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ObjectiveAntenatal anaemia is associated with increased peripartum transfusion requirement in South Africa. We studied whether HIV was associated with the response to treatment of iron-deficiency anaemia.DesignProspective cohort study.SettingHospital-based antenatal anaemia clinic in South Africa.SampleEqual-sized cohorts of pregnant women testing positive for HIV (HIV+) and testing negative for HIV (HIV-) with iron-deficiency anaemia.MethodsHaemoglobin trajectories of women with confirmed iron-deficiency anaemia (ferritin&nbsp

IntroductionDelivering preventive chemotherapy through mass drug administration (MDA) is a central approach in controlling or eliminating several neglected tropical diseases (NTDs). Treatment coverage, a primary indicator of MDA performance, can be measured through routinely reported programmatic data or population-based coverage evaluation surveys. Reported coverage is often the easiest and least expensive way to estimate coverage; however, it is prone to inaccuracies due to errors in data compilation and imprecise denominators, and in some cases measures treatments offered as opposed to treatments swallowed.ObjectiveAnalyses presented here aimed to understand (1) how often coverage calculated using routinely reported data and survey data would lead programme managers to make the same programmatic decisions; (2) the magnitude and direction of the difference between these two estimates, and (3) whether there is meaningful variation by region, age group or country.MethodsWe analysed and compared reported and surveyed treatment coverage data from 214 MDAs implemented between 2008 and 2017 in 15 countries in Africa, Asia and the Caribbean. Routinely reported treatment coverage was compiled using data reported by national NTD programmes to donors, either directly or via NTD implementing partners, following the implementation of a district-level MDA campaign; coverage was calculated by dividing the number of individuals treated by a population value, which is typically based on national census projections and occasionally community registers. Surveyed treatment coverage came from post-MDA community-based coverage evaluation surveys, which were conducted as per standardised WHO recommended methodology.ResultsCoverage estimates using routine reporting and surveys gave the same result in terms of whether the minimum coverage threshold was reached in 72% of the MDAs surveyed in the Africa region and in 52% in the Asia region. The reported coverage value was within ±10 percentage points of the surveyed coverage value in 58/124 of the surveyed MDAs in the Africa region and 19/77 in the Asia region. Concordance between routinely reported and surveyed coverage estimates was 64% for the total population and 72% for school-age children. The study data showed variation across countries in the number of surveys conducted as well as the frequency with which there was concordance between the two coverage estimates.ConclusionsProgramme managers must grapple with making decisions based on imperfect information, balancing needs for accuracy with cost and available capacity. The study shows that for many of the MDAs surveyed, based on the concordance with respect to reaching the minimum coverage thresholds, the routinely reported data were accurate enough to make programmatic decisions. Where coverage surveys do show a need to improve accuracy of routinely reported results, NTD programme managers should use various tools and approaches to strengthen data quality in order to use data for decision-making to achieve NTD control and elimination goals.

Fraudulent resource consumption (FRC) attacks threaten the economic viability of cloud consumers. Detection of these attacks is difficult as they often blend in with normal traffic patterns although they can still cause dramatic financial consequences. We employ a variety of data science techniques to detect FRC attacks in a cloud environment. Statistical, time series, and machine learning methods all achieve various levels of success and, in some cases, failure at detection. Unfortunately, none of these techniques is independently sufficient for detection for our experiments due to characteristics of the data set we used, but we summarize lessons learned from our research.

BACKGROUND Obstetric hemorrhage (OH) and access to peripartum blood transfusion remains a global health challenge. The rates of peripartum transfusion in South Africa exceed those in high-income countries despite comparable rates of OH. We sought to evaluate factors associated with peripartum transfusion. STUDY DESIGN AND METHODS A case-control study was conducted at four large South African hospitals. Transfused peripartum women (cases) and nontransfused controls were stratum matched 1:2 by hospital and delivery date. Data on obstetric, transfusion, and human immunodeficiency virus (HIV) history were abstracted from medical records. Blood was obtained for laboratory evaluation. We calculated unadjusted and adjusted odds ratios (ORs) for transfusion using logistic regression. RESULTS A total of 1200 transfused cases and 2434 controls were evaluated. Antepartum hemorrhage (OR, 197.95; 95% confidence interval [CI], 104.27-375.78), hemorrhage with vaginal delivery (OR, 136.46; 95% CI, 75.87-245.18), prenatal anemia (OR, 22.76; 95% CI, 12.34-41.93 for prenatal hemoglobin level

BACKGROUND Globally, data on antenatal blood transfusion practices are scarce. We sought to characterize the epidemiology of antenatal transfusion in South Africa. STUDY DESIGN AND METHODS A cross-sectional study was conducted of women who were transfused during pregnancy (>48 hr before anticipated delivery) at two hospitals in Durban and Soweto in 2014 to 2015. Medical record data on demographics, obstetric history, anemia, HIV status, and indications for blood transfusion were abstracted. RESULTS The records on a total of 560 transfused pregnant women were evaluated; mean age was 28 years, 98% were of black African ethnicity, and 28% were HIV positive. At time of transfusion, one-half were in the first trimester. Hemorrhage was noted in 76% of women, most of which was associated with abortion (67%) or ectopic pregnancy (27%). Most women were transfused with red blood cells (RBCs; median, 2 units); 14% of women were transfused with plasma and 2% with platelets. Median pre- and posttransfusion hemoglobin levels were 6.9 g/dL and 9.2 g/dL, respectively; the latter differed by hospital (8.7 g/dL vs. 9.5 g/dL; p

The current article reviews economic aspects of selected HIV/noncommunicable disease (NCD) service delivery integration programs to assess the efficiency of integration in limited capacity settings. We define economies of scope and scale and their relevance to HIV/NCD integration. We summarize the results of a systematic review of cost and cost-effectiveness studies of integrated care, which identified 12 datasets (nine studies) with a wide range of findings driven by differences in research questions, study methods, and health conditions measured. All studies were done in Africa and examined screening interventions only. No studies assessed the cost of integrated, long-term disease management. Few studies estimated the cost-effectiveness of integrated screening programs. The additional cost of integrating NCD screening with HIV care platforms represented a 6-30% increase in the total costs of the programs for noncancer NCDs, with cervical cancer screening costs dependent on screening strategy. We conducted 11 key informant interviews to uncover perceptions of the economics of HIV/NCD integration. None of the informants had hard information about the economic efficiency of integration. Most expected integrated care to be more cost-effective than current practice, though a minority thought that greater specialization could be more cost-effective. In the final section of this article, we summarize research needs and propose a 'minimum economic dataset' for future studies. We conclude that, although integrated HIV/NCD care has many benefits, the economic justification is unproven. Better information on the cost, cost-effectiveness, and fiscal sustainability of integrated programs is needed to justify this approach in limited-resource countries.

BACKGROUND: Obstetric hemorrhage and access to peripartum blood transfusion remains a global health challenge. The rates of peripartum transfusion in South Africa exceed those in high-income countries despite comparable rates of obstetric hemorrhage. We sought to evaluate factors associated with peripartum transfusion. STUDY DESIGN AND METHODS: A case-control study was conducted at four large South African hospitals. Transfused peripartum women (cases) and non-transfused controls were stratum-matched 1:2 by hospital and delivery date. Data on obstetric, transfusion and HIV history were abstracted from medical records. Blood was obtained for laboratory evaluation. We calculated unadjusted and adjusted odds ratios (ORs) for transfusion using logistic regression. RESULTS: A total of 1,200 transfused cases and 2,434 controls were evaluated. Antepartum hemorrhage (OR=197.95, 95% CI 104.27–375.78), hemorrhage with vaginal delivery (OR=136.46, 95% CI 75.87–245.18), prenatal anemia (OR=22.76, 95% CI 12.34–41.93 for prenatal hemoglobin < 7g/dl) and failed access to prenatal care (OR=6.71, 95% CI 4.32–10.42) were the major risk factors for transfusion. Platelet count (ORs 4.10, 2.66 and 1.77 for ≤50,000, 51–100,000 and 101–150,000 cells per mm(3), respectively), HIV infection (OR 1.29, 95% CI 1.02–1.62) and admitting hospital (two-fold variation) were also associated with transfusion. Mode of delivery, race, age category, gravidity, parity, gestational age, and birth weight were not independently associated with transfusion. CONCLUSION: Major risk factors of peripartum transfusion in South Africa, namely prenatal anemia and access to prenatal care, may be amenable to intervention. HIV infection and moderately low platelet count are novel risk factors which merit further investigation.

Objective We present lessons learned from over a decade of HIV bio- behavioral risk study implementation and capacity-building in African militaries. Introduction Circumstances within the military environment may place military personnel at increased risk of contracting sexually transmitted infections (STI) including HIV. HIV bio-behavioral risk studies provide a critical source of data to estimate HIV/STI prevalence and identify risk factors, allowing programs to maximize impact by focusing on the drivers of the epidemic. Methods Since 2005, RTI has provided technical assistance (TA) to support HIV/STI Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) in 14 countries across Sub-Saharan Africa and Asia. SABERS are cross-sectional studies consisting of a survey to assess knowledge, attitudes and behaviors related to HIV, coupled with rapid testing for HIV and other STIs. RTI tailored each survey instrument to be culturally appropriate in content and methodology, trained military personal to serve as data collection staff, and provided logistical support for study implementation. Results Key lessons learned are summarized below: Data collection mode varied from paper-based to computer- assisted surveys, depending on country preference, in-country staff capabilities, and the country’s technological capacity. Computer- assisted data collection systems were preferable because they improved data quality through the use of programmed skip patterns, range, and consistency checks. By eliminating the need for data entry, computer-assisted systems also saved program resources and enabled faster access to the data for analysis. Survey administration method varied from self-administered to interviewer-administered surveys. Literacy rates, technological familiarity, and confidentiality concerns were key drivers in determining the best data collection method. Self-administered surveys such as computer-assisted self-interview (CASI) were preferable due to the high-level of confidentiality they provide, but required a high-level of literacy and computer familiarity. If confidentiality was a big concern in low-literacy settings, audio computer-assisted self-interview (ACASI) was used if the population had some computer familiarity. Interviewer-administered surveys such as computer-assisted personal interview (CAPI) were used in most low-literacy settings. Tailoring the survey instrument and administration for cultural appropriateness was vital to the acquisition of sound, viable data. Sexual behaviors and the definition of “regular sexual partner” and other terms varied according to local custom. The sensitive nature of the survey questions also impacted survey administration operationally. The preference for same-sex or opposite sex interviewers varied by country and military setting. It was imperative to pre-test the survey. A skilled workforce and staff retention are essential to provide high quality data. Literacy levels, technological familiarity, HIV knowledge, and time commitments must all be considered when selecting data collection staff. Retention of staff throughout the duration of data collection activities can be a major issue especially among military personnel who were often called away from study activities to perform military duties. Host military ownership was integral to the success of the SABERS program. By engaging military leadership early and involving them in all decision making processes we ensured the partner military was invested in the study and its success and found value in the resulting data and findings. Host militaries were actively involved in SABERS by providing staff for data collection, leading sensitization activities, and monitoring data collection activities in the field. Inclusion of capacity building elements during study implementation led to increased host military buy-in. Capacity building included staff trainings and practical experience in survey methodology, use of electronic data collection instruments, study logistics and data monitoring. Confidentiality of survey data and HIV test results was of increased concern given that these studies were conducted in a work place environment. For this reason, it was imperative to assure participants that disclosures of drug or alcohol use and positive HIV/STI test results would remain confidential and would not affect their military employment. Conclusions Based on our experience, the following are required for the successful implementation of an HIV Bio-behavioral Risk Study in resource-poor military settings: (1) selection of a data collection mode and survey administration method that is context-appropriate, (2) utilization of local wording and customs, (3) a skilled workforce, (4) local buy-in/partnership, (5) inclusion of capacity building elements, and (6) assurance of confidentiality.

Overview After two decades of civil war, South Sudan has limited published data on HIV prevalence and behavioral determinants of HIV infection risk. A surge in HIV/AIDS prevalence is a real concern for this new country with limited access to medical or HIV preventive services, and low education and literacy levels. We present findings from the first bio-behavioral surveillance survey conducted within the Sudan People’s Liberation Army (SPLA). Methods A cross-sectional survey of 1,149 randomly selected soldiers from thirteen SPLA bases was conducted in two phases: July to August 2010 and April to May 2012. Consenting participants received HIV rapid tests, pre- and post-test counseling, and a personal interview. Demographics, knowledge, attitudes, and behaviors, including sexual behavior, alcohol use, and mental health were assessed using computer-assisted interviews. Findings The final sample included 1,063 survey participants (96.7% male). Education levels within the SPLA are low; only 16.4% attended school beyond the primary level. The overall HIV prevalence in the sample was 5.0% (95% confidence interval [CI]: 3.6–6.9). High-risk behaviors (e.g., multiple or concurrent sexual partners, heavy alcohol use, low condom use) were noted among SPLA members. High levels of HIV stigma were identified: 90.6% (n = 916) responded with one or more negative beliefs towards PLHIV, and 60.3% thought a healthy-looking person with HIV should not be allowed to remain in the SPLA. Conclusion Results from this first evaluation of risk behaviors and HIV prevalence among the SPLA highlight high-risk behaviors that may contribute to the spread of HIV. Understanding potential comorbid conditions will be critical to designing strategies to reduce HIV risk. This survey represents the first steps in understanding the HIV epidemic within the SPLA context.

This study sought to examine relationships between depressive symptoms and prenatal smoking and/or household environmental tobacco smoke exposure (HH-ETSE) among urban minority women. We analyzed private, audio computer-assisted self interview data from a clinic-based sample of 929 minority pregnant women in Washington, DC. Depressive symptoms were assessed via the Beck Depression Inventory Fast Screen. HH-ETSE, current smoking, and former smoking were assessed via self-report. Depression levels and demographic characteristics were compared: (1) among nonsmokers, for those reporting HH-ETSE versus no HH-ETSE; and (2) among smokers, for those reporting current smoking (in last 7 days) versus former smokers. Measures associated with HH-ETSE/current smoking in bivariate analysis at P < 0.20 were included in adjusted logistic regression models. HH-ETSE, as a possible indicator of a social smoking network, was assessed as a mediator for the relationship between depression and current smoking. Results: Non-smokers reporting moderate-to-severe depressive symptoms showed significantly higher adjusted odds of prenatal HH-ETSE (AOR 2.5, 95% CI [1.2, 5.2]). Smokers reporting moderate-to-severe or mild depressive symptoms showed significantly higher adjusted odds of current smoking (AOR 1.9, 95% CI [1.1, 3.5] and AOR 1.8, 95% CI [1.1, 3.1], respectively). Among smokers, HH-ETSE was a significant mediator for the association between moderate-to-severe symptoms and current smoking. In conclusion, health care providers should be aware that depressed urban minority women are at risk of continued smoking/HH-ETSE during pregnancy. Interventions designed to encourage behavior change should include screening for depression, and build skills so that women are better able to address the social environment.

Adolescent mothers in Washington, DC have a high rate of subsequent teen pregnancies, often within 24 months. Children of teen mothers are at risk for adverse psychosocial outcomes. When adolescents are strongly attached to parents, schools, and positive peers, they may be less likely to repeat a pregnancy. This study tested the efficacy of a counseling intervention delivered by cell phone and focused on postponing subsequent teen pregnancies by strengthening healthy relationships, reproductive practices, and positive youth assets. The objective of this study was to compare time to a repeat pregnancy between the intervention and usual care groups, and, secondarily, to determine whether treatment intensity influenced time to subsequent conception. Primiparous pregnant teens ages 15–19, were recruited in Washington, DC. Of 849 teens screened, 29.3% (n = 249) met inclusion criteria, consented to participate, and completed baseline measures. They were then randomized to the intervention (N = 124) or to usual care (N = 125). Intervention group teens received cell phones for 18 months of counseling sessions, and quarterly group sessions. Follow-up measures assessed subsequent pregnancy through 24 months post-delivery. A survival analysis compared time to subsequent conception in the two treatment groups. Additional models examined the effect of treatment intensity. By 24 months, 31% of the intervention and 36% of usual care group teens had a subsequent pregnancy. Group differences were not statistically significant in intent-to-treat analysis. Because there was variability in the degree of exposure of teens to the curriculum, a survival analysis accounting for treatment intensity was performed and a significant interaction with age was detected. Participants who were aged 15–17 years at delivery showed a significant reduction in subsequent pregnancy with increased levels of intervention exposure (P

Anorexia nervosa is a disorder that affects millions in the United States and has the highest mortality rate of any mental illness, estimated at or above 10%. The majority of sufferers are female, though the number of male cases continues to increase. The current study seeks to explore and interpret the internal experiences of females with anorexia through the lens of British object-relations theories regarding schizoid phenomena. This dissertation offers a review of the current clinical and psychoanalytic literature on female anorexia, as well as current empirical findings. There is also a summary of the theories of Guntrip and Laing on schizoid mechanisms, along with a discussion of psychological aspects of modernity as discussed by Sass and Bordo. This study utilizes published memoirs of women in recovery from anorexia, and through narrative inquiry methodology explores the hypothesis that anorexia is an attempt to alleviate and resolve schizoid concerns. In the analyses, thirteen themes emerge that capture the paradoxical nature of anorexia, in which the sufferer engages in a process of destructive self-preservation. Central to these findings is a self-annihilating narcissism that describes the internal experiences of preoccupation and self-loathing within the sufferer, as well as a desire to become a person without needs and without a body. These are shown to provide a protective boundary between the internal self and the external world. In an attempt to assert a sense of self through starvation, the sufferer exists in a state between being and non-being, which often leads to serious medical complications and sometimes death. Lastly, these paradoxical themes tie into literature on the schizoid condition, which provides insight into the contradictory experiences of anorexia. The splitting that occurs in anorexia between an inner self and a body self appears to parallel the splitting within the schizoid, which protects the person against fears of annihilation, engulfment, implosion, and petrification by the other.

In epidemiologic research, effective tools for study management improve data quality, staff/time efficiency, and cost-effectiveness and strengthen study outcomes. The Web-based data management system (DMS) is a relatively new technology in epidemiologic research which provides significant benefits of these kinds. This paper addresses the design, technical implementation, and field experiences of using a Web-based DMS for the GirlTalk for Teen Moms Study, conducted as part of the NIH-DC Initiative to Reduce Infant Mortality in Minority Populations in Washington, DC (the NIH-DC Initiative). RTI developed a Web-based DMS for the GirlTalk study to assist field staff from multiple sites in efficiently managing participant activities and data collection for this multiple component, multisite longitudinal study. The GirlTalk DMS monitors all activities for screening, recruitment, enrollment, in-depth interviews, randomization, interventions, repeated measures, outcomes, adverse events, and follow-up activities for each participant over the course of her 2-year enrollment in the study. Field staff from multiple sites use the DMS to manage more than 100 possible activities with a complex series of dependencies between activities that lead from one activity to the next. We compare the features of the Web-based DMS used for GirlTalk with those of a personal computer (PC)-based DMS used previously by this research group. Our comparison presents the efficiencies obtained, including real-time data access, simplified software management, data security, and anytime/anywhere access for all users. We outline cost considerations for the Web-based DMS versus the PC-based system in terms of study size, study duration, number of sites, and technical infrastructure. We illustrate several features of the DMS, including the role-based menu, events tracking, appointment scheduling, shared calendars, report generation, access to study documents, and uploading of data files to RTI International secure servers. Finally, we compare the value of the Web-based tool versus the PC-based tool for study management.