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Pogue SD, Saito S, Tlhomola M, West CA, Asiimwe F, Ramphalla P, Poirot E, Steiner C, Greenleaf AR. HIV retesting among people living with HIV in Lesotho in 2022. Int J STD AIDS 2025; 36:114-118. [PMID: 39434648 PMCID: PMC11844745 DOI: 10.1177/09564624241289984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2024]
Abstract
BACKGROUND Despite widespread HIV testing in sub-Saharan Africa, regular testing among at-risk populations is crucial for effective prevention. However, reports increasingly indicate retesting among people living with HIV (PLHIV), a group that would not require additional testing since they would already have received a confirmed diagnosis. We describe the demographic characteristics of PLHIV retesters in Lesotho, report the average number of HIV tests post-diagnosis among PLHIV, and share motivations for retesting. METHODS In August 2022, a nationally representative cohort in Lesotho participated in a cell phone survey about their HIV status and testing history. Study participants were recruited from a face-to-face survey conducted in 2020, Lesotho Population Based HIV Impact Assessment survey. RESULTS Of the 1523 participants called, 1111 participants responded (72.9%) and 266 reported living with HIV. We found 18.8% of people living with HIV (PLHIV) reported retesting at least once for HIV, and 58% of PLHIV who reported retesting were likely or very likely to retest for HIV in the coming year. The main reason PLHIV reported retesting was because a health care worker offered the test (61.7%) followed by self-initiated testing to confirm their status (29.1%). Among male PLHIV who had a history of retesting, 92.0% were very likely or likely to retest, compared to only 30.6% of female PLHIV. CONCLUSION We found almost a fifth of PLHIV in Lesotho reported a history of retesting for HIV, and 58% of PLHIV were likely or very likely to retest for HIV in the coming year. Educating providers and men living with HIV could reduce retesting among PLHIV.
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Affiliation(s)
| | - Suzue Saito
- ICAP at Columbia, Mailman School of Public Health, Columbia Unviersity, New York, NY, USA
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Christine A West
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Fred Asiimwe
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Maseru, Lesotho
| | - Puleng Ramphalla
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Maseru, Lesotho
| | - Eugenie Poirot
- ICAP at Columbia, Mailman School of Public Health, Columbia Unviersity, New York, NY, USA
| | - Claire Steiner
- ICAP at Columbia, Mailman School of Public Health, Columbia Unviersity, New York, NY, USA
| | - Abigail R Greenleaf
- ICAP at Columbia, Mailman School of Public Health, Columbia Unviersity, New York, NY, USA
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
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Olislagers Q, van Leth F, Shabalala F, Dlamini N, Simelane N, Masilela N, Gomez GB, Pell C, Vernooij E, Reis R, Molemans M. Reasons for, and factors associated with, positive HIV retesting: a cross-sectional study in Eswatini. AIDS Care 2022:1-8. [PMID: 36449635 DOI: 10.1080/09540121.2022.2142930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Eswatini has a high HIV prevalence but has made progress towards improving HIV-status awareness, ART uptake and viral suppression. However, there is still a delay in ART initiation, which could partly be attributed to positive HIV-retesting. This study examines reasons for, and factors associated with, positive HIV-retesting among MaxART participants in Eswatini. Data from 601 participants is included in this cross-sectional study. Descriptive statistics and logistic regressions were used. Of the participants, 32.8% has ever retested after a previous positive result. Most participants who retested did this because they could not accept their results (61.9% of all retesters). Other main reasons are related to external influences, gender or the progression of their HIV infection (respectively 18.3%, 10.2%, and 6.1% of all retesters). Participants without a current partner and participants with less time since their first positive test have lower odds of retesting. To decrease retesting and reduce the delay in ART initiation resulting from it, efforts could be made on increasing the acceptance of positive HIV results. Providing more information on the process of testing and importance of early ART initiation, could be part of the solution.
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Affiliation(s)
- Quint Olislagers
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Frank van Leth
- Department of health sciences, VU University, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Fortunate Shabalala
- Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini
| | - Njabuliso Dlamini
- National Emergency Response Council on HIV and AIDS (NERCHA), Mbabane, Eswatini
| | | | - Nelisiwe Masilela
- Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Ria Reis
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
- The Children’s Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Marjan Molemans
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
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Kaggwa MM, Najjuka SM, Bongomin F, Mamun MA, Griffiths MD. Prevalence of depression in Uganda: A systematic review and meta-analysis. PLoS One 2022; 17:e0276552. [PMID: 36264962 PMCID: PMC9584512 DOI: 10.1371/journal.pone.0276552] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/09/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Depression is one of the most studied mental health disorders, with varying prevalence rates reported across study populations in Uganda. A systematic review and meta-analysis was carried out to determine the pooled prevalence of depression and the prevalence of depression across different study populations in the country. METHODS Papers for the review were retrieved from PubMed, Scopus, PsycINFO, African Journal OnLine, and Google Scholar databases. All included papers were observational studies regarding depression prevalence in Uganda, published before September 2021. The Joanna Briggs Institute Checklist for Prevalence Studies was used to evaluate the risk of bias and quality of the included papers, and depression pooled prevalence was determined using a random-effects meta-analysis. RESULTS A total of 127 studies comprising 123,859 individuals were identified. Most studies were conducted among individuals living with HIV (n = 43; 33.9%), and the most frequently used instrument for assessing depression was the Depression sub-section of the Hopkins Symptom Checklist (n = 34). The pooled prevalence of depression was 30.2% (95% confidence interval [CI]: 26.7-34.1, I2 = 99.80, p<0.001). The prevalence of depression was higher during the COVID-19 pandemic than during the pre-pandemic period (48.1% vs. 29.3%, p = 0.021). Refugees had the highest prevalence of depression (67.6%; eight studies), followed by war victims (36.0%; 12 studies), individuals living with HIV (28.2%; 43 studies), postpartum or pregnant mothers (26.9%; seven studies), university students (26.9%; four studies), children and adolescents (23.6%; 10 studies), and caregivers of patients (18.5%; six studies). LIMITATION Significantly high levels of heterogeneity among the studies included. CONCLUSION Almost one in three individuals in Uganda has depression, with the refugee population being disproportionately affected. Targeted models for depression screening and management across various populations across the country are recommended. TRIAL REGISTRATION Protocol registered with PROSPERO (CRD42022310122).
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Affiliation(s)
- Mark Mohan Kaggwa
- Department of Psychiatry, Mbarara University of Science & Technology, Mbarara, Uganda
- African Centre for Suicide Prevention and Research, Mbarara, Uganda
- Department of Psychiatry and Behavioural Neurosciences, Forensic Psychiatry Program, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Maria Najjuka
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Mohammed A. Mamun
- CHINTA Research Bangladesh, Savar, Dhaka, Bangladesh
- Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, Bangladesh
| | - Mark D. Griffiths
- Psychology Department, Nottingham Trent University, Nottingham, United Kingdom
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. METHODS We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis. RESULTS AND DISCUSSION We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. CONCLUSIONS Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Global Health Institute, Cambridge, Massachusetts, USA
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Marson K, Ndyabakira A, Kwarisiima D, Camlin CS, Kamya MR, Havlir D, Thirumurthy H, Chamie G. HIV retesting and risk behaviors among high-risk, HIV-uninfected adults in Uganda. AIDS Care 2020; 33:675-681. [PMID: 33172300 DOI: 10.1080/09540121.2020.1842319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
There are limited data characterizing HIV retesting among high-risk adults in sub-Saharan Africa. From October-December 2018, we distributed recruitment cards offering health evaluations with HIV testing at venues frequented by individuals at-risk of HIV infection in Southwest Uganda. Those who attended were asked about their HIV testing history and risk factors: having >1 sexual partner, an HIV+ partner, STIs, and/or transactional sex. We defined "highest risk" as ≥3 risk factors and "frequent testing" as ≥3 tests within the past year. Of 1,777 cards distributed, 1,482 (83%) adults came to clinic: median age was 26(IQR: 22-31), 598 (40%) were men, and 334 (23%) were HIV+. Of 1,148 HIV-negative adults, 338 (29%) were highest risk and 205 (18%) were frequent testers. Frequent testing was similar in women (19%) and men (16%, p = 0.22). Among women, those at highest risk were more likely to report any testing (90% vs. 81%, p = 0.01) and frequent testing (25% vs. 18%, p = 0.06) than those at lower risk. Among men, any testing and frequent testing were similar between risk levels. Among adults recruited from high-risk venues in peri-urban Uganda, HIV risk behaviors were commonly reported, yet frequent retesting remained low. Interventions to promote retesting are needed, particularly among men.
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Affiliation(s)
- Kara Marson
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Diane Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Harsha Thirumurthy
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
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Grimsrud A, Wilkinson L, Eshun-Wilson I, Holmes C, Sikazwe I, Katz IT. Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind. Curr HIV/AIDS Rep 2020; 17:458-466. [PMID: 32844274 PMCID: PMC7497373 DOI: 10.1007/s11904-020-00522-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions. RECENT FINDINGS There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.
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Affiliation(s)
- Anna Grimsrud
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Lynne Wilkinson
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Charles Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Massachusetts General Hospital Center for Global Health, Boston, MA USA
- Harvard Global Health Institute, Cambridge, MA USA
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Maheu-Giroux M, Marsh K, Doyle CM, Godin A, Lanièce Delaunay C, Johnson LF, Jahn A, Abo K, Mbofana F, Boily MC, Buckeridge DL, Hankins CA, Eaton JW. National HIV testing and diagnosis coverage in sub-Saharan Africa: a new modeling tool for estimating the 'first 90' from program and survey data. AIDS 2019; 33 Suppl 3:S255-S269. [PMID: 31764066 PMCID: PMC6919235 DOI: 10.1097/qad.0000000000002386] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/20/2019] [Accepted: 09/19/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE HIV testing services (HTS) are a crucial component of national HIV responses. Learning one's HIV diagnosis is the entry point to accessing life-saving antiretroviral treatment and care. Recognizing the critical role of HTS, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the 90-90-90 targets stipulating that by 2020, 90% of people living with HIV know their status, 90% of those who know their status receive antiretroviral therapy, and 90% of those on treatment have a suppressed viral load. Countries will need to regularly monitor progress on these three indicators. Estimating the proportion of people living with HIV who know their status (i.e. the 'first 90'), however, is difficult. METHODS We developed a mathematical model (henceforth referred to as 'Shiny90') that formally synthesizes population-based survey and HTS program data to estimate HIV status awareness over time. The proposed model uses country-specific HIV epidemic parameters from the standard UNAIDS Spectrum model to produce outputs that are consistent with other national HIV estimates. Shiny90 provides estimates of HIV testing history, diagnosis rates, and knowledge of HIV status by age and sex. We validate Shiny90 using both in-sample comparisons and out-of-sample predictions using data from three countries: Côte d'Ivoire, Malawi, and Mozambique. RESULTS In-sample comparisons suggest that Shiny90 can accurately reproduce longitudinal sex-specific trends in HIV testing. Out-of-sample predictions of the fraction of people living with HIV ever tested over a 4-to-6-year time horizon are also in good agreement with empirical survey estimates. Importantly, out-of-sample predictions of HIV knowledge of status are consistent (i.e. within 4% points) with those of the fully calibrated model in the three countries when HTS program data are included. The model's predictions of knowledge of status are higher than available self-reported HIV awareness estimates, however, suggesting - in line with previous studies - that these self-reports could be affected by nondisclosure of HIV status awareness. CONCLUSION Knowledge of HIV status is a key indicator to monitor progress, identify bottlenecks, and target HIV responses. Shiny90 can help countries track progress towards their 'first 90' by leveraging surveys of HIV testing behaviors and annual HTS program data.
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Affiliation(s)
- Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, Canada
| | - Kimberly Marsh
- The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Carla M. Doyle
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, Canada
| | - Arnaud Godin
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, Canada
| | - Charlotte Lanièce Delaunay
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, Canada
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Andreas Jahn
- Ministry of Health, Lilongwe, Malawi and I-TECH, Department of Global Health, University of Washington, Seattle, USA
| | - Kouamé Abo
- Programme national de lutte contre le Sida, Abidjan, Côte d’Ivoire
| | | | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary's Hospital, London, UK
| | - David L. Buckeridge
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, Canada
| | - Catherine A. Hankins
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, Canada
| | - Jeffrey W. Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary's Hospital, London, UK
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