RegistrationClinicalTrials.gov NCT06270121; https://clinicaltrials.gov/study/NCT06270121

Abstract Introduction In South Africa, the HIV care cascade remains suboptimal. We investigated the impact of small conditional financial incentives (CFIs) and male‐targeted HIV‐specific decision‐support application (EPIC‐HIV) on the HIV care cascade. Methods In 2018, in uMkhanyakude district, 45 communities were randomly assigned to one of four arms: (i) CFI for home‐based HIV testing and linkage to care within 6 weeks (R50 [US$3] food voucher each); (ii) EPIC‐HIV which are based on self‐determination theory; (iii) both CFI and EPIC‐HIV; and (iv) standard of care. EPIC‐HIV consisted of two components: EPIC‐HIV 1, provided to men through a tablet before home‐based HIV testing, and EPIC‐HIV 2, offered 1 month later to men who tested positive but had not yet linked to care. Linking HITS trial data to national antiretroviral treatment (ART) programme data and HIV surveillance programme data, we estimated HIV status awareness after the HITS trial implementation, ART status 3 month after the trial and viral load suppression 1 year later. Analysis included all known individuals living with HIV in the study area including those who did not participated in the HITS trial. Results Among the 33,778 residents in the study area, 2763 men and 7266 women were identified as living with HIV by the end of the intervention period and included in the analysis. After the intervention, awareness of HIV‐positive status was higher in the CFI arms compared to non‐CFI arms (men: 793/908 [87.3%] vs. 1574/1855 [84.9%], RR = 1.03 [95% CI: 0.99−1.07]; women: 2259/2421 [93.3%] vs. 4439/4845 [91.6%], RR = 1.02 [95% CI: 1.00−1.04]). Three months after the intervention, no differences were found for linkage to ART between arms. One year after the intervention, only 1829 viral test results were retrieved. Viral suppression was higher but not significant in the EPIC‐HIV intervention arms among men (65/99 [65.7%] vs. 182/308 [59.1%], RR = 1.11 [95% CI: 0.88−1.40]). Conclusions Small CFIs can contribute to achieve the first step of the HIV care cascade. However, neither CFIs nor EPIC‐HIV was sufficient to increase the number of people on ART. Additional evidence is needed to confirm the impact of EPIC‐HIV on viral suppression.

Objective: This in vitro study aimed to quantitatively and qualitatively evaluate and compare the horizontal and vertical accuracies of complete-arch casts produced by six 3D printers with different printing principles and resolutions using a low-viscosity resin material. Methods: A reference cast was designed by CAD software. The 3D printers used were DLPa (Asiga MAX), DLPk (cara Print 4.0), LCD2o (Ondemand 2 K Printer), LCD2p (Photon Mono X), LCD4s (SONIC 4 K), and SLA (ZENITH U). Ten casts were printed for each 3D printer using a low-viscosity resin. The accuracy of each printed cast was evaluated using shell-to-shell deviations, 12 linear, one angular, and five height deviations, with a reference cast as the control. The surface features of the casts were examined using field-emission scanning electron microscopy (FE-SEM) and digital cameras. Results: The evaluation of shell-to-shell deviation revealed that DLPa and SLA printers exhibited low trueness values, whereas LCD printers displayed high trueness values. Among the LCD printers, LCD4s and LCD2o exhibited the lowest and highest trueness values, respectively. DLPa printers showed lower trueness values for intercanine and intermolar distances, whereas LCD printers generally demonstrated high trueness values. However, LCD4s exhibited similar trueness values to those of SLA and DLPk. The height deviation was smallest in the anterior area, whereas the largest height deviation occurred in the canine teeth. The surface characteristics indicated that the SLA casts had greater light reflection and blunt canine tips. The FE-SEM observations highlighted that the LCD and DLP printers exhibited varying layer characteristics, with some presenting rough and uneven borders in the anterior lingual area. Significance: The accuracy of 3D printed casts varied among the 3D printer groups: DLPa and SLA were accurate for shell-to-shell deviation, with DLPa being the most accurate for linear and angular deviations. Regardless of the XY resolution, the DLP printers outperformed the LCD printers. Among the LCD group of 3D printers, higher-resolution LCD4s demonstrated increased accuracy. The SLA exhibited soft layer borders in the FE-SEM owing to its laser spot characteristics and prominent light reflection in the digital camera images.

Abstract YPL-001 is a drug substance of Pseudolysimachion rotundum var. subintegrum and has been reported to be a potent COPD inhibitor. For the first time, this study demonstrated a correlation among the iridoid constituents, antioxidants, and MUC5AC inhibition activities in P. rotundum during different growth stages (5 to 11 weeks). Single-factor extraction was used to optimize the plant extraction conditions to maximize the major iridoid constituents (70% ethanol, 40 °C, 1 h); isolated metabolites 1–6 were identified using nuclear magnetic resonance spectroscopy (NMR) and mass spectrometry (MS). The contents of each metabolite and antioxidant/MUC5AC inhibition effects were markedly changed according to the growth stages, especially for catalposide (2, 5.97 → 10.99 mg/g, 1.8-fold) and isovanillyl catapol (5, 4.42 → 20.00 mg/g, 4.5-fold), which were the predominant substances in August. Our results indicated that YPL-001 could potentially contribute to enhancing the P. rotundum value in accumulated iridoids at the growth stage and the biological effect aspects to develop industrial medicinal crops.

Men in sub-Saharan Africa are less likely to accept HIV testing and link to HIV care than women. We conducted a trial to investigate the impact of conditional financial incentives and a decision support application, called EPIC-HIV, on HIV testing and linkage to care. We report the findings of the trial process evaluation to explore whether the interventions were delivered as intended, identify mechanisms of impact and any contextual factors that may have impacted the trial outcomes. Between August 2018 and March 2019, we conducted in-depth interviews and focus group discussions with trial participants (n = 31) and staff (n = 14) to examine views on the implementation process, participant responses to the interventions and the external factors that may have impacted the implementation and outcomes of the study. Interviews were audio-recorded, transcribed, and translated where necessary, and thematically analyzed using ATLAS-ti and NVivo. Both interventions were perceived to be acceptable and useful by participants and implementers. EPIC-HIV proved challenging to implement as intended because it was difficult to ensure consistent use of earphones, and maintenance of privacy. Some participants struggled to navigate the EPIC-HIV app independently and select stories that appealed to them without support. Some participants stopped exploring the app before the end, resulting in an incomplete use of EPIC-HIV. While the financial incentive was implemented as intended, there were challenges with eligibility. The convenience and privacy of home testing influenced the uptake of HIV testing. Contextual barriers including fear of HIV stigma and disclosure if diagnosed with HIV, and expectations of poor treatment in clinics may have inhibited linkage to care. Financial incentives were relatively straightforward to implement and increased uptake of home-based rapid HIV testing but were not sufficient as a 'stand-alone' intervention. Barriers like fear of stigma should be addressed to facilitate linkage to care.

Introduction As people living with HIV (PLHIV) are experiencing longer survival, the co-occurrence of HIV and non-communicable diseases has become a public health priority. In response to this emerging challenge, we aimed to characterise the spatial structure of convergence of chronic health conditions in an HIV hyperendemic community in KwaZulu-Natal, South Africa.Methods In this cross-sectional study, we used data from a comprehensive population-based disease survey conducted in KwaZulu-Natal, South Africa, which collected data on HIV, diabetes and hypertension. We implemented a novel health needs scale to categorise participants as: diagnosed and well-controlled (Needs Score 1), diagnosed and suboptimally controlled (Score 2), diagnosed but not engaged in care (Score 3) or undiagnosed and uncontrolled (Score 4). Scores 2–4 were indicative of unmet health needs. We explored the geospatial structure of unmet health needs using different spatial clustering methods.Results The analytical sample comprised 18 041 individuals. We observed a similar spatial structure for HIV among those with combined needs Score 2–3 (diagnosed but uncontrolled) and Score 4 (undiagnosed and uncontrolled), with most PLHIV with unmet needs clustered in the southern urban and peri-urban areas. Conversely, a high prevalence of need Scores 2 and 3 for diabetes and hypertension was mostly distributed in the more rural central and northern part of the surveillance area. A high prevalence of need Score 4 for diabetes and hypertension was mostly distributed in the rural southern part of the surveillance area. Multivariate clustering analysis revealed a significant overlap of all three diseases in individuals with undiagnosed and uncontrolled diseases (unmet needs Score 4) in the southern part of the catchment area.Conclusions In an HIV hyperendemic community in South Africa, areas with the highest needs for PLHIV with undiagnosed and uncontrolled disease are also areas with the highest burden of unmet needs for other chronic health conditions, such as diabetes and hypertension. Our study has revealed remarkable differences in the distribution of health needs across the rural to urban continuum even within this relatively small study site. The identification and prioritisation of geographically clustered vulnerable communities with unmet health needs for both HIV and non-communicable diseases provide a basis for policy and implementation strategies to target communities with the highest health needs.

Pyocele in infants is rarely described in the literature, but it is an emergent condition that requires rapid recognition and treatment to prevent testicular loss. If peritonitis due to gastrointestinal perforation occurs, abdominal contamination may spread through a patent processus vaginalis in an infant, which may lead to pyocele. We report the cases of three infants with scrotal pyocele due to the spread of infection or inflammatory material from the intraperitoneal cavity through a patent processus vaginalis. Two infants were surgically treated, while the other was treated with percutaneous aspiration and intravenous antibiotic administration. Although rare, pyocele should be considered in the differential diagnosis of acute scrotum in infants, especially in infants who previously had peritonitis due to gastrointestinal perforation.

Abstract Background Prioritization of higher-risk people for COVID-19 vaccination could prevent more deaths, but could slow vaccination speed. We used mathematical modeling to examine the trade-off between vaccination speed and prioritization for individuals age 65+ and essential workers. Methods We used a stochastic, discrete-time susceptible-exposed-infected-recovered (SEIR) model with age- and comorbidity-adjusted COVID-19 outcomes (infections, hospitalizations, and deaths). The model was calibrated to COVID-19 hospitalizations, ICU census, and deaths in NYC. We assumed 10,000 vaccinations per day, initially restricted to healthcare workers and nursing home populations, and subsequently expanded to other populations at alternative times (4, 5, or 6 weeks after vaccine launch) and speeds (20,000, 50,000, 100,000, or 150,000 vaccinations per day), as well as prioritization options (+/− prioritization of people age 65+ and essential workers). In sensitivity analyses, we examined the effect of a SARS-COV-2 variant with greater transmissibility. Results To be beneficial, prioritization must not create a bottleneck that decreases vaccination speed by > 50% without a more transmissible variant, or by > 33% with the emergence of the more transmissible variant. More specifically, prioritizing people age 65+ and essential workers increased the number of lives saved per vaccine dose delivered: 3000 deaths could be averted by delivering 83,000 vaccinations per day without prioritization or 50,000 vaccinations per day with prioritization. Other tradeoffs involve vaccination speed and timing. Compared to the slowest-examined vaccination speed of 20,000 vaccinations per day, achieving the fastest-examined vaccination speed of 150,000 vaccinations per day would avert additional 313,700 (28.6%) infections and 1693 (24.1%) deaths. Emergence of a more transmissible variant would double COVID-19 infections, hospitalizations, and deaths over the first 6 months of vaccination. The fastest-examined vaccination speed could only offset the harm of the more transmissible variant if achieved within 5 weeks of vaccine launch. Conclusions Faster vaccination speed with sooner vaccination expansion would save more lives. Prioritization of COVID-19 vaccines to higher-risk populations would be more beneficial only if it does not create an excessive vaccine delivery bottleneck.

Abstract Objectives We evaluated the association between cardiovascular risk factors and the magnitude of the difference in systolic blood pressure (SBP) between office and ambulatory measurements (masked effect) in untreated individuals without apparent hypertension-mediated organ damage (HMOD). Methods The inclusion criteria were 1) age ≥ 20 years, 2) blood pressure ≥ 140/90 mmHg at the outpatient clinic, and 3) not receiving antihypertensive medications. The difference between office and ambulatory SBP was calculated by subtracting the ambulatory daytime SBP from the office SBP. The association between the masked effect and SBP variability was analyzed in individuals without HMOD (no electrocardiographic left ventricular hypertrophy, spot urine albumin-to-creatinine ratio -5 mmHg exhibited a higher SD and cv of 24-h SBP than those with a negative SBP difference ≤ -5 mmHg or a positive SBP difference. Conclusions The results of our study suggest that the magnitude of the negative difference in office and ambulatory SBP may be a potential risk factor, even in individuals without apparent HMOD. Trial registration This trial is registered with ClinicalTrials.gov ( NCT03855605 ).

Introduction Several low-and middle-income countries are undergoing rapid epidemiological transition with a rising burden of non-communicable diseases (NCDs). South Africa (SA) is a country with one of the largest HIV epidemics worldwide and a growing burden of NCDs where the collision of these epidemics poses a major public health challenge. Methods Using data from a large nationally representative survey, the South Africa Demographic and Health Survey (SADHS 2016), we conducted a geospatial analysis of several diseases including HIV, tuberculosis (TB), cardiovascular, respiratory, and metabolic diseases to identify areas with a high burden of co-morbidity within the country. We explored the spatial structure of each disease and associations between diseases using different spatial and visual data methodologies. We also assessed the individual level co-occurrence of HIV and the other diseases included in the analysis. Results The spatial distribution for HIV prevalence showed that this epidemic is most intense in the eastern region of the country, mostly within the Gauteng, Mpumalanga, and Kwazulu-Natal provinces. In contrast, chronic diseases had their highest prevalence rates the southern region of the country, particularly in the Eastern and Western Cape provinces. Individual-level analyses were consistent with the spatial correlations and found no statistically significant associations between HIV infection and the presence of any NCDs. Conclusions We found no evidence of geospatial overlap between the HIV epidemic and NCDs in SA. These results evidence the complex epidemiological landscape of the country, characterized by geographically distinct areas exhibiting different health burdens. The detailed description of the heterogenous prevalence of HIV and NCDs in SA reported in this study could be a useful tool to inform and direct policies to enhance targeted health service delivery according to the local health needs of each community.

Background: Methyl lucidone (ML), a methyl derivative of lucidone, has anti-inflammatory properties. However, the molecular mechanisms that reduce the inflammatory effect of ML in human lung epithelial cells remain unkown. This study aimed to elucidate the molecular mechanisms underlying the anti-inflammatory effect of ML. Methods: Four compounds (ML, methyl linderone, kanakugiol, and linderone) from Lindera erythrocarpa Makino were evaluated for their ability to reduce MUC5AC secretion levels in phorbol-12-myristate-13-acetate (PMA)-stimulated NCI–H292 cells using ELISA. The expression and secretion levels of inflammatory response-related proteins were analyzed using quantitative reverse transcription-PCR, ELISA, and western blotting. To determine whether ML directly regulates TGF-β-activated kinase 1 (TAK1), we performed an in vitro kinase assay. Results: ML treatment effectively reduced the levels of inflammatory cytokines, including interleukin-1β and TNF-α, increased by stimulation. Furthermore, ML downregulated the pathway cascade of both IκB kinase (IKK)/NF-κB and p38 mitogen-activated protein (MAP) kinase/CREB by inhibiting the upstream kinase TAK1. An in vitro kinase analysis confirmed that ML treatment significantly reduced the kinase activity of TAK1. Conclusion: ML pretreatment repressed the PMA-stimulated inflammation reaction by reducing the TAK1-mediated IKK/NF-κB and p38 MAP kinase/CREB signaling. These findings suggest that ML may improve respiratory health and can be used as a dietary supplement or functional food to prevent inflammatory lung diseases.

Abstract Introduction While it is widely acknowledged that family relationships can influence health outcomes, their impact on the uptake of individual health interventions is unclear. In this study, we quantified how the efficacy of a randomized health intervention is shaped by its pattern of distribution in the family network. Methods The “Home‐Based Intervention to Test and Start” (HITS) was a 2×2 factorial community‐randomized controlled trial in Umkhanyakude, KwaZulu‐Natal, South Africa, embedded in the Africa Health Research Institute's population‐based demographic and HIV surveillance platform (ClinicalTrials.gov # NCT03757104). The study investigated the impact of two interventions: a financial micro‐incentive and a male‐targeted HIV‐specific decision support programme. The surveillance area was divided into 45 community clusters. Individuals aged ≥15 years in 16 randomly selected communities were offered a micro‐incentive (R50 [$3] food voucher) for rapid HIV testing (intervention arm). Those living in the remaining 29 communities were offered testing only (control arm). Study data were collected between February and November 2018. Using routinely collected data on parents, conjugal partners, and co‐residents, a socio‐centric family network was constructed among HITS‐eligible individuals. Nodes in this network represent individuals and ties represent family relationships. We estimated the effect of offering the incentive to people with and without family members who also received the offer on the uptake of HIV testing. We fitted a linear probability model with robust standard errors, accounting for clustering at the community level. Results Overall, 15,675 people participated in the HITS trial. Among those with no family members who received the offer, the incentive's efficacy was a 6.5 percentage point increase (95% CI: 5.3−7.7). The efficacy was higher among those with at least one family member who received the offer (21.1 percentage point increase (95% CI: 19.9−22.3). The difference in efficacy was statistically significant (21.1–6.5 = 14.6%; 95% CI: 9.3−19.9). Conclusions Micro‐incentives appear to have synergistic effects when distributed within family networks. These effects support family network‐based approaches for the design of health interventions.

HIV/AIDS and maternal mortality are the two leading causes of death among women of reproductive age in sub-Saharan Africa. A growing body of research investigates opportunities for multipurpose prevention technologies (MPTs) that prevent unintended pregnancy, HIV, and/or other sexually transmitted infections (STIs) with a single product. More than two dozen MPTs are currently in development, most of them combining contraception with HIV pre-exposure prophylaxis, with or without protection from other STIs. If successful, such MPTs could offer women benefits at multiple levels: greater motivation for effective use; lower product administration burden; accelerated integration of HIV, STI, and reproductive health services; and opportunities to circumvent stigma by using contraception as a “fig leaf” for HIV and/or STI prevention. However, even if women find respite from product burden, lack of motivation, and/or stigma in contraceptive-containing MPTs, their use of MPTs will be interrupted, often multiple times, over the reproductive lifecourse due to desire for pregnancy, pregnancy and breastfeeding, menopause, and changes in risk. Interruptions to the benefits of MPTs could be avoided by combining HIV/STI prevention with other life-stage-appropriate reproductive health products. New product concepts could include combining prenatal supplements with HIV and STI prevention, emergency contraception with HIV post-exposure prophylaxis, or hormone replacement therapies for menopause with HIV and STI prevention. Research is needed to optimize the MPT pipeline based on the populations underserved by available options and the capacity of resource-constrained health systems to deliver novel preventative healthcare products.

IntroductionWomen in sub-Saharan Africa (SSA) experience the world's highest rates of both HIV infection and unintended pregnancy. The Dual Prevention Pill (DPP) is a novel multipurpose prevention technology (MPT) that co-formulates HIV pre-exposure prophylaxis (PrEP) and combined hormonal oral contraception into a single daily pill. As a dual indication product, the DPP may be preferred by women facing these overlapping health risks. However, most SSA countries face severe healthcare resource constraints. Research is needed to assess whether, in what populations, and in what use cases the DPP would be cost-effective.MethodsWe augmented an agent-based SSA HIV model with maternal health parameters including unintended pregnancy, abortion, and maternal mortality. Based on a previous market analysis, we assumed a primary DPP user population of current oral contraceptive users ages 25–49, and alternative user populations in different risk groups (age 15–24, sex workers, HIV-serodiscordant couples) and baseline product use profiles (unmet need for contraception, oral PrEP use, condom use). In three geographies (western Kenya, Zimbabwe, South Africa), we estimated HIV infections averted, pregnancies averted, disability-adjusted life-years (DALYs) averted, and the incremental cost-effectiveness ratio (ICER) over a 30-year time horizon, assuming equivalent adherence to the DPP as to oral contraceptives, higher adherence, or lower adherence.ResultsThe DPP is likely to be a cost-effective alternative to oral PrEP among users in need of contraception. Among women not already using PrEP, the DPP is likely to be cost-saving in sex workers and serodiscordant couples. The DPP is unlikely to be cost-effective in oral contraceptive users in the general population. Switching from oral contraception to the DPP could be net harmful in some settings and populations if it were to substantially reduces adherence to oral contraception. Results were robust to a range of time horizons or discount rates.ConclusionThe DPP has the potential to be cost-effective and cost-saving in populations at substantial HIV risk. Outcomes are sensitive to adherence, implying that effective counseling and decision-making tools for users considering the DPP will be essential. More research is needed to understand real-life adherence patterns and ensure health benefits achieved from contraception alone are not lost.

Introduction: The AmpFire HPV genotyping Assay (Atila Biosystems, Mountain View, CA, USA) is a new test for which there are few data regarding its analytic performance and reliability. Using anal and penile swab specimens from a cohort study of men who have sex with men (MSM) in Rwanda, we compared high-risk HPV (hrHPV) detection by AmpFire done at two laboratories, one at University of California San Francisco (UCSF) and the other Rwanda Military Hospital, and well-validated MY09/11-based assay done at UCSF. Methods: Anal and penile specimens collected from 338 MSM from March 2016 to September 2016 were tested for high-risk HPV genotypes (hrHPV) by MY09/11, AmpFire UCSF and AmpFire RMH. Cohen's kappa coefficient was used to test for reproducibility. Results: The hrHPV positivity by MY09/11 and AmpFire UCSF was 13% and 20.7% (k = 0.73) for anal specimens and was 26.3% and 32.6% (k = 0.67) for penile specimens. Specifically, good reproducibility was for types 16 and 18 (k = 0.69 and k = 0.71) for anal specimens and (k = 0.50 and k = 0.72) for penile specimens. The hrHPV positivity by AmpFire at UCSF and RMH was 20.7% for both laboratories (k = 0.87) for anal specimens and was 34.9% and 31.9% (k = 0.89) for penile specimens. Specifically, excellent reproducibility was for types 16 and 18 for anal specimens (k = 0.80 and k = 1.00) and penile specimens (k = 0.85 and k = 0.91). Conclusion: Results show that MY09/11 and AmpFire assays have good reproducibility while the AmpFire UCSF and RMH assays have excellent reproducibility. These results show that AmpFire is a promising HPV genotyping test.

Abstract Stay-at-home restrictions such as closure of non-essential businesses were effective at reducing SARS-CoV-2 transmission in New York City (NYC) in the spring of 2020. Relaxation of these restrictions was desirable for resuming economic and social activities, but could only occur in conjunction with measures to mitigate the expected resurgence of new infections, in particular social distancing and mask-wearing. We projected the impact of individuals’ adherence to social distancing and mask-wearing on the duration, frequency, and recurrence of stay-at-home restrictions in NYC. We applied a stochastic discrete time-series model to simulate community transmission and household secondary transmission in NYC. The model was calibrated to hospitalizations, ICU admissions, and COVID-attributable deaths over March–July 2020 after accounting for the distribution of age and chronic health conditions in NYC. We projected daily new infections and hospitalizations up to May 31, 2021 under the different levels of adherence to social distancing and mask-wearing after relaxation of stay-at-home restrictions. We assumed that the relaxation of stay-at-home policies would occur in the context of adaptive reopening, where a new hospitalization rate of ≥ 2 per 100,000 residents would trigger reinstatement of stay-at-home restrictions while a new hospitalization rate of ≤ 0.8 per 100,000 residents would trigger relaxation of stay-at-home restrictions. Without social distancing and mask-wearing, simulated relaxation of stay-at-home restrictions led to epidemic resurgence and necessary reinstatement of stay-at-home restrictions within 42 days. NYC would have stayed fully open for 26% of the time until May 31, 2021, alternating reinstatement and relaxation of stay-at-home restrictions in four cycles. At a low (50%) level of adherence to mask-wearing, NYC would have needed to implement stay-at-home restrictions between 8% and 32% of the time depending on individual adherence to social distancing. At moderate to high levels of adherence to mask-wearing without social distancing, NYC would have needed to implement stay-at-home restrictions. In threshold analyses, avoiding reinstatement of stay-at-home restrictions required a minimum of 60% adherence to mask-wearing at 50% adherence to social distancing. With low adherence to mask-wearing and social distancing, reinstatement of stay-at-home restrictions in NYC was inevitable. High levels of adherence to social distancing and mask-wearing could have attributed to avoiding recurrent surges without reinstatement of stay-at-home restrictions.

Abstract Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15–49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20–24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19–3.57), and 2.9-times higher among young men aged 20–24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69–3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 – 0.99) and men (aHR = 0.73, 95% CI 0.66 – 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.

BackgroundTuberculosis (TB) is one of the serious infectious diseases in South Korea, with 49 new cases per 100,000 people and 629 multi-drug resistant (MDR) cases reported in 2020. TB is increasing among immigrants in S. Korea, and various TB case finding strategies are being performed for screening. We compared active case finding (ACF) with passive case finding (semi-PCF) across epidemiological characteristics and investigated a cost-effective strategy for screening immigrants for TB.MethodsACF driven by non-governmental organizations and semi-PCF as part of the government's visa renewal process using CXR with additional acid-fast bacilli (AFB) smear and cultures were performed. Epidemiological parameters were compared between the two TB screening projects, and costs were collected. Cost-effectiveness was evaluated using a decision analysis model from the health system perspective. The primary outcome was incremental cost-effectiveness ratio (ICER) per averted TB case. Additional probabilistic sensitivity analysis was conducted.ResultsACF (2.02%) showed a higher TB prevalence rate than semi-PCF (0.67%) on CXR. For subjects older than 60 years, the suspected TB rate on CXR was significantly higher in ACF (36.6%) than in semi-PCF (12.2%) (PConclusionACF found more TB cases than semi-PCF through CXR screening, and suspect cases with old age and family visa type were more common in ACF than in semi-PCF. ACF is cost-effective as a TB screening strategy for immigrants.

IntroductionStudies of the effectiveness of home blood pressure (BP) measurement on the treatment of hypertension in the real world are sparse, and the results are controversial. There is an efficacy-effectiveness gap in the treatment of hypertension using home BP measurements. We aimed to investigate the effect of reporting home BP to physicians on ambulatory BP control as a factor contributing to the efficacy-effectiveness gap in treating patients with hypertension.MethodsWe recruited patients ≥20 years of age taking antihypertensive drugs. Office and 24-h ambulatory BP were measured. A questionnaire to the measurement of home BP was conducted. Participants were divided into an HBPM(−) group, home BP was not measured (n = 467); HBPM(+)-R(−) group, home BP was measured but not reported (n = 81); and HBPM(+)-R(+) group, home BP was measured and reported (n = 125).ResultsThe HBPM(+)-R(+) group had significantly lower office systolic BP (SBP, p = 0.035), 24-h SBP (p = 0.009), and daytime SBP (p = 0.016) than the HBPM(−) group, and lower nighttime SBP (p = 0.005) and diastolic BP (DBP, p = 0.008) than the HBPM(+)-R(−) group. In the multivariate analysis, the differences in 24-h SBP, daytime SBP, and nighttime DBP remained significant. There was a significant difference between groups in the target achievement rate of 24-h SBP (p = 0.046), nighttime SBP (p = 0.021), and nighttime DBP (p = 0.023). The nighttime SBP and DBP target achievement rates in the HBPM(+)-R(+) group were higher than those in the HBPM(+)-R(−) group (p = 0.006 and 0.010, respectively). Among patients measuring home BP, the adjusted odds ratio for 24-h and nighttime BP target achievement in the HBPM(+)-R(+) group were 2.233 and 3.658, respectively.ConclusionHome BP measurements should be reported to the treating physician to effectively manage hypertension.Clinical trial registrationhttps://clinicaltrials.gov, identifier NCT03868384.

We reviewed the timeline of key policies for control of the coronavirus disease epidemic and determined their impact on the epidemic and hospital burden in South Korea. Using a discrete stochastic transmission model, we estimated that multilevel policies, including extensive testing, contact tracing, and quarantine, reduced contact rates by 90% and rapidly decreased the epidemic in Daegu and nationwide during February‒March 2020. Absence of these prompt responses could have resulted in a >10-fold increase in infections, hospitalizations, and deaths by May 15, 2020, relative to the status quo. The model suggests that reallocation of persons who have mild or asymptomatic cases to community treatment centers helped avoid overwhelming hospital capacity and enabled healthcare workers to provide care for more severely and critically ill patients in hospital beds and negative-pressure intensive care units. As small outbreaks continue to occur, contact tracing and maintenance of hospital capacity are needed.

Background: High-risk human papillomavirus (hrHPV) may cause more than 99% of cervical cancers worldwide. Little is known about performance differences in tests for hrHPV. Objective: This study analysed agreement for detection of hrHPV between the established, clinically validated Xpert HPV assay and the novel isothermal amplification-based AmpFire HPV genotyping assay. Methods: This study was nested in a larger project on cervical cancer screening among approximately 5000 women living with HIV in Kigali, Rwanda. This sub-study included 298 participants who underwent initial screening for cervical cancer using the Xpert HPV assay and visual inspection with acetic acid in 2017 and tested positive by either or both. Participants were rescreened using colposcopy, and cervical samples were collected between June 2018 and June 2019. Samples were then tested for HPV using the Xpert HPV assay and AmpFire HPV genotyping assay. Agreement between results from both tests was analysed using an exact version of McNemar test and chi-square test. Results: Overall agreement and kappa value for detection of hrHPV by Xpert and AmpFire were 89% and 0.77 (95% confidence interval: 0.70–0.85). AmpFire was marginally more likely to diagnose hrHPV-positive than Xpert (p = 0.05), due primarily to the extra positivity for HPV16 (p 0.001). Conclusion: Overall, there was good to excellent agreement between the Xpert and AmpFire when testing hrHPV types among women living with HIV. AmpFire was more likely to test extra cases of HPV16, the most carcinogenic HPV type, but the clinical meaning of detecting additional HPV16 infections remains unknown.

Abstract The role of geographical disparities of health-related risk factors with anemia are poorly documented for women of reproductive age in sub-Saharan Africa (SSA). We aimed to determine the contribution of potential factors and to identify areas at higher risk of anemia for women in reproductive age in SSA. Our study population comprised 27 nationally representative samples of women of reproductive age (15–49) who were enrolled in the Demographic and Health Surveys and conducted between 2010 and 2019 in SSA. Overall, we found a positive association between being anemic and the ecological exposure to malaria incidence [adjusted odds ratio (AOR) = 1.02, 95% confidence interval (CI) 1.02–1.02], and HIV prevalence (AOR = 1.01, CI 1.01–1.02). Women currently pregnant or under deworming medication for the last birth had 31% (AOR = 1.31, CI 1.24–1.39) and 5% (AOR = 1.05, CI 1.01–1.10) higher odds of having anemia, respectively. Similarly, women age 25–34 years old with low education, low income and living in urban settings had higher odds of having anemia. In addition, underweight women had 23% higher odds of suffering anemia (AOR = 1.23, CI 1.15–1.31). Females with low levels of education and wealth index were consistently associated with anemia across SSA. Spatial distribution shows increased risk of anemia in Central and Western Africa. Knowledge about the contribution of known major drivers and the spatial distribution of anemia risk can mitigate operational constraints and help to design geographically targeted intervention programs in SSA.

In the future, tuberculosis (TB) will place a heavy burden on the aging population in Korea. To prepare for this crisis, it is important to analyze the disease burden trend of drug-susceptible tuberculosis (DS-TB) and multidrug-resistant tuberculosis (MDR-TB). Measuring disability-adjusted life years (DALYs) and economic burden on MDR-TB patients can help reduce the incidence of TB. Accordingly, in this study, we measured the DALYs and economic burden on DS-TB and MDR-TB patients in 2014–2017 using a combination of National Health Insurance claims data, Annual Report on the Notified TB data, and Statistics Korea's mortality data. The incidence-based DALY approach implemented involved the summation of years of life lost and years lived with disability. For measuring economic burden, direct and indirect costs incurred by patients were totaled. From 2014 to 2017, DALYs per 100,000 people with DS-TB were 56, 49, 46, and 40, respectively, and DALYs per 100,000 people with MDR-TB were 3, 2, 2, and 2, respectively. The economic burden for the DS-TB population from 2014 to 2017 was $143.89 million, $136.36 million, $122.85 million, and $116.62 million, respectively, while that for MDR-TB was $413.44 million, $380.25 million, $376.46 million and $408.14 million, respectively. The results showed a decreasing trend in DALYs and economic burden for DS-TB, whereas MDR-TB was still found to be burdensome without a specific trend. With respect to age, the economic burden for both DS-TB and MDR-TB was higher among men than among women till ≤ 79 years. Conversely, the economic burden for women aged ≥80 years was higher as compared to their male counterparts. In conclusion, the incidence and spread of TB in all areas of society must be suppressed through intensive management of MDR-TB in the older population. We hope that the national TB management project will proceed efficiently when the infectious disease management system is biased to one side due to the COVID-19 pandemic.

Abstract Background Meconium peritonitis is defined as aseptic chemical inflammation caused by intrauterine bowel perforation. The underlying causes of bowel perforation include intestinal atresia, midgut volvulus, intussusception, congenital bands, and meconium ileus. Case presentation Siblings with prenatally diagnosed meconium peritonitis of different etiologies were found. The elder sister was born at 36 + 6 weeks gestation with a birth weight of 3110 g. She was diagnosed with meconium peritonitis caused by ileal atresia. Two years later, the younger brother was born at 34 + 3 weeks gestation with a birth weight of 2850 g. He was diagnosed with meconium peritonitis caused by midgut volvulus. Conclusions Among the previously reported cases of meconium peritonitis, familial occurance of meconium peritonitis is extremely rare. We present a case of prenatally diagnosed meconium peritonitis in siblings to promote further understanding of its etiology and clinical course.

Novel "differentiated service delivery" models for HIV treatment that reduce clinic visit frequency, minimize waiting time, and deliver treatment in the community promise retention improvement for HIV treatment in Sub-Saharan Africa. Quantitative assessments of differentiated service delivery (DSD) feature most preferred by patient populations do not widely exist but could inform selection and prioritization of different DSD models. We used a discrete choice experiment (DCE) to elicit patient preferences of HIV treatment services and how they differ across DSD models. We surveyed 18+year-olds, enrolled in HIV care for ≥6 months between February-March, 2019 at four facilities in Kisumu County, Kenya. DCE offered patients a series of comparisons between three treatment models, each varying across seven attributes: ART refill location, quantity of dispensed ART at each refill, medication pick-up hours, type of adherence support, clinical visit frequency, staff attitude, and professional cadre of person providing ART refills. We used hierarchical Bayesian model to estimate attribute importance and relative desirability of care characteristics, latent class analysis (LCA) for groups of preferences and mixed logit model for willingness to trade analysis. Of 242 patients, 128 (53.8%) were females and 150 (62.8%) lived in rural areas. Patients placed greatest importance on ART refill location [19.5% (95% CI 18.4, 10.6) and adherence support [19.5% (95% CI 18.17, 20.3)], followed by staff attitude [16.1% (95% CI 15.1, 17.2)]. In the mixed logit, patients preferred nice attitude of staff (coefficient = 1.60), refill ART health center (Coeff = 1.58) and individual adherence support (Coeff = 1.54), 3 or 6 months for ART refill (Coeff = 0.95 and 0.80, respectively) and pharmacists (instead of lay health workers) providing ART refill (Coeff = 0.64). No differences were observed by gender or urbanicity. LCA revealed two distinct groups (59.5% vs. 40.5%). Participants preferred 3 to 6-month refill interval or clinic visit spacing, which DSD offers stable patients. While DSD has encouraged community ART group options, our results suggest strong preferences for ART refills from health-centers or pharmacists over lay-caregivers or community members. These preferences held across gender&urban/rural subpopulations.

Understanding spatial configuration of sexual network structure is critical for effective use of HIV preventative interventions in a community. However, this has never been described at the population level for any setting in sub-Saharan Africa. We constructed the comprehensive geospatial sexual network among new heterosexual partnerships in rural KwaZulu-Natal, South Africa. In the Africa Health Research Institute (AHRI)'s population-based surveillance, we identified stable sexual partnerships among individuals (≥15 years) from 2003 to 2016. Sexual partnerships and residency were recorded via household surveys (every 4-6 months). We geolocated residents and migration events and mapped the geospatial linkages of sexual partners at the start of sexual partnerships. In a grid composed by 108 cells (nodes; 3kmx3km per cell) covering the surveillance area (438km2), we calculated the degree of connectivity and centrality of the nodes and examined their association with HIV prevalence and incidence per cell. Of 2401 new sexual partnerships, 21% (n = 495) had both partners living within the surveillance area at the start of sexual partnerships, and 76% (376/495) were linked to the geographic HIV cluster with high HIV prevalence identified in a peri-urban community. Overall, 57 nodes had at least one connection to another node. The nodes in the peri-urban cluster had higher connectivity (mean = 19, range: 9-32), compared to outside the cluster (6, range: 1-16). The node's degree of connectivity was positively associated with HIV prevalence of the cell (Pearson correlation coefficient = 0.67; p

In this study, we hypothesize that HIV geographical clusters (geospatial areas with significantly higher numbers of HIV positive individuals) can behave as the highly connected nodes in the transmission network. Using data come from one of the most comprehensive demographic surveillance systems in Africa, we found that more than 70% of the HIV transmission links identified were directly connected to an HIV geographical cluster located in a peri-urban area. Moreover, we identified a single central large community of highly connected nodes located within the HIV cluster. This module was composed by nodes highly connected among them, forming a central structure of the network that was also connected with the small sparser modules located outside of the HIV geographical cluster. Our study supports the evidence of the high level of connectivity between HIV geographical high-risk populations and the entire community.

Purpose To identify the effects of superoxide dismutase (SOD)3 on diabetes mellitus (DM)-induced retinal changes in a diabetic rat model. Methods Diabetic models were established by a single intraperitoneal injection of streptozotocin (STZ) in Sprague-Dawley rats. After purification of the recombinant SOD3, intravitreal injection of SOD3 was performed at the time of STZ injection, and 1 and 2 weeks following STZ injection. Scotopic and photopic electroretinography (ERG) were recorded. Immunofluorescence staining with ɑ-smooth muscle actin (SMA), glial fibrillary acidic protein (GFAP), pigment epithelium-derived factor (PEDF), Flt1, recoverin, parvalbumin, extracellular superoxide dismutase (SOD3), 8-Hydroxy-2’deoxyguanosine (8-OHdG) and tumor necrosis factor-ɑ (TNF-ɑ) were evaluated. Results In the scotopic ERG, the diabetic group showed reduced a- and b-wave amplitudes compared with the control group. In the photopic ERG, b-wave amplitude showed significant (p < 0.0005) reduction at 8 weeks following DM induction. However, the trend of a- and b-wave reduction was not evident in the SOD3 treated group. GFAP, Flt1, 8-OHdG and TNF-ɑ immunoreactivity were increased, and ɑ-SMA, PEDF and SOD3 immunoreactivity were decreased in the diabetic retina. The immunoreactivity of these markers was partially recovered in the SOD3 treated group. Parvalbumin expression was not decreased in the SOD3 treated group. In the diabetic retinas, the immunoreactivity of recoverin was weakly detected in both of the inner nuclear layer and inner plexiform layer compared to the control group but not in the SOD3 treated group. Conclusions SOD3 treatment attenuated the loss of a/b-wave amplitudes in the diabetic rats, which was consistent with the immunohistochemical evaluation. We also suggest that in rod-dominant rodents, the use of blue on green photopic negative response (PhNR) is effective in measuring the inner retinal function in animal models of diabetic retinopathy. SOD3 treatment ameliorated the retinal Müller cell activation in diabetic rats and pericyte dysfunction. These results suggested that SOD3 exerted protective effects on the development of diabetic retinopathy.

BackgroundDigital health technologies have been used to enhance adherence to TB medication, but the cost-effectiveness remains unclear.MethodsWe used the real data from the study conducted from April 2014 to December 2020 in Morocco using a smart pillbox with a web-based medication monitoring system, called Medication Event Monitoring Systems (MEMS). Cost-effectiveness was evaluated using a decision analysis model including Markov model for Multi-drug resistant (MDR) TB from the health system perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER) per disability adjusted life-year (DALY) averted. Two-way sensitive analysis was done for the treatment success rate between MEMS and standard of care.ResultsThe average total per-patient health system costs for treating a new TB patient under MEMS versus standard of care were $398.70 and $155.70, respectively. The MEMS strategy would reduce the number of drug-susceptible TB cases by 0.17 and MDR-TB cases by 0.01 per patient over five years. The ICER of MEMS was $434/DALY averted relative to standard of care, and was most susceptible to the TB treatment success rate of both strategies followed by the managing cost of MEMS.ConclusionMEMS is considered cost-effective for managing infectious active TB in Morocco.

The Republic of Korea has a high incidence of tuberculosis (TB) and TB-specific mortality rate. In 2019, it had the second highest TB-specific mortality among Organization for Economic Co-operation and Development countries. Understanding the factors associated with TB-specific deaths may help eradicate the disease. Therefore, we aimed to identify the general characteristics associated with TB-specific mortality among Koreans. Using Causes of Death Statistics data from Statistics Korea, we assessed the year of death, sex, age, occupation, area of residence, marital status, and education level reported between 2008 and 2017. Patient characteristics associated with TB-specific deaths were analyzed using the Chi-squared test, while influencing factors of TB-specific mortality were analyzed using logistic regression analysis to calculate adjusted odds ratios (AOR). Female (AOR: 0.509, 95% CI: 0.493–0.526), those with a graduate degree or higher (AOR: 0.559, 95% CI: 0.474–0.660) had lower TB-specific mortality rates than those of their counterparts. Conversely, those aged ≥70 years (AOR: 1.239, 95% CI: 1.199–1.280), single (AOR: 1.355, 95% CI: 1.315–1.396), and skilled agricultural, forestry, and fishery workers (AOR: 1.441, 95% CI: 1.359–1.529) had higher TB-specific mortality rates than those of their counterparts. In conclusion, TB-specific mortality rates differed according to the characteristics of the deceased patients. In order to establish effective TB control, multisectoral action on broader determinants should be strengthened.

BackgroundPublic-private mix (PPM) programs on tuberculosis (TB) have a critical role in engaging and integrating the private sector into the national TB control efforts in order to meet the End TB Strategy targets. South Korea's PPM program can provide important insights on the long-term impact and policy gaps in the development and expansion of PPM as a nationwide program.Methods and findingsHealthcare is privatized in South Korea, and a majority (80.3% in 2009) of TB patients sought care in the private sector. Since 2009, South Korea has rapidly expanded its PPM program coverage under the National Health Insurance (NHI) scheme as a formal national program with dedicated PPM nurses managing TB patients in both the private and public sectors. Using the difference in differences (DID) analytic framework, we compared relative changes in TB treatment outcomes-treatment success (TS) and loss to follow-up (LTFU)-in the private and public sector between the 2009 and 2014 TB patient cohorts. Propensity score matching (PSM) using the kernel method was done to adjust for imbalances in the covariates between the 2 population cohorts. The 2009 cohort included 6,195 (63.0% male, 37.0% female; mean age: 42.1) and 27,396 (56.1% male, 43.9% female; mean age: 45.7) TB patients in the public and private sectors, respectively. The 2014 cohort included 2,803 (63.2% male, 36.8% female; mean age: 50.1) and 29,988 (56.5% male, 43.5% female; mean age: 54.7) patients. In both the private and public sectors, the proportion of patients with transfer history decreased (public: 23.8% to 21.7% and private: 20.8% to 17.6%), and bacteriological confirmed disease increased (public: 48.9% to 62.3% and private: 48.8% to 58.1%) in 2014 compared to 2009. After expanding nationwide PPM, absolute TS rates improved by 9.10% (87.5% to 93.4%) and by 13.6% (from 70.3% to 83.9%) in the public and private sectors. Relative to the public, the private saw 4.1% (95% confidence interval [CI] 2.9% to 5.3%, p-value < 0.001) and -8.7% (95% CI -9.7% to -7.7%, p-value ConclusionsWe found that the nationwide scale-up of the PPM program was associated with improvements in TB treatment outcomes in the private sector in South Korea. Centralized financial governance and regulatory mechanisms were integral in facilitating the integration of highly diverse South Korean private sector into the national TB control program and scaling up of the PPM intervention nationwide. However, TB care gaps continued to exist for patients who transferred at least once during their treatment. These programmatic gaps may be improved through reducing administrative hurdles and making programmatic amendments that can help facilitate management TB patients between institutions and healthcare sectors, as well as across administrative regions.

Background: Growing travel connectivity and economic development have dramatically increased the magnitude of human mobility in Africa. In public health, vulnerable population groups such as mobile individuals are at an elevated risk of sexually transmitted diseases, including HIV. Methods: The population-based Demographic Health Survey data of five Southern African countries with different HIV epidemic intensities (Angola, Malawi, South Africa, Zambia, and Zimbabwe) were used to investigate the association between HIV serostatus and population mobility adjusting for socio-demographic, sexual behavior and spatial covariates. Results: Mobility was associated with HIV seropositive status only in Zimbabwe (adjusted odds ratio [AOR] = 1.37 [95% confidence interval [CI]: 1.01–1.67]). These associations were not significant in Angola, Malawi, South Africa, and Zambia. Females had higher odds of mobility than males in Zimbabwe (AOR = 1.37, CI: 1.10–1.69). The odds of mobility decreased with age in all five countries. Conclusions: Our findings highlight the heterogeneity of the social and health determinants of mobile populations in several countries with different HIV epidemic intensities. Effective interventions using precise geographic focus combined with detailed attribute characterization of mobile populations can enhance their impact especially in areas with high density of mobile individuals and high HIV prevalence.

BackgroundAntiretroviral therapy (ART) success has led people to live longer with HIV/AIDS (PLWH) and thus be exposed to increasing risk of cardiovascular diseases (CVD). Hypertension (HTN), the biggest contributor to CVD burden, is a growing concern among PLWH. The current report describes the prevalence and predictors of HTN among PLWH in care in Cameroon.MethodsThis cross-sectional study included all PLWH aged 20 years and above who received care between 2016 and 2019 at one of the three Central Africa International Epidemiology Databases to Evaluate AIDS (CA-IeDEA) sites in Cameroon (Bamenda, Limbe, and Yaoundé). HTN was defined as blood pressure (BP) ≥140/90 mm Hg or self-reported use of antihypertensive medication. Logistic regressions models examined the relationship between HTN and clinical characteristics, and HIV-related factors.ResultsAmong 9,839 eligible PLWH, 66.2% were women and 25.0% had prevalent HTN [age-standardized prevalence 23.9% (95% CI: 22.2-25.6)], among whom 28 (1.1%) were on BP lowering treatment, and 6 of those (21.4%) were at target BP levels. Median age (47.4 vs. 40.5 years), self-reported duration of HIV infection (5.1 vs 2.8 years years), duration of ART exposure (4.7 vs 2.3 years), and CD4 count (408 vs 359 cell/mm3) were higher in hypertensives than non-hypertensives (all pConclusionAbout a quarter of these Cameroonian PLWH had HTN, driven among others by age and adiposity. Appropriate integration of HIV and NCDs services is needed to improve early detection, treatment and control of common comorbid NCD risk factors like hypertension and safeguard cardiovascular health in PLWH.

BackgroundIn South Africa, within-country migration is common. Mobility affects many of the factors in the pathway for entry to or retention in care among people living with HIV. We characterized the patterns of migration (i.e., change in residency) among peripartum women from rural South Africa and their association with first-year postpartum mortality.Methods and findingsAll pregnant women aged ≥15 years were followed-up during pregnancy and the first year postpartum in a population-based longitudinal demographic and HIV surveillance program in KwaZulu-Natal, South Africa, from 2000 to 2016. During the household surveys (every 4-6 months), each household head was interviewed to record demographic components of the household, including composition, migration, and mortality. External migration was defined as moving (i.e., change in residency) into or out of the study area. For women of reproductive age, detailed information on new pregnancy and birth was recorded. Maternal death was ascertained via verbal autopsy and HIV status at delivery via annual HIV surveys. We fitted mixed-effects Cox regression models adjusting for multiple pregnancies per individual. Overall, 19,334 women had 30,291 pregnancies: 3,339 were HIV-positive, 10,958 were HIV-negative, and 15,994 had unknown HIV status at delivery. The median age was 24 (interquartile range: 20-30) years. During pregnancy and the first year postpartum, 64% (n = 19,344) and 13% (n = 3,994) did not migrate and resided within and outside the surveillance area, respectively. Of the 23% who had externally migrated at least once, 39% delivered outside the surveillance area. Overall, the mortality rate was 5.8 per 1,000 person-years (or 831 deaths per 100,000 live births) in the first year postpartum. The major causes of deaths were AIDS- or tuberculosis-related conditions both within 42 days of delivery (53%) and during the first year postpartum (62%). In this study, we observed that HIV-positive peripartum women who externally migrated and delivered outside the surveillance area had a hazard of mortality more than two times greater (hazard ratio = 2.74; 95% confidence interval 1.01-7.40, p-value = 0.047)-after adjusting for age, time period (before or after 2010), and sociodemographic status-compared to that of HIV-positive women who continuously resided within the surveillance area. Study limitations include lack of data on access to antiretroviral therapy (ART) care and social or clinical context at the destinations among mobile participants, which could lead to unmeasured confounding. Further information on how mobile postpartum women access and remain in care would be instructive.ConclusionsIn this study, we found that a substantial portion of peripartum women moved within the country around the time of delivery and experienced a significantly higher risk of mortality. Despite the scale-up of universal ART and declining trends in maternal mortality, there is an urgent need to derive a greater understanding of the mechanisms underlying this finding and to develop targeted interventions for mobile HIV-positive peripartum women.

BackgroundA cost analysis of implementation of interventions informs budgeting and economic evaluations.ObjectiveTo estimate the cost of implementing the integrated chronic disease management (ICDM) model in primary healthcare (PHC) clinics in South Africa.MethodsCost data from the provider's perspective were collected in 2019 from four PHC clinics with comparable patient caseloads (except for one). We estimated the costs of implementing the ICDM model current activities for three (facility reorganization, clinical supportive management and assisted self-management) components and additional costs of implementing with enhanced fidelity. Costs were estimated based on budget reviews, interviews with management teams, and other published data. The standard of care activities such as medication were not included in the costing. One-way sensitivity analyses were carried out for key parameters by varying patient caseloads, required infrastructure and staff. Annual ICDM model implementation costs per PHC clinic and per patient per visit are presented in 2019 US dollars.ResultsThe overall mean annual cost of implementing the ICDM model was $148 446.00 (SD: $65 125.00) per clinic. Current ICDM model activities cost accounted for 84% ($124 345.00) of the annual mean cost, while additional costs for higher fidelity were 16% ($24 102.00). The mean cost per patient per visit was $6.00 (SD:$0.77); $4.94 (SD:0.70) for current cost and $1.06 (SD:0.33) for additional cost to enhance ICDM model fidelity. For the additional cost, 49% was for facility reorganization, 31% for adherence clubs and 20% for training of nursing staff. In the sensitivity analyses, the major cost drivers were the proportion of effort of assisted self-management staff and the number of patients with chronic diseases receiving care at the clinic.ConclusionMinimal additional cost are required to implement the ICDM model with higher fidelity. Further research on the cost-effectiveness of the ICDM model in middle-income countries is required.

Esophageal atresia (EA) with proximal tracheoesophageal fistula (TEF; gross type B) is a rare defect. Although most patients have long-gap EA, there are still no established surgical guidelines. A premature male infant with symmetric intrauterine growth retardation (birth weight, 1,616 g) was born at 35 weeks and 5 days of gestation. The initial diagnosis was pure EA (gross type A) based on failure to pass an orogastric tube and the absence of stomach gas. A “feed and grow” approach was implemented, with gastrostomy performed on postnatal day 2. A fistula was detected during bronchoscopy for recurrent pneumonia; thus, we confirmed type B EA and performed TEF excision and cervical end esophagostomy. As the infant’s stomach volume was insufficient for bolus feeding after reaching a body weight of 2.5 kg, continuous tube feeding was provided through a gastrojejunal tube. On the basis of these findings, esophageal reconstruction with gastric pull-up was performed on postnatal day 141 (infant weight, 4.7 kg), and he was discharged 21 days postoperatively. At 12 months after birth, there was no catch-up growth; however, he is currently receiving a baby food diet without any complications. In patients with EA, bronchoscopy is useful for confirming TEF, whereas for those with long-gap EA with a small stomach volume, esophageal reconstruction with gastric pull-up after continuous feeding through a gastrojejunal tube is worth considering.

Purpose: The purpose of this study was to examine changes in the self-rated health of adolescents and to identify its predictors using longitudinal data from the KCYPS. Methods: A sample of 2,351 adolescents who were in the first grade of middle school in 2010 was analyzed. The study employed latent growth analysis using data from 2010 to 2016. Results: Results indicated that self-rated health of adolescents increased, following the form of a linear function. The analyses revealed that adolescent self-perception of health were conceptualized not only by their health-related behaviors, but also by personal, socioeconomic and psychological factors. Specifically, physical activity, passive leisure time activities, gender (initial: b=-.060, slope: b=.030), place of residence (initial: b=-.079), self-rated economic condition (b=.098), working status of mother (b=.016), monthly family income (b=-.001), aggression (b=.061), depression (initial: b=-.104, slope: b=.012), stress (initial: b=-.172, slope: b=.014, ego-resiliency (initial: b=.197, slope: b=-.021), and self-esteem (initial: b=.106, slope: b=-.017) had significant effects on the overall linear change of self-rated health (p

Background/purpose: To evaluate the reproducibility of the marginal and internal gaps of metal copings fabricated using dental micro-stereolithography (μ-SLA), which is an additive manufacturing system. Materials and methods: A study cast of abutment tooth 46 was made from type-IV dental stone and was scanned to create a standard triangulation language file. Arrays of one (ORM), three (TRM), and six (SRM) resin copings were then fabricated on the μ-SLA build platform using investment, burnout, and casting (n = 12). The marginal and internal gaps of these metal copings were measured using a silicone-replica technique with a digital microscope (×160). The data obtained were analyzed using a non-parametric Kruskal–Wallis H test, a post-hoc Mann–Whitney U test, and a Bonferroni correction. Results: The mean and standard deviation of the marginal gap for each group were measured and found to be 81.1 and 53.2 μm, 68.3 and 44.8 μm, and 90.3 and 57.7 μm for ORM, TRM, and SRM, respectively. There were no statistical differences in the marginal gaps of the three groups (p > 0.05). Conclusion: The marginal and internal gap of ORM, TRM and SRM groups were considered clinically acceptable. Keywords: CAD/CAM, marginal gap, micro-stereolithography, Ni–Cr

Background: Small intestinal volvulus often occurs with malrotation. However, in some cases, it could develop without any other clinical conditions, and this is called primary segmental volvulus (PSV) of the small intestine. Two types of PSV (early and late neonatal) have been described previously, especially in preterms. Moreover, there were other cases occurring beyond the neonatal period.Methods: The medical records of 14 cases definitively identified as PSV were retrospectively reviewed. The patients were divided into 2 groups according to postnatal age at diagnosis: neonatal group and beyond neonatal group. Then, the 2 groups were compared in terms of clinical features.Results: There were 11 patients in the neonatal group (78.6%) and 3 patients in the beyond neonatal group (21.4%). There were no differences in gestational age, birth weight, and ratio of prematurity. In the neonatal group, the antenatal abnormal sonographic findings were found more frequently and the perforation of the involved segment were relatively common. Meanwhile, the involved segment was confined to the ileum and more commonly associated with mesentery change in the beyond neonatal group. There was no mortality.Conclusion: The 2 clinical types of PSV according to postnatal age at diagnosis show some differences in clinical features. Moreover, PSV should be considered a possible cause of surgical problems beyond the neonatal period.

Glanzmann's thrombasthenia (GT) is a very rare platelet disorder and could cause spontaneous bleeding. Without known past medical history about bleeding, diagnosing this condition may be difficult. It commonly presents with mucocutaneous bleeding, but can also cause other types of bleeding. Intramural duodenal hematoma (IDH) is an uncommon medical condition generally accompanying with certain predisposing factors. Diagnosing IDH is challenging particularly when atypical image findings were observed with unknown risk factors. This is a case report of a 9-year-old boy with spontaneous IDH followed by serious complications due to unrecognized GT.

The purpose of this review is to summarize the results of studies on of the association between exposure to dental X-rays and health risk. To perform the systematic review, We searched the PUBMED, EMBASE, and MEDLINE databases for papers published before December 15, 2016. A total of 2 158 studies, excluding duplicate studies, were found. Two reviewers independently evaluated the eligibility of each study. The final 21 studies were selected after application of exclusion criteria. In terms of health outcomes, there were 10 studies about brain tumors, 5 about thyroid cancer, 3 about tumors of head and neck areas, and 3 related to systemic health. In brain tumor studies, the association between dental X-ray exposure and meningioma was statistically significant in 5 of the 7 studies. In 4 of the 5 thyroid-related studies, there was a significant correlation with dental diagnostic X-rays. In studies on head and neck areas, tumors included laryngeal, parotid gland, and salivary gland cancers. There was also a statistically significant correlation between full-mouth X-rays and salivary gland cancer, but not parotid gland cancer. Health outcomes such as leukemia, low birth weight, cataracts, and thumb carcinomas were also reported. In a few studies examining health effects related to dental X-ray exposure, possibly increased risks of meningioma and thyroid cancer were suggested. More studies with a large population and prospective design are needed to elaborate these associations further.

INTRODUCTION:Inefficient clinic-level delivery of HIV services is a barrier to linkage and engagement in care. We used value stream mapping to quantify time spent on each component of a clinic visit while receiving care following a hospital admission in South Africa. METHODS:We described time for each clinic service ("process time") and time spent waiting for that service ("lead time"). We also determined time and patient costs associated with travel to the clinic and expenditures during the clinic visits for 15 clinic visits in South Africa. Participants were selected consecutively based on timing of scheduled clinic visit from a cohort of HIV-positive patients recently discharged from inpatient hospital care. During the mapping we asked the participants to assess challenges faced at the clinic visit. We subsequently conducted in depth interviews and included themes from the care experience in this analysis. RESULTS:The 15 clinic visits occurred at five clinics; four primary care and one hospital-based specialty clinic. Nine (64%) of the participants were women, the median age was 44 years (IQR: 32-49), three of the participants had one or more clinic visit in the prior 14 days, all but one participant was on antiretroviral therapy (ART) at the time of the clinic visit (ART was stopped following the hospital visit for that participant). The median time since hospital discharge was 131 days (interquartile range; IQR: 121-183) for the observed visits. The median travel time to and from the clinic to a place of residence was 60 minutes. The median time spent at the clinic was 3.5 hours (IQR: 2.5-5.3) of which 2.9 hours was lead time and 25 minutes was process time (registration, vital signs, clinician assessment, laboratory, and check-out). The median patient cost for transport and food while at the clinic was ZAR43/USD2.8 (median monthly household income in the district was ZAR2450/USD157). Participants highlighted long queues, repeat clinic visits, and multiple queues during the visit (median of 5 queues) as challenges. CONCLUSIONS:Accessing HIV care in South Africa is time consuming, complicated by multiple queues and frequent visits. A more patient-centered approach to care may decrease the burden of receiving care and improve outcomes.

Background: Several circumcision devices have been evaluated for a safe and simplified male circumcision among adults. The PrePex device was prequalified for voluntary male medical circumcision (VMMC) in May 2013 by the World Health Organization and is expected to simplify the procedure safely while reducing cost. South Africa is scaling up VMMC. Objective: To evaluate the overall unit cost of VMMC at a mixed site vs. a hypothetical PrePex-only site in South Africa. Design: We evaluated the overall unit cost of VMMC at a mixed site where PrePex VMMC procedure was added to routine forceps-guided scalpel-based VMMC in Soweto, South Africa. We abstracted costs and then modeled these costs for a hypothetical PrePex-only site, at which 9,600 PrePex circumcisions per year could be done. We examined cost drivers and modeled costs, varying the price of the PrePex device. The healthcare system perspective was used. Results: In both sites, the main contributors of cost were personnel and consumables. If 10% of all VMMC were by PrePex at the mixed site, the overall costs of the surgical method and PrePex were similar – US$59.62 and $59.53, respectively. At the hypothetical PrePex-only site, the unit cost was US$51.10 with PrePex circumcisions having markedly lower personnel and biohazardous waste management costs. In sensitivity analysis with the cost of PrePex kit reduced to US$10 and $2, the cost of VMMC was further reduced. Conclusions: Adding PrePex to an existing site did not necessarily reduce the overall costs of VMMC. However, starting a new PrePex-only site is feasible and may significantly reduce the overall cost by lowering both personnel and capital costs, thus being cost-effective in the long term. Achieving a lower cost for PrePex will be an important contributor to the scale-up of VMMC.