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Faith Moyo,1 Charles Chasela,2,3 Alana T Brennan,1,4 Osman Ebrahim,5 Ian M Sanne,1,6 Lawrence Long,1 Denise Evans1 1Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 2Epidemiology and Biostatistics Department, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 3Epidemiology and Strategic Information (ESI), HIV/AIDS/STIs and TB, Human Sciences Research Council, Pretoria, South Africa; 4Center for Global Health and Development, Boston University, Boston, MA, USA; 5Brenthurst Clinic, Parktown, South Africa; 6Right to Care, Helen Joseph Hospital, Westdene, Johannesburg, South Africa Background: Despite the widely documented success of antiretroviral therapy (ART), stakeholders continue to face the challenges of poor HIV treatment outcomes. While many studies have investigated patient-level causes of poor treatment outcomes, data on the effect of health systems on ART outcomes are scarce.Objective: We compare treatment outcomes among patients receiving HIV care and treatment at a public and private HIV clinic in Johannesburg, South Africa.Patients and methods: This was a retrospective cohort analysis of ART naïve adults (≥18.0 years), initiating ART at a public or private clinic in Johannesburg between July 01, 2007 and December 31, 2012. Cox proportional-hazards regression was used to identify baseline predictors of mortality and loss to follow-up (>3 months late for the last scheduled visit). Generalized estimating equations were used to determine predictors of failure to suppress viral load (≥400 copies/mL) while the Wilcoxon rank-sum test was used to compare the median absolute change in CD4 count from baseline to 12 months post-ART initiation.Results: 12,865 patients initiated ART at the public clinic compared to 610 at the private clinic. The patients were similar in terms of sex and age at initiation. Compared to public clinic patients, private clinic patients initiated ART at higher median CD4 counts (159 vs 113 cells/mm3) and World Health Organization stage I/II (76.1% vs 58.5%). Adjusted hazard models showed that compared to public clinic patients, private clinic patients were less likely to die (adjusted hazard ratio [aHR] 0.50; 95% confidence interval [CI] 0.35–0.70) but were at increased risk of loss to follow-up (aHR 1.80; 95% CI 1.59–2.03). By 12 months post-ART initiation, private clinic patients were less likely to have a detectable viral load (adjusted relative risk 0.65; 95% CI 0.49–0.88) and recorded higher median CD4 change from baseline (184 cells/mm3 interquartile range 101–300 vs 158 cells/mm3 interquartile range 91–244), when compared to public clinic patients.Conclusion: We identified differences in treatment outcomes between the two HIV clinics. Findings suggest that the type of clinic at which ART patients initiate and receive treatment can have an impact on treatment outcomes. Further research is necessary to provide more conclusive results. Keywords: health systems, attrition, HIV programs, viral suppression

Background Suicide is a global public health problem and Nigeria is one of the epicentres of suicide in the world. However, there is a dearth of research exploring the epidemiological aspects of suicide in Nigeria.Aim To examine the demographic information and precipitating events for suicides in Nigeria by analysing the contents of newspaper reports of suicide.Methods We searched, collected, and analysed published news reports about suicide from 10 English newspapers in Nigeria. A total of 350 suicide reports were assessed between January 2010 and December 2019 after screening and sorting.Results The mean (SD) age of the reported cases was 36.33 (15.48) years. Majority of the reported cases were male (80.6%), married (51.8%), students (33.6%), living in a semi-urban area (40.3%) and among the age group of 25–34 (25.3%). Hanging (48.6%) and poisoning (32.2%) were the most commonly reported methods of suicide. Financial constraints and marital conflicts were most commonly assumed precipitating factors.Conclusion This study suggests that being male, married, or living in semi-urban areas are associated with suicide in Nigeria. Further community-based studies are warranted to generalise the findings and adopt appropriate preventive strategies.

Ecotoxicity of rhodium (Rh) from the model of mining waste water side stream was examined in this paper. Rh was extracted from the model of the mining waste water using an emulsion liquid membrane (ELM). The extractions were done at pH of 1.87 and pH 2.92 and 41.6 % and 46.2 % of Rh was extracted respectively. The side streams of pH of 1.87 and pH 2.92 after the extractions were examined for ecotoxicity using Daphnia pulex in the acute toxicity testing. All test organisms died after 48 hours of exposure to the side stream effluent with the original pH = 1.87, while 10-60 % survival rates were observed at the mining spent effluent with original pH of 2.92 if the strength of the effluent ranged from 12.5 to 62.5 %. Results for ethylenediaminetetraacetic acid tetrasodium salt dehydrate (EDTA) showed that an increase in concentration of EDTA in the test concentrations lead to the death of D. pulex. It was concluded that the very dilute water side streams are toxic hence the discharge of the spent Rh side-stream should thus be discouraged and prevented at all costs. [ABSTRACT FROM AUTHOR]

Objective: To describe rates of retention in care and control of hypertension, diabetes and HIV among participants receiving integrated care services for a period of up to 24 months in East Africa., Methods: Between 5 October 2018 and 23 June 2019 participants enrolled into a prospective cohort study evaluating the feasibility of integrated care delivery for HIV, diabetes and hypertension from a single point of care in Tanzania and Uganda (MOCCA study). Integrated care clinics were established in 10 primary healthcare facilities and care was provided routinely according to national guidelines. Initial follow-up was 12 months. Outcomes were rates of retention in care, proportions of participants with controlled hypertension (blood pressure <140/90 mmHg), diabetes (fasting blood glucose <7.0 mmol/L) and HIV (plasma viral load <1000 copies/ml). The study coincided with the COVID-19 pandemic response. Afterwards, all participants were approached for extended follow-up by a further 12 months in the same clinics. We evaluated outcomes of the cohort at the end of long-term follow-up., Results: The MOCCA study enrolled 2273 participants of whom 1911 (84.5%) were retained in care after a median follow-up of 8 months (Interquartile range: 6.8-10.7). Among these, 1283/1911 (67.1%) enrolled for a further year of follow-up, 458 (24.0%) were unreachable, 71 (3.7%) reverted to vertical clinics (clinics providing services dedicated to study conditions), 31 (1.6%) died and 68 (3.6%) refused participation. Among participants who enrolled for longer follow-up, mean age was 51.4 ± 11.7 years, 930 (72.5%) were female and 509 (39.7%) had multiple chronic conditions. Overall, 1236 (96.3%) [95% confidence interval 95.2%-97.3%] participants were retained in care, representing 1236/2273 (54.3%) [52.3%-56.4%] of participants ever enrolled in the study. Controlled hypertension, diabetes and HIV at the end of follow-up was, 331/618 (53.6%) [49.5%-57.5%], 112/354 (31.6%) [26.8%-36.8%] and 332/343 (96.7%) [94.3%-98.4%] respectively., Conclusion: Integrated care can achieve high rates of retention in care long term, but control of blood pressure and blood sugar remains low., (© 2024 The Authors Tropical Medicine & International Health published by John Wiley & Sons Ltd.)

Aquatic biota of tropical temporary ponds typically experience a wide range of stressors that can drive the structure and dynamics of natural communities. Particularly in regions with intense agricultural activity, aquatic biota may not only experience predation pressure but also stress from pesticides that inadvertently enter the ponds. We increasingly understand how these different sources of stress affect classic model taxa under controlled laboratory conditions, but how predators and pesticides may jointly affect pond invertebrate communities is still unclear, particularly for tropical systems. Here, we conducted an outdoor mesocosm experiment to study how fish predation combined with exposure to an environmentally relevant concentration of the commonly used insecticide cypermethrin (0.8 ng/L) affects the structure of invertebrate communities, and its potential effects on leaf litter decomposition and invertebrate grazing efficiency as measures of ecosystem functioning. A total of seven invertebrate taxa were recorded in the mesocosm communities. Fish predation effectively lowered the number of invertebrate taxa, with fish mesocosms being dominated by high densities of rotifers, associated with lower phytoplankton levels, but only when communities were not simultaneously exposed to cypermethrin. In contrast, cypermethrin exposure did not affect invertebrate community structure, and neither fish predation nor cypermethrin exposure affected our measures of ecosystem functioning. These findings suggest that predation by killifish can strongly affect invertebrate community structure of tropical temporary ponds, and that downstream effects on phytoplankton biomass can be mediated by exposure to cypermethrin. More broadly, we contend that a deeper understanding of (tropical) temporary pond ecology is necessary to effectively manage these increasingly polluted systems., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Artisanal and small-scale mining is characterized by excessive exposure to physical, chemical, ergonomic, psychosocial and biological hazards. There is a high burden of tuberculosis (TB), human immunodeficiency virus (HIV) infections and silicosis among artisanal and small-scale miners (ASMs). The aim of this project report is to describe lessons learned from strategies implemented to reach ASMs with screening services for TB, HIV and silicosis in Zimbabwe through the Kunda-Nqob'i TB (KNTB) project supported by the United States Agency for International Development (USAID). The intervention package for screening ASMs for TB, HIV and silicosis included service provision through two occupational health clinics at two provincial hospitals and a mobile workplace-based screening (WBS) facility at the mining sites. From 1 October 2020 to 30 September 2023, 10,668 ASMs were screened, with a high number of cases of silicosis (21%) and TB (7.4%). There was a high burden of HIV (30%) in ASMs attending the occupational health clinics. The two occupational health clinics screened 3453 ASMs, while the mobile WBS activities screened 7215 ASMs during the period. A total of 370 healthcare workers (doctors/clinical officers, nurses, environmental health technicians and district tuberculosis and Leprosy control officers) were trained on TB and the fundamental diagnostic principles of silicosis. The KNTB project has been successful in reaching out to many ASMs operating in remote and hard-to-reach mining areas. The KNTB project has brought to light the positive health-seeking behavior of ASMs operating in remote areas. The project has brought to the fore the effectiveness of multi-stakeholder engagement and collaboration in reaching out to ASMs in remote areas with health screening services. There is a high burden of TB, HIV and silicosis in ASMs. Screening for TB, HIV and silicosis using workplace-based screening and occupational health clinics is an effective strategy and should be rolled out to all areas with high artisanal and small-scale mining activity.

In Zimbabwe, artisanal and small-scale miners (ASMs) have a high prevalence of tuberculosis (TB), human immunodeficiency virus (HIV), and silicosis. Previous studies on ASMs utilised programme data, and it was not possible to understand reasons for the high prevalence of these comorbidities. We conducted a cross-sectional study to investigate the knowledge, attitudes, and practices of ASMs regarding TB, HIV, and silicosis. We enrolled a convenience sample of 652 ASMs. Their mean (standard deviation) age was 34.2 (10.8) years. There were 602 (92%) men and over 75% had attained secondary education. A total of 504 (80%) of the ASMs knew that TB is a curable disease, and 564 (87%) knew that they were at higher risk of TB than the general population. However, they were less likely to know that HIV increases the risk of TB disease, 340 (52%), with only 226 (35%) who perceived the risk of TB infection to be high among ASMs. Only 564 (59%) were aware that silica dust causes permanent and incurable lung diseases. Six hundred and twenty (97%) showed a positive attitude towards healthcare when they were sick, and 97% were willing to use special respirators to prevent dust inhalation. On practices, only 159 (30%) reported consistent use of either cloth or respirators to prevent dust inhalation. Three hundred and five (49%) ASMs reported consistent use of condoms outside their homes and 323 (50%) reported use of water to suppress dust. Only 480 (75%) of ASMs sought healthcare services when sick. ASMs cited challenges of accessing healthcare services due to lack of money to pay for healthcare (50%), long distances to clinics (17%), and the shortage of medicines at clinics (11%). Effective control of TB, silicosis, and HIV among ASMs requires addressing the identified knowledge gaps and barriers that are faced by ASMs in accessing personal protective equipment and healthcare services. This will require multisector collaboration and the involvement of ASMs in co-designing a package of healthcare services that are tailored for them.

Land inequality stalls economic development, entrenches poverty, and is associated with environmental degradation. Yet, rigorous assessments of land-use interventions attend to inequality only rarely. A land inequality lens is especially important to understand how recent large-scale land acquisitions (LSLAs) affect smallholder and indigenous communities across as much as 100 million hectares around the world. This paper studies inequalities in land assets, specifically landholdings and farm size, to derive insights into the distributional outcomes of LSLAs. Using a household survey covering four pairs of land acquisition and control sites in Tanzania, we use a quasi-experimental design to characterize changes in land inequality and subsequent impacts on well-being. We find convincing evidence that LSLAs in Tanzania lead to both reduced landholdings and greater farmland inequality among smallholders. Households in proximity to LSLAs are associated with 21.1% ( P = 0.02) smaller landholdings while evidence, although insignificant, is suggestive that farm sizes are also declining. Aggregate estimates, however, hide that households in the bottom quartiles of farm size suffer the brunt of landlessness and land loss induced by LSLAs that combine to generate greater farmland inequality. Additional analyses find that land inequality is not offset by improvements in other livelihood dimensions, rather farm size decreases among households near LSLAs are associated with no income improvements, lower wealth, increased poverty, and higher food insecurity. The results demonstrate that without explicit consideration of distributional outcomes, land-use policies can systematically reinforce existing inequalities.

The ecosystem is confronted with numerous challenges as a consequence of the escalating human population and its corresponding activities. Among these challenges lies the degradation of forest biomass, which directly contributes to a reduction in forested areas and poses a significant threat to the survival of wildlife species through the intensification of intraspecific competition. In this paper, a non-linear mathematical model to study the conservation of forest and wildlife species that are reliant on forest ecosystem within the framework of human population dynamics and its related activities is developed and analysed. The study assessed the impacts of economic measures in the form of incentives on reducing population pressure on forest resources as well as the potential benefits of technological efforts to accelerate the rate of reforestation. Qualitative and quantitative analyses reveals that economic and technological factors have the potential to contribute to resource conservation efforts. However, these efforts can only be used to a limited extent, and contrary to that, the system will be destabilised. Sensitivity analysis identified the parameters pertaining to human population, human activities, economic measures, and technological efforts as the most influential factors in the model., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Environmental risks posed by widespread pesticide application have attracted global attention. Currently, chemical risk assessments in aquatic environments rely on extrapolation of toxicity data from classic model species. However, similar assessments based on local species could be complementary, particularly for unusual living environments such as temporary ponds. Here, we carried out an environmental risk assessment (ERA) of a pyrethroid model compound, cypermethrin, based on local temporary pond species. First, we measured cypermethrin residue concentrations in rivers, irrigation canals and temporary ponds in the Lake Manyara Basin (LMB). Then, we estimated the environmental risks of cypermethrin by combining these data with acute toxicity data of three resident species across three trophic levels: primary producers (Arthrospira platensis), invertebrate grazers (Streptocephalus lamellifer) and fish (Nothobranchius neumanni). Furthermore, we compared the derived ERA to that obtained using toxicity data from literature of classic model species. Cypermethrin residue concentrations in contaminated systems of the LMB ranged from 0.01 to 57.9 ng/L. For temporary pond species, S. lamellifer was the most sensitive one with a 96 h-LC 50 of 0.14 ng/L. Regardless of the assumed exposure concentration (0.01 and 57.9 ng/L), the estimated risks were low for primary producers and high for invertebrate grazers, both for local species as well as for classic model species. The highest detected cypermethrin concentration resulted in a moderate risk estimation for local fish species, while the estimated risk was high when considering classic fish models. Our results confirm that, at least for pyrethroids, ERAs with classic model species are useful to estimate chemical risks in temporary pond ecosystems, and suggest that complementary ERAs based on local species could help to fine-tune environmental regulations to specific local conditions and conservation targets., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: Diabetes prevalence has risen rapidly in Sub-Saharan Africa, but rates of retention in diabetes care are poorly understood. We conducted a systematic review and meta-analysis to determine rates of retention in care of persons with type 2 diabetes., Methods: We searched MEDLINE, Global Health and CINAHL online databases for cohort studies and randomised control trials (RCTs) published up to 12 October 2021, that reported retention in or attrition from care for patients with type 2 diabetes in Sub-Saharan Africa. Retention was defined as persons diagnosed with diabetes who were alive and in care or with a known outcome, while attrition was defined as loss from care., Results: From 6559 articles identified, after title and abstract screening, 209 articles underwent full text review. Forty six papers met the inclusion criteria, comprising 22,610 participants. Twenty one articles were of RCTs of which 8 trials had 1 year or more of follow-up and 25 articles were of non-randomised studies of which 19 had 12 months or more of follow-up. A total of 11 studies (5 RCTs and 6 non-randomised) were assessed to be of good quality. Sixteen RCTs were done in secondary or tertiary care settings. Their pooled retention rate (95% CI) was 80% (77%, 84%) in the control arm. Four RCTs had been done in primary care settings and their pooled retention rate (95% CI) was 53% (45%, 62%) in the control arm. The setting of one trial was unclear. For non-randomised studies, retention rates (95% CI) were 68% (62%, 75%) among 19 studies done in secondary and tertiary care settings, and 40% (33%, 49%) among the 6 studies done in primary care settings., Conclusion: Rates of retention in care of people living with diabetes are poor in primary care research settings., (© 2023 The Authors Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Woody species have been introduced in many parts of the world to provide economic benefits, but some of those species are now among the worst invaders, causing widespread economic and environmental damage. Management of woody species to restore original ecosystem services, such as biodiverse grassland that can provide fodder and sequester carbon, are needed to limit the impacts of alien species. However, the best management methods, i.e., the most economically efficient and effective way to remove trees and the most effective way to restore or rehabilitate the cleared land, are not developed for many species. In Eastern Africa, prosopis ( Prosopis julifora ) has invaded large areas of savanna and grassland, thereby affecting, among other things, fodder and water for livestock, access to dry season grazing lands and ultimately pastoral livelihoods. We tested three prosopis treatments (manual uprooting and cut stump and basal bark herbicide application) in combination with three incremental restoration interventions (divots, divots + mulching, divots + mulching + grass seed sowing). The three-year study was replicated in Ethiopia (Afar National Regional State), Kenya (Baringo county) and Tanzania (Moshi district). Prosopis survival and vegetation development, both diversity and biomass, were recorded. The prosopis treatments were all highly effective (between 85 and 100% tree mortality in almost all cases), but the two treatments that involved the complete removal of the aboveground biomass (manual and cut stump) yielded a more productive and more diverse vegetation than the treatment that killed the trees standing (basal bark). Compared to the effect of prosopis removal, the effect of restoration interventions on vegetation composition was small, indicating that most species re-established from the soil seed bank. The results show that it is possible to restore land previously invaded by prosopis. Despite the different rates of vegetation establishment and variation in species composition, the restoration interventions resulted in vegetation that in some cases contained a substantial fraction of perennial grasses. The method chosen to control prosopis depends on the availability of resources, including herbicides, and the need to remove rootstocks if the intention is to plant crops., Supplementary Information: The online version contains supplementary material available at 10.1186/s43170-023-00163-5., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2023.)

Artisanal and small-scale mining is characterized by an excessive exposure to silica-containing dust, overcrowding, poor living conditions and limited access to primary health services. This poses a risk to tuberculosis, HIV infection and silicosis. The main purpose of the study is to evaluate the burden of tuberculosis, HIV and silicosis among artisanal and small-scale miners. We conducted a cross sectional study on 3821 artisanal and small-scale miners. We found a high burden of silicosis (19%), tuberculosis (6.8%) and HIV (18%) in a relatively young population, with the mean age of 35.5 years. Men were 1.8 times more likely to be diagnosed with silicosis compared to women, adjusted prevalence ratio [aPR = 1.75 (95% CI: 1.02-2.74)]. Artisanal and small-scale miners who were living with HIV were 1.25 times more likely to be diagnosed with silicosis compared to those who were negative, [aPR = 1.25 (1.00-1.57)]. The risk of silicosis increased with both duration as a miner and severity of exposure to silica dust. The risk of tuberculosis increased with the duration as a miner. Zimbabwe is currently experiencing a high burden of TB, silicosis and HIV among artisanal and small-scale miners. Multi-sectoral and innovative interventions are required to stem this triple epidemic in Zimbabwe.

Sub-Sahara African countries face immense challenges in ensuring adequate sanitation and hygiene behaviours to the rapidly growing populations. Attempts to address these challenges require empirical evidence to inform policy and planning. We contribute toward that goal by unveiling findings of formative research conducted in Babati, a rapidly growing town in Tanzania. We conducted a cross-sectional study involving 486 households, to unwind motives and barriers for individuals to invest in improved sanitation services and hygiene behaviour change. We used several methods including household survey, focus group discussions, behaviour observations and spot checks. The findings revealed that households derive their motivation to invest in improved sanitation and hygiene practices from comfort, raising social status, and the need for personal safety and privacy. Other motives include fear of penalties and fines and fear of disease outbreaks, whilst the barriers include, limited water availability and accessibility, environmental factors, property rights, cultural issues, financial constraints, and a person's attitude. Quantitative data were subjected to multivariate analysis to identify determinants of households to invest in sanitation and hygiene practices. The logistic regression analyses revealed that sources of water, property rights, and education level were the main determinants of households to invest in sanitation and hygiene facilities, while household income was the main determinant for households to invest in both construction of handwashing facility and water treatment. We argue that the initiative to promote sanitation and hygiene behaviour change in small towns should focus on promoting motivation factors and abating the determinant factors identified in this study., Competing Interests: The authors have declared that no competing interests exist.

There is an excessive burden of diabetes complications in low-resource settings. We conducted a systematic review to determine the nature and frequency of diabetes complications in newly diagnosed with type 2 diabetes. A systematic search was performed using Medline, CINAHL and Global Health online databases from inception to July 2020. Articles reporting prevalence of microvascular or macrovascular complications within six months of type 2 diabetes diagnosis and published in English or French from low- and middle-income countries (LMICs) were eligible for analysis. Data were extracted using a standardized data extraction tool. Descriptive statistics were used to describe the prevalence of micro and macrovascular complications in newly diagnosed type 2 diabetes. Assessment of heterogeneity was conducted using the inconsistency index (I2) and Cochran-Q chi2 statistical tests. Publication bias was assessed by the Funnel plot and Egger test. A total of 3 292 records underwent title or abstract screening and 95 articles underwent full text review. Thirty-three studies describing 13 283 participants (aged 20 years and older) met the inclusion criteria. The eligible studies were from Asia (n = 24), Africa (n = 4), Oceania (n = 2), South America (n = 2) and the Caribbean (n = 1). For microvascular complications, the median prevalence (interquartile range) of retinopathy, nephropathy and neuropathy were 12% (6%-15%), 15% (7%-35%) and 16% (10%25%) respectively. For macrovascular complications, the median prevalence (interquartile range) was 10% (7%-17%) for ischaemic heart disease, 6% (1%-20%) for peripheral arterial disease and 2% (1%-4%) for stroke. There was evidence of substantial heterogeneity between studies for all outcomes (I2 > 90%. We found a high prevalence of complications in newly diagnosed type 2 diabetes in LMICs. Findings suggest that many people live with diabetes and are only diagnosed when they present with complications in LMICs. Research is needed to guide timely and effective identification of people living with diabetes in these settings., Competing Interests: The authors declared that no competing interests exist., (Copyright: © 2022 Aikaeli et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Pesticides are crucial to improve agricultural productivity, but often adversely affect surrounding aquatic systems and their fauna. To determine the environmental risk of pesticides, routine ecotoxicological tests are performed on several organisms, including standard fish models. However, these typically do not include fish species from variable habitats and with non-generic life-histories. In particular, inhabitants from temporary ponds such as annual killifish are conventionally understood to be resilient to natural stressors which could translate to higher pesticide resistance or, alternatively, trade-off with their resistance to pesticides and render them more sensitive than classic fish models. Using standard exposure tests, we assessed short-term toxicity effects of two commonly used pesticides, Roundup and cypermethrin, on the annual killifish Nothobranchius neumanni, and compared its sensitivity with that of classic fish models. For Roundup, we found a 72 h-LC 50 of 1.79 ± 0.11 mg/L, which is lower than the values reported for zebrafish, medaka, fathead minnow and rainbow trout, suggesting that N. neumanni is more sensitive to the compound. The opposite was true for cypermethrin, with a 72 h-LC 50 of 0.27 ± 0.03 mg/L. However, these LC 50 -values do not deviate strongly from those reported for other fish species, supporting earlier findings in the congeneric N. furzeri that the sensitivity of annual killifish to pollutants is similar to that of classic fish models despite their assumed robustness to environmental stress., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Artisanal and small-scale miners (ASMs) labour under archaic working conditions and are exposed to high levels of silica dust. Exposure to silica dust has been associated with an increased risk of tuberculosis and silicosis. ASMs are highly mobile and operate in remote areas with near absent access to health services. The main purpose of this study was to evaluate the prevalence of tuberculosis, silicosis and silico-tuberculosis among ASMs in Zimbabwe. A cross-sectional study was conducted from 1 October to 31 January 2021 on a convenient sample of 514 self-selected ASMs. We report the results from among those ASMs who attended an outreach medical facility and an occupational health clinic. Data were collected from clinical records using a precoded data proforma. Data variables included demographic (age, sex), clinical details (HIV status, GeneXpert results, outcomes of chest radiographs, history of tuberculosis) and perceived exposure to mine dust. Of the 464 miners screened for silicosis, 52 (11.2%) were diagnosed with silicosis, while 17 (4.0%) of 422 ASMs were diagnosed with tuberculosis (TB). Of the 373 ASMs tested for HIV, 90 (23.5%) were sero-positive. An HIV infection was associated with a diagnosis of silicosis. There is need for a comprehensive occupational health service package, including TB and silicosis surveillance, for ASMs in Zimbabwe. These are preliminary and limited findings, needing confirmation by more comprehensive studies.

Objective: To describe changes in maternal viral control over time in South African women living with HIV (WLHIV) using surveillance data from the National Health Laboratory Service's Corporate Data Warehouse (NHLS CDW)., Design: A retrospective cohort analysis of maternal viral load during pregnancy and up to 15 months postpartum was performed amongst WLHIV (15-49 years) within the public-health sector between 2016 and 2017., Methods: HIV and pregnancy-related test data were used to create a synthetic cohort of pregnant WLHIV from the NHLS CDW. Syphilis-screening, in association with ward type and/or postpregnancy cervical screening and/or birth HIV test and/or positive β-hCG, was used as a proxy for pregnancy. The syphilis-screening date marked the first antenatal care visit (fANC). Fractional polynomial models described viral load evolution from fANC up to 15 months postdelivery. Piecewise linear regression models determined factors associated with viral load decline., Findings: Among 178 319 pregnant WLHIV, 345 174 viral load tests were performed [median = 2 (IQR: 2-3) per woman]. At fANC, 85 545 (48%) women were antiretroviral therapy (ART) experienced; 88 877 (49.8%) were not and 3897 (2.2%) unknown. Proportions of viraemia (viral load ≥50 copies/ml) were 39 756 (53.6%) at first viral load performed during pregnancy, 14 780 (36.9%) at delivery and 24 328 (33.5%) postpartum. Maternal age at least 25 years, CD4+ cell count at least 500 cells/μl and viral load less than 50 copies/ml at baseline predicted sustained viral load suppression during follow-up., Conclusion: Despite high-ART coverage among pregnant women in South Africa, only 63% of WLHIV achieved viral load less than 50 copies/ml at delivery. Maternal viral load monitoring requires prioritization for maternal health and eMTCT., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Women of reproductive age living with HIV (WRLHIV), HIV-positive pregnant women, adolescent girls and young women (AGYW) are key populations for eliminating mother-to-child of HIV (eMTCT) in South Africa. We describe the geographical distribution of WRLHIV, their pregnant counterparts and AGYW for risk-adjusted allocation of eMTCT interventions., Methods: For the year 2018, we triangulated data from the Thembisa Model with five routine HIV-related and demographic data sources to determine the distribution of WRLHIV (15-49 years) and AGYW (15-24 years) nationally and by province. Data analysed included total population estimates, number of live-births, live-births to HIV-positive women, age-specific HIV prevalence rates, intrauterine (IU)-transmission rates and IU-case rates/100 000 live-births. IU-transmission rates and IU-case rates were calculated from de-duplicated routine HIV test-data for neonates (aged <7days). Data de-duplication was achieved by a patient-linking algorithm that uses probabilistic matching of demographics (name, surname, date of birth), supplemented by manual matching to account for spelling errors., Results: There were 58 million people in South Africa in 2018. Females (all ages) constituted 51% of the population. Women of reproductive age constituted 27% and AGYW constituted 8% of the total population. WRLHIV, AGYW living with HIV and HIV-positive pregnant women accounted for 7%, 0.8% and 0.4% of the total population respectively. Gauteng was the most populous province followed by KwaZulu-Natal, with Western Cape and Eastern Cape in third and fourth positions. The distribution of WRLHIV and AGYW followed a similar trend. However, Mpumalanga and Limpopo provinces had higher proportions of WRLHIV and AGYW living with HIV ahead of Western Cape. KwaZulu-Natal had the highest number of live-births to HIV-positive women. The national IU-transmission rate of <1% translated into 241 cases/100 000. While provincial IU-case rates were fairly similar at 179-325, districts IU-case rates varied, ranging from 87-415 cases/100 000 live-births., Conclusion: Findings suggest that the need for eMTCT interventions is greatest in Gauteng, KwaZulu-Natal, Western Cape and Eastern Cape. Limpopo and Mpumalanga provinces may require more HIV prevention and family planning services because of high fertility rates, high number of WRLHIV and AGYW living with HIV. eMTCT will require robust viral load monitoring among WRLHIV, pregnant and breastfeeding women. The national laboratory database can provide this service near-real time., Competing Interests: Authors declare no competing interests. Paediatric HIV Diagnostics is not a commercial company; it is a division of Wits Health Consortium(WHC), which is wholly-owned by the University of the Witwatersrand where authors FM and GGS are employed. Authors did not receive any additional funding from any commercial company other than funds received from the ELMA Foundation which have been declared already in the initial submission.

Introduction: Maternal viral load monitoring (mVL) and early infant diagnosis (EID) are necessary to achieve elimination of mother-to-child transmission of HIV. Point-of-care testing can achieve better outcomes compared to centralized laboratory testing (CLT). We describe the first implementation of point-of-care (POC) mVL and EID testing around delivery at four high volume tertiary obstetric units (TOUs) in Gauteng, South Africa., Methods: Prospective study of pregnant women living with HIV (WLHIV) and their infants. During the period 1 June 2018 to 31 March 2019, routine staff collected blood specimens from women and their infants around delivery. Specimen collection occurred throughout the week while dedicated POC operators, conducted testing during working hours on weekdays. Descriptive statistics and multivariable Poisson regression with robust error variance were used to describe outcomes and associated factors. Outcomes determined were (i) coverage of mVL and EID testing defined as a proportion of live births to WLHIV admitted at each facility (ii) results returned prior to discharge (iii) turn-around time (TAT) and iv) performance of POC testing compared to CLT., Results: In total, 8147 live births to pregnant WLHIV were recorded in the implementation period. Of these, 2912 mVL and 5074 EID specimens were included in the analysis, with 131 (4.5%) mVL and 715 (14.1%) EID specimens having initial invalid/error results. Overall coverage of POC mVL and EID testing was 35.6% (range 20.9% to 60.1%) and 61.9% (range 47.0% to 88.0%) respectively. Proportions of POC tested mothers and infants with results returned prior to discharge were 74.3% (range 39.0% to 95.7%) and 73.0% (range 50.0 to 97.9%). Return of results was independently associated with TOU, after-hours specimen collection, having an initial invalid or error result and period of implementation. Overall TAT for specimens collected from mother-infant pairs where both had POC testing, during weekdays was longer for EID compared to mVL testing (median 3.3 hours vs. 2.9 hours, p-value sign test <0.001). POC results were comparable to those from laboratory testing., Conclusion: Accurate and timely POC mVL and EID testing around delivery was implemented with variable success across TOUs. Further scale up would need to address health system factors at facility level and high analytical error rates., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Background: Elimination of mother-to-child transmission of HIV requires sustained viral load suppression during pregnancy and breastfeeding among women living with HIV (WLHIV). Antenatal antiretroviral therapy coverage is reported at >95% in South Africa, but viral load suppression rates are unknown. We describe maternal VL burden around time of delivery at 4 tertiary obstetric units (TOUs) in Gauteng Province., Methods: Between June 2018 and March 2019, routine point-of-care (PoC) maternal HIV VL and early infant diagnosis (EID) testing were implemented at 3 TOUs in Johannesburg and 1 in Tshwane district. WLHIV and HIV-exposed neonates were eligible for HIV VL (Xpert HIV-1 VL) and EID (Xpert HIV-1 EID or m-PIMA HIV1/2 detection) testing around time of delivery, respectively. Proportions of viremic women and intrauterine (IU)-infected neonates were calculated among valid PoC results., Results: Among 8147 live births to WLHIV, 2769 (34.0%) women and 4333 (53.2%) neonates had valid PoC results. Median VL at delivery was <40 copies/mL (interquartile range: 0-398). The proportion of women with a VL < 50, 50 to <1000, and ≥1000 copies/mL was 63.6%, 13.9% and 22.4%, respectively. There were 65/4333 (1.5%) IU-infected neonates. Among 1449 mother-neonate pairs with both VL and EID results, IU transmission by VL threshold was 3/946 (0.3%), 6/187 (3.2%), and 25/316 (7.9%) for VL < 50, 50 to <1000, and ≥1000 copies/mL, respectively (P < 0.001)., Conclusions: Despite high antiretroviral therapy coverage, >1/3 of WLHIV had a VL ≥50 copies/mL at delivery. Among mother-neonate pairs, maternal VL ≥50 copies/mL accounted for 31/34 (91%) IU infections. Improvement in the quality of HIV care among WLHIV is essential if South Africa is to achieve elimination of mother-to-child transmission.

Sustainable Development Goal (SDG) 6.2 sets an ambitious target of leaving no-one without adequate and equitable sanitation by 2030. The key concern is the lack of local human and financial capital to fund the collection of reliable information to monitor progress towards the goal. As a result, national and local records may be telling a different story of the proportion of safely managed sanitation that counts towards achieving the SDG. This paper unveils such inconsistency in sanitation data generated by urban authorities and proposes a simple approach for collecting reliable and verifiable information on access to safely managed sanitation. The paper is based on a study conducted in Babati Town Council in Tanzania. Using a smartphone-based survey tool, city health officers were trained to map 17,383 housing units in the town. A housing unit may comprise of two or more households. The findings show that 5% practice open defecation, while 82% of the housing units have some form of sanitation. Despite the extensive coverage, only 31% of the fecal sludge generated is safely contained, while 64% is not. This study demonstrates the possibility of using simple survey tools to collect reliable data for monitoring progress towards safely managed sanitation in the towns of global South.

Objective: The objective of the review was to determine the effectiveness of the use of decision aids to facilitate the shared decision-making process between a person and a healthcare provider on smoking cessation rates, knowledge of smoking cessation methods and decisional quality., Introduction: The tobacco epidemic is one of the biggest health threats in the world, and it is the single most important preventable cause of disease. In the smoking cessation process, people move through different stages in their readiness to quit. Healthcare providers are well positioned to impact smoking cessation, however, challenges continue to exist. Using decision aids in the smoking cessation decision-making process may be one means in moving people toward the decision to quit smoking., Inclusion Criteria: The review considered randomized controlled trials and quasi-experimental studies which included adults, 18 years and over, who smoke tobacco products. The intervention of interest was implementation of decision aids to promote shared decision-making related to smoking cessation. The comparator was usual care without the use of decision aids. Outcomes of interest were smoking abstinence, smoking quit attempts, knowledge of smoking cessation methods and decisional quality., Methods: A comprehensive search was undertaken to locate relevant published and unpublished quantitative English language studies from the inception of each database searched through July 30, 2017. Databases searched included: CINAHL, Cochrane Central Register of Controlled Trials, Embase, PsycINFO and PubMed. A search of gray literature was also performed. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria. Studies meeting the inclusion criteria were retrieved in full and assessed in detail against the inclusion criteria by two independent reviewers. Two reviewers independently evaluated the included studies for methodological quality using critical appraisal tools from the Joanna Briggs Institute (JBI). Data related to the methods, participants, interventions and findings were extracted by two independent reviewers using a standardized data extraction tool from JBI. Due to clinical and methodological heterogeneity in the interventions and outcome measures of the included studies, statistical meta-analysis was not possible. Results have been presented in narrative form., Results: Eight papers representing seven unique studies evaluating smoking cessation decision aids were included. Of the six studies that measured abstinence, only two had positive findings, with one reaching statistical significance. The fours studies that measured quit attempts all demonstrated a trend toward an increase in the number of quit attempts, with one study reaching statistical significance. Four of the five studies that measured knowledge reported an initial increase in the knowledge of smoking cessation methods, with two studies reaching statistical significance. Two of the three studies that measured decisional quality showed an improvement in decisional quality after use of the decision aid, with one study reaching statistical significance., Conclusions: The evidence suggests that decision aids may be effective in increasing smoking cessation knowledge and decisional quality while increasing quit attempts. There is, however, inconclusive evidence to support the definitive effectiveness of decision aids for long term and sustained smoking cessation.

We describe the extent of and variables associated with irreproducible HIV-1 PCR positive results within South Africa's Early Infant Diagnosis (EID) program from 2010 to 2015 and propose criteria for differentiating indeterminate from clearly positive results using the COBAS® AmpliPrep/COBAS® TaqMan HIV-1 Qualitative Test version 2.0 (CAP/CTM Qual v2.0). Fourteen percent of specimens with an instrument-positive result that were repeat-tested yielded a negative result for which cycle threshold (Ct) proved to be the only predictive variable. A Ct <33.0 was found to be the most accurate threshold value for differentiating clearly positive from irreproducible cases, correctly predicting 96.8% of results. Among 70 patients with an irreproducible positive result linked to a follow up HIV-1 PCR test, 67 (95.7%) were negative and 3 (4.3%) were instrument-positive. Criteria differentiating clearly positive from indeterminate results need to be retained within EID services and infants with indeterminate results closely monitored and final HIV status determined., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Early advance care planning and anticipatory decision making in the Alzheimer disease (AD) trajectory is a strategy NPs can incorporate to improve managing uncertainty around common decisions. This article explores decisions patients and caregivers face along the AD trajectory and provides resources for patients, caregivers, and NPs.

Background: South Africa represents the first high-burden setting to introduce routine virologic testing at birth within its early infant diagnosis program, implemented in June 2015. National HIV birth testing coverage, intrauterine transmission rates and case rates for the first year since introduction of universal birth testing are reported., Methods: HIV polymerase chain reaction (PCR) test data from June 2015 to May 2016 were extracted from the National Health Laboratory Service's central data repository by year, month, age, result and geographic location. Birth testing was defined as all HIV PCR tests performed at <7 days of life; coverage as the proportion of all HIV-exposed neonates born who were tested at birth; estimated intrauterine transmission rate as the percentage of HIV PCR positive tests in HIV-exposed neonates tested and case rates as the number of HIV PCR positive tests per 100,000 total live births., Results: Between June 2015 and May 2016, the South African national monthly birth testing coverage increased from 39% (8636 tests) to 93% (20,479 tests). During this period, the number of positive tests at birth increased from 114 to 234 per month, equating to a national intrauterine transmission rate of 1.1% and a birth case rate of 247 per 100,000 live births., Conclusions: Universal birth testing for all HIV-exposed neonates is rapidly being achieved in South Africa, facilitating earlier detection of intrauterine infected neonates. However, the successful linkage into care of HIV-infected neonates and their treatment outcomes remain to be assessed.

Objective: To describe baseline HIV-1 RNA viral load (VL) trends within South Africa's Early Infant Diagnosis program 2010-2016, with reference to prevention of mother-to-child transmission guidelines., Methods: HIV-1 total nucleic acid polymerase chain reaction (TNA PCR) and RNA VL data from 2010 to 2016 were extracted from the South African National Health Laboratory Service's central data repository. Infants with a positive TNA PCR and subsequent baseline RNA VL taken at age <7 months were included. Descriptive statistics were performed for quantified and lower-than-quantification limit (LQL) results per annum and age in months. Trend analyses were performed using log likelihood ratio tests. Multivariable linear regression was used to model the relationship between RNA VL and predictor variables, whereas logistic regression was used to identify predictors associated with LQL RNA VL results., Results: Among 13,606 infants with a positive HIV-1 TNA PCR linked to a baseline RNA VL, median age of first PCR was 57 days and VL was 98 days. Thirteen thousand one hundred ninety-five (97.0%) infants had a quantified VL and 411 (3.0%) had an LQL result. A significant decline in median VL was observed between 2010 and 2016, from 6.3 log10 (interquartile range: 5.6-6.8) to 5.6 log10 (interquartile range: 4.2-6.5) RNA copies per milliliter, after controlling for age (P < 0.001), with younger age associated with lower VL (P < 0.001). The proportion of infants with a baseline VL <4 Log10 RNA copies per milliliter increased from 5.4% to 21.8%. Subsequent to prevention of mother-to-child transmission Option B implementation in 2013, the proportion of infants with an LQL baseline VL increased from 1.5% to 6.1% (P < 0.001)., Conclusions: Between 2010 and 2016, a significant decline in baseline viremia within South Africa's Early Infant Diagnosis program was observed, with loss of detectability among some HIV-infected infants.

Review Question: The objective of this review is to determine the effectiveness of the use of decision aids in a shared decision-making encounter between any healthcare provider and adult patients who smoke, compared to standard education on smoking cessation, in any healthcare setting.Specifically, the review questions are: What is the effectiveness of the use of decision aids in a shared decision-making encounter in any healthcare setting between the healthcare provider and adult patients who smoke compared to standard education, based on the patient's.

Background: Samples submitted for HIV PCR testing that fail to yield a positive or negative result represent missed diagnostic opportunities. We describe HIV PCR test rejections and indeterminate results, and the associated delay in diagnosis, within South Africa's early infant diagnosis (EID) program from 2010 to 2015., Methods: HIV PCR test data from January 2010 to December 2015 were extracted from the National Health Laboratory Service Corporate Data Warehouse, a central data repository of all registered test-sets within the public health sector in South Africa, by laboratory number, result, date, facility, and testing laboratory. Samples that failed to yield either a positive or negative result were categorized according to the rejection code on the laboratory information system, and descriptive analysis performed using Microsoft Excel. Delay in diagnosis was calculated for patients who had a missed diagnostic opportunity registered between January 2013 and December 2015 by means of a patient linking-algorithm employing demographic details., Results: Between 2010 and 2015, 2 178 582 samples were registered for HIV PCR testing of which 6.2% (n = 134 339) failed to yield either a positive or negative result, decreasing proportionally from 7.0% (n = 20 556) in 2010 to 4.4% (n = 21 388) in 2015 (p<0.001). Amongst 76 972 coded missed diagnostic opportunities, 49 585 (64.4%) were a result of pre-analytical error and 27 387 (35.6%) analytical error. Amongst 49 694 patients searched for follow-up results, 16 895 (34.0%) had at least one subsequent HIV PCR test registered after a median of 29 days (IQR: 13-57), of which 8.4% tested positive compared with 3.6% of all samples submitted for the same period., Conclusions: Routine laboratory data provides the opportunity for near real-time surveillance and quality improvement within the EID program. Delay in diagnosis and wastage of resources associated with missed diagnostic opportunities must be addressed and infants actively followed-up as South Africa works towards elimination of mother-to-child transmission.

Objectives: To report predictors of outcomes of second-line ART for HIV treatment in a resource-limited setting., Methods: All adult ART-naïve patients who initiated standard first-line treatment between April 2004 and February 2012 at four public-sector health facilities in Johannesburg, South Africa, experienced virologic failure and initiated standard second-line therapy were included. We assessed predictors of attrition (death and loss to follow-up [≥3 months late for a scheduled visit]) using Cox proportional hazards regression and predictors of virologic suppression (viral load <400 copies/ml ≥3 months after switch) using modified Poisson regression with robust error estimation at 1 year and ever after second-line ART initiation., Results: A total of 1236 patients switched to second-line treatment in a median (IQR) of 1.9 (0.9-4.6) months after first-line virologic failure. Approximately 13% and 45% of patients were no longer in care at 1 year and at the end of follow-up, respectively. Patients with low CD4 counts (<50 vs. ≥200, aHR: 1.85; 95% CI: 1.03-3.32) at second-line switch were at greater risk for attrition by the end of follow-up. About 75% of patients suppressed by 1 year, and 85% had ever suppressed by the end of follow-up., Conclusions: Patients with poor immune status at switch to second-line ART were at greater risk of attrition and were less likely to suppress. Additional adherence support after switch may improve outcomes., (© 2016 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Background: While most breast-related research focuses on cancer, presentation of symptomatic persons in non-screened environments requires understanding the spectrum of breast diseases so as to plan services in resource-constrained settings. This study presents the variety of breast disease managed at a government, open-access breast clinic in South Africa., Methods: We performed a retrospective file review using a systematic random sample of patients 18 years and above presenting for breast care over a 14-month period. We collected demographics, clinical characteristics, management and final diagnoses from the first visit and twelve subsequent months., Results: The final sample contained 365 individuals (97 · 5% women). Most were black, unmarried and South African citizens with a median age of 43 years (IQR 31-55) . Of those reporting their status (24 · 1%) 38 · 6% were HIV-positive. A mass (57 · 0%) and/or pain (28 · 5%) were the most common symptoms. Imaging and breast biopsies were required in 78 and 25% of individuals, respectively. Nearly half of biopsies identified breast cancer (44 · 1% of women ≤40 and 57 · 3% for women >40). Benign conditions (47 · 7%) and no abnormality (18 · 2%) were common final classifications among women. There was no difference between the final classifications of patients who self-referred versus those who were formally referred from another health care provider. Nearly half of the participants (46 · 6%) travelled 20 km or more to attend the clinic., Conclusions: Benign breast conditions far outweighed cancer diagnoses. As breast cancer awareness increases in resource-limited countries, facilities offering breast care require administrative and clinical preparation to manage a range of non-cancer related conditions.

Background: In 2010 South Africa revised its HIV treatment guidelines to allow the initiation and management of patients on antiretroviral therapy (ART) by nurses, rather than solely doctors, under a program called NIMART (Nurse Initiated and Managed Antiretroviral Therapy). We compared the outcomes and costs of NIMART between the two major public sector HIV treatment delivery models in use in South Africa today, primary health clinics and hospital-based HIV clinics., Methods and Findings: The study was conducted at one hospital-based outpatient HIV clinic and one primary health clinic (PHC) in Gauteng Province. A retrospective cohort of adult patients initiated on ART at the PHC was propensity-score matched to patients initiated at the hospital outpatient clinic. Each patient was assigned a 12-month outcome of alive and in care or died/lost to follow up. Costs were estimated from the provider perspective for the 12 months after ART initiation. The proportion of patients alive and in care at 12 months did not differ between the PHC (76.5%) and the hospital-based site (74.2%). The average annual cost per patient alive and in care at 12 months after ART initiation was significantly lower at the PHC (US$238) than at the hospital outpatient clinic (US$428)., Conclusions: Initiating and managing ART patients at PHCs under NIMART is producing equally good outcomes as hospital-based HIV clinic care at much lower cost. Evolution of hospital-based clinics into referral facilities that serve complicated patients, while investing most program expansion resources into PHCs, may be a preferred strategy for achieving treatment coverage targets., Competing Interests: The authors have declared that no competing interests exist.

High levels of adherence are required to achieve the full benefit of ART. We assess the effectiveness of electronic adherence monitoring devices among patients failing second-line ART, as measured by viral load suppression. Cohort study of Wisepill™ real-time adherence monitoring in addition to intensified adherence counselling over 3 months in adults with a viral load ≥400 copies/ml on second-line ART in Johannesburg, South Africa between August 2013 and January 2014. Patients were sent SMS reminders upon missing a scheduled dose. We compared outcomes to earlier historical cohorts receiving either intensified adherence counselling or adherence counselling alone. Overall, 63 % of the participants (31/49) took >80 % of their prescribed medication; this dropped from 76 to 53 and 49 % at 1, 2 and 3 months post-enrolment respectively. Compared to those with good adherence (>80 %), participants with poor adherence (≤80 %) had a higher risk for a subsequently elevated viral load ≥400 copies/ml (relative risk (RR) 1.47 95 % CI 0.97-2.23). Participants found the intervention "acceptable and useful" but by 6 months after eligibility they were only slightly more likely to be alive, in care and virally suppressed compared to those who received intensified adherence counselling (44.9 vs. 38.5 %; RR 1.19; 95 % CI 0.85-1.67) or adherence counselling alone (44.9 vs. 40.9 %; RR 1.12; 95 % CI 0.81-1.56). In patients with an elevated viral load on second-line ART electronic adherence monitoring was associated with a modest, but not significant, improvement in viral suppression., Competing Interests: The authors declare that they have no conflict of interest.