The economic costs and cost-effectiveness of HIV self-testing among truck drivers in Kenya

HIV status awareness is critical for ending the HIV epidemic but remains low in high-HIV-risk and hard-to-reach sub-populations. Targeted, efficient interventions are needed to improve HIV test-uptake. We examined the incremental cost-effectiveness of offering the choice of self-administered oral HIV-testing (HIVST-Choice) compared with provider-administered testing only [standard-of-care (SOC)] among long-distance truck drivers. Effectiveness data came from a randomized-controlled trial conducted at two roadside wellness clinics in Kenya (HIVST-Choice arm, n = 150; SOC arm, n = 155). Economic cost data came from the literature, reflected a societal perspective and were reported in 2020 international dollars (I$), a hypothetical currency with equivalent purchasing power as the US dollar. Generalized Poisson and linear gamma regression models were used to estimate effectiveness and incremental costs, respectively; incremental effectiveness was reported as the number of long-distance truck drivers needing to receive HIVST-Choice for an additional HIV test-uptake. We calculated the incremental cost-effectiveness ratio (ICER) of HIVST-Choice compared with SOC and estimated 95% confidence intervals (CIs) using non-parametric bootstrapping. Uncertainty was assessed using deterministic sensitivity analysis and the cost-effectiveness acceptability curve. HIV test-uptake was 23% more likely for HIVST-Choice, with six individuals needing to be offered HIVST-Choice for an additional HIV test-uptake. The mean per-patient cost was nearly 4-fold higher in HIVST-Choice (I$39.28) versus SOC (I$10.80), with an ICER of I$174.51, 95% CI [165.72, 194.59] for each additional test-uptake. HIV self-test kit and cell phone service costs were the main drivers of the ICER, although findings were robust even at highest possible costs. The probability of cost-effectiveness approached 1 at a willingness-to-pay of I$200 for each additional HIV test-uptake. HIVST-Choice improves HIV-test-uptake among truck drivers at low willingness-to-pay thresholds, suggesting that HIV self-testing is an efficient use of resources. Policies supporting HIV self-testing in similar high risk, hard-to-reach sub-populations may expedite achievement of international targets.

Exposure to comprehensive sexuality education in schools in South Africa: the implications on the uptake of HIV testing services among HIV positive adolescent girls

Comprehensive sexuality education (CSE) is seen as a key instrument through which to affect behaviour and improve sexual and reproductive health (SRH) outcomes amongst adolescents. However, few studies have to date evaluated key SRH outcomes following exposure to CSE within a school setting. This study estimates the association between CSE and HIV testing and HIV testing self-efficacy amongst HIV positive adolescent girls. Data were collected from a cross-sectional survey administered in four high HIV prevalence districts . Independent variables included exposure to CSE, with outcome variables measuring uptake of HIV testing in the 12 months preceding the survey, and HIV testing self-efficacy. The sample comprised 505 HIV positive adolescent girls aged 12-19. . Attending CSE was associated with both; being more confident to get an HIV test (AOR: 2.44, 95% CI: 1.47-4.06, p < 0.001) and having ever tested for HIV (AOR: 2.15, 95% CI: 1.39-3.33, p < 0.001) while controlling for numerous variables. Results suggest CSE can play an important role in not only affecting HIV-related behaviours themselves, but also critical factors that affect HIV behaviours, including self-efficacy.

Reducing Initial Loss to Follow-up Among People With Bacteriologically Confirmed Tuberculosis: LINKEDin, a Quasi-experimental Study in South Africa

Every person diagnosed with tuberculosis (TB) needs to initiate treatment. The World Health Organization estimated that 61% of people who developed TB in 2021 were included in a TB treatment registration system. Initial loss to follow-up (ILTFU) is the loss of persons to care between diagnosis and treatment initiation/registration. LINKEDin, a quasi-experimental study, evaluated the effect of 2 interventions (hospital recording and an alert-and-response patient management intervention) in 6 subdistricts across 3 high-TB burden provinces of South Africa. Using integrated electronic reports, we identified all persons diagnosed with TB (Xpert MTB/RIF positive) in the hospital and at primary health care facilities. We prospectively determined linkage to care at 30 days after TB diagnosis. We calculated the risk of ILTFU during the baseline and intervention periods and the relative risk reduction in ILTFU between these periods. We found a relative reduction in ILTFU of 42.4% (95% CI, 28.5%-53.7%) in KwaZulu Natal (KZN) and 22.3% (95% CI, 13.3%-30.4%) in the Western Cape (WC), with no significant change in Gauteng. In KZN and the WC, the relative reduction in ILTFU appeared greater in subdistricts where the alert-and-response patient management intervention was implemented (KZN: 49.3%; 95% CI, 32.4%-62%; vs 32.2%; 95% CI, 5.4%-51.4%; and WC: 34.2%; 95% CI, 20.9%-45.3%; vs 13.4%; 95% CI, 0.7%-24.4%). We reported a notable reduction in ILTFU in 2 provinces using existing routine health service data and applying a simple intervention to trace and recall those not linked to care. TB programs need to consider ILTFU a priority and develop interventions specific to their context to ensure improved linkage to care.

Examining the uptake of COVID-19 vaccine booster doses among healthcare workers in South Africa: A mixed-methods study

This study aimed examin the factors associated with the uptake and non-acceptance of COVID-19 vaccine booster doses among healthcare workers (HCWs) in South Africa. We used a mixed-methods design with data from a web-based self-administered survey followed by semi-structured in-depth interviews (IDIs) with selected participants. Of the 6235 HCWs included in our analysis who had fully vaccinated, 3470 (56%) had taken their booster dose with a further 17% intending to get the booster. HCWs aged 35 to 49 years (OR = 1.30 [95% CI: 1.15-1.46]), and those aged 50 years or older (OR = 2.66 [95% CI: 2.32-3.05]) were more likely to get the booster dose. Females were less likely to have received the booster dose (OR = 0.88 [95% CI: 0.79-0.98]) with doctors more likely (OR = 1.58 [95% CI: 1.35-1.84]) than Nurses to have received the booster dose. HCWs in direct contact with patients (OR = 1.17 [95% CI: 1.00-1.38]) and who had previously received a flu vaccine (OR = 1.99 [95% CI: 1.56-2.55]) were more likely to have received the booster dose. Four themes emerged from the qualitative data analysis: (1) Vaccination as routine practice among HCWs; (2) Emergence of new COVID-19 variants necessitating vaccine boosters; (3) Fear of potential side-effects; and (4) Limited value of COVID-19 vaccine boosters. Some HCWs broadly accepted the value of vaccination, and believed that boosters were necessary to effectively combat emergent new virus strains, which contrasted with peers who believed that boosters offered little defence against virus mutations. Fear prohibited some HCWs from getting the booster, with some having experienced adverse side effects from their initial vaccination, whilst others were concerned about future complications. Waning booster uptake rates could be arrested through invigorated communication strategies, while effective evidence-based training can potentially create positive normative vaccination practices amongst HCWs.

A step towards rational design of carbon nanobelts with tunable electronic properties

Belt-shaped aromatic compounds are among the most attractive classes of radial π-conjugated nanocarbon molecules with unique physical and chemical properties. In this work, we computationally studied a number of all-carbon and heteroatom-bridged nanobelts, as well as their inclusion complexes with fullerene C60. Our results provide a useful guide for modulating the electronic properties of the nanobelts. An in-depth analysis of the ground and excited state properties of their complexes has allowed us to establish structure-property relationships and propose simple principles for the design of nanobelts with improved electron-donating properties suitable for photovoltaic applications.

Pre-Clinical Validation of Targeting Cholesterol Metabolism for Radiotherapy Sensitization in Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

This study examines the potential benefits of targeting cholesterol metabolism in combination with radiation therapy (RT) for treating Head and Neck Squamous Cell Carcinoma (HNSCC). Despite advancements in RT delivery, 60% of patients still experience a relapse within 2 years, highlighting the need for improved treatment strategies. Our hypothesis is that a specific, biological response to RT by a subset of tumor cells drives radio-resistance and recurrence, and that targeting cholesterol metabolism may be an effective way to improve RT efficacy.

MATERIALS/METHODS

To identify radiation-induced biological responses, whole-genome RNA sequencing analysis was carried out on Cal27 (HPV-) and UMSCC47 (HPV+) cell lines after X-Ray (6MeV Linac) or proton (pencil beam scanning, center part of SOBP) radiations. Potential radio-resistance targets were identified by comparing RT-induced transcriptomic changes with publicly available GEO and TCGA transcriptomic data from human HNSCC samples. Cholesterol metabolism as a driver of HNSCC radio-resistance was validated in vitro by pharmacological and genetic approaches.

RESULTS

Transcriptomic analysis revealed a significant increase in 11 genes related to sterol and cholesterol in both the Cal27 and UMSCC47 cell lines after radiation exposure (pathway functional enrichment analysis, p = 2.05e-05). High expression of these RT-induced cholesterol gene signatures correlated with decreased overall survival among HNSCC patients based on the TCGA database (log rank p = 0.022, HR = 1.4). Moreover, a Gene Set Enrichment Analysis of the GSE23036 dataset (pre-treatment HNSCC tumors: locoregional recurrence vs. nonrecurrence) also linked cholesterol metabolism and local recurrence (p = 0.002, FDR = 0.07, NES = 1.72). Single-cell RNA sequencing data from the GSE164690 dataset revealed high expression of cholesterol metabolism genes in human HNSCC epithelial and mesenchymal fractions. In vitro studies demonstrated that RT increased the nuclear translocation of the master transcription factors controlling cholesterol gene expression SREBP2 and increased the expression of the SREBP2 target gene SQLE at the protein level. In accordance with this result, RT increased cellular cholesterol content and uptake in human (p = 0.027) and murine (p = 0.015) HNSCC cell lines. Drug or genetic targeting of SREBP2 reduced cellular cholesterol levels in HNSCC cells and increased toxicity when combined with RT in both 2D and 3D cell cultures compared to RT alone.

CONCLUSION

Targeting cholesterol metabolism in combination with RT could be beneficial for treating HNSCC. In vivo validation in immunocompetent mouse models and orthotopic patient-derived xenograft models is ongoing.

Determinants of health-related quality of life in people with Human Immunodeficiency Virus, failing first-line treatment in Africa

BACKGROUND

Antiretroviral treatment improves health related quality of life (HRQoL) of people with human immunodeficiency virus (PWH). However, one third initiating first-line treatment experience virological failure and the determinants of HRQoL in this key population are unknown. Our study aims to identify determinants of among PWH failing antiretroviral treatment in sub-Saharan Africa.

METHODS

We analysed data from a cohort of PWH having virological failure (> 1,000 copies/mL) on first-line ART in South Africa and Uganda. We measured HRQoL using the EuroQOL EQ-5D-3L and used a two-part regression model to obtain by-country analyses for South Africa and Uganda. The first part identifies risk factors that were associated with the likelihood of participants reporting perfect health (utility = 1) versus non-perfect health (utility < 1). The second part identifies risk factors that were associated with the EQ-5 L-3L utility scores for participants reporting non-perfect health. We performed sensitivity analyses to compare the results between the two-part model using tobit models and ordinary least squares regression.

RESULTS

In both countries, males were more likely to report perfect health and participants with at least one comorbidity were less likely to report perfect health. In South Africa, participants with side effects and in Uganda those with opportunistic infections were also less likely to report perfect health. In Uganda, participants with 100% ART adherence were more likely to report perfect health. In South Africa, high HIV viral load, experiencing ART side effects, and the presence of opportunistic infections were each associated with lower HRQoL, whereas participants with 100% ART adherence reported higher HRQoL. In Uganda participants with lower CD4 count had lower HRQoL.

CONCLUSION

Markers of advanced disease (opportunistic infection, high viral load, low CD4), side effects, comorbidities and lack of ART adherence negatively impacted HRQoL for PWH experiencing virological failure.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02787499.

Associations of Social Support with Sexual Practices, Health Behaviours, and Health Outcomes Among Adolescent Girls and Young Women: Evidence From a Longitudinal Study in KwaZulu-Natal, South Africa

BACKGROUND

Several studies have reported on the benefits of social support for health behaviour, including risky sex. Social support may thus be an important resource for promoting individual health and well-being, particularly in regions where HIV rates are high and healthcare resources are scarce. However, prior research on the implications of social support for the health behaviour of young women has yielded mixed and inconclusive findings. Using prospective data from young women in South Africa, this study examines the associations of social support with subsequent sexual practices, health behaviour, and health outcomes.

METHOD

We used two rounds of longitudinal data from a sample of n = 1446 HIV-negative emerging adult women, aged 18 to 29 years, who participated in a population-based HIV study in KwaZulu-Natal, South Africa. Applying the analytic template for outcome-wide longitudinal designs, we estimated the associations between combinations of social support (i.e. tangible, educational, emotional) and ten HIV risk-related outcomes.

RESULTS

Combinations of tangible, educational, and emotional support, as well as tangible support by itself, were associated with lower risk for several outcomes, whereas educational and emotional support, by themselves or together, showed little evidence of association with the outcomes.

CONCLUSION

This study highlights the protective role of tangible support in an environment of widespread poverty, and the additional effect of combining tangible support with non-tangible support. The findings strengthen recent evidence on the benefits of combining support in the form of cash and food with psychosocial care in mitigating risk behaviours associated with HIV and negative health outcomes among young women.

When Social and Personal Norms Collide: Narratives of South African Women Navigating Transactional Sexual Relationships with Blessers

Due to the negative implications of transactional sexual relationships (TSRs) for women's sexual and reproductive health, studies of social norms in sub-Saharan and South Africa have sought to inform HIV-related risk and interventions in this key population. To date, however, little research has investigated the normative conflicts facing women in African settings when initiating, continuing or abstaining from participation in TSRs. In 2017-2018, we investigated conflicts black South African women in KwaZulu-Natal expressed between adhering to social versus personal norms in TSRs with "blessers"-wealthy men who gift women financially or materially-typically in exchange for sex. Participants expressed conflicts between social norms of blesser engagement to satisfy aspirations for money/material items vs. personal norms of retaining virginity and fidelity to partners. Women largely ignored adverse sexual health risks of HIV and unintended pregnancy. Participants highlighted internal conflicts, prompting reflection on their desires, choices and normative behaviors, also informing women's self-concept, self-efficacy and desires for relationship satisfaction. Greater reflection from women about personal norms and values-and attention to their self-efficacy in relationships-may assist in understanding and advancing women's holistic health and wellbeing in research and interventions among this population and potentially women in other settings.

Health and total factor productivity nexus in selected sub-Saharan African countries: quadratic and threshold modelling

OBJECTIVES

The sub-Saharan African (SSA) countries have been recording a decline in total factor productivity (TFP) growth, inadequate health funding and poor health outcomes are regarded as problems that might have impeded productivity in the region. This study therefore aligns with Grossman's theory that better health could be instrumental to productivity growth. In this paper, we establish a predictive TFP model that accommodates the roles of health, which has been omitted in prior studies. To corroborate our findings we examine the threshold relationship between health and TFP.

METHODS

The study employs the fixed and random effect model, panel two-stage least squares, static and dynamic panel threshold regression model on a balanced panel data of 25 selected SSA countries from 1995 to 2020 as the estimating technique for the linear relationship and the non-linear relationship between health and TFP.

RESULTS

The result of the analysis reveals a positive relationship between health expenditure and TFP, health expenditure per capita and TFP. Education and other non-health factors, like Information Communication Technology (ICT) and control of corruption equally have significant positive impact on TFP. The result further shows the existence of a threshold relationship between TFP and health at 3.5% level of public health expenditure. We also discover threshold relationship between TFP and some non-health variables like education and ICT at 2.56% and 21%, respectively CONCLUSIONS: More importantly, the study confirms health as a determinant of TFP and also validates the existence of a non-linear relationship between TFP and health. Overall, improvements in health and its proxies have implications for TFP growth in SSA. Therefore, the increase in public health expenditure stipulated in this study should be passed into law for optimal productivity growth rate.

Understanding COVID-19 Vaccine Hesitancy among Healthcare Workers in South Africa

Healthcare workers (HCWs) were the first population group offered coronavirus disease 2019 (COVID-19) vaccines in South Africa because they were considered to be at higher risk of infection and required protecting as they were a critical resource to the health system. In some contexts, vaccine uptake among HCWs has been slow, with several studies citing persistent concerns about vaccine safety and effectiveness. This study aimed to determine vaccine uptake among HCWs in South Africa whilst identifying what drives vaccine hesitancy among HCWs. We adopted a multimethod approach, utilising both a survey and in-depth interviews amongst a sample of HCWs in South Africa. In a sample of 7763 HCWS, 89% were vaccinated, with hesitancy highest among younger HCWs, males, and those working in the private sector. Among those who were hesitant, consistent with the literature, HCWs raised concerns about the safety and effectiveness of the vaccine. Examining this further, our data revealed that safety and effectiveness concerns were formed due to first-hand witnessing of patients presenting with side-effects, concern over perceived lack of scientific rigor in developing the vaccine, confidence in the body's immune system to stave off serious illness, and both a general lack of information and distrust in the available sources of information. This study, through discursive narratives, provides evidence elucidating what drives safety and effectiveness concerns raised by HCWs. These concerns will need to be addressed if HCWs are to effectively communicate and influence public behaviour. HCWs are key role players in the national COVID-19 vaccination programme, making it critical for this workforce to be well trained, knowledgeable, and confident if they are going to improve the uptake of vaccines among the general population in South Africa, which currently remains suboptimal.

Aromaticity controls the excited-state properties of host-guest complexes of nanohoops

π-Conjugated organic molecules have exciting applications as materials for batteries, solar cells, light-emitting diodes, etc. Among these systems, antiaromatic compounds are of particular interest because of their smaller HOMO-LUMO energy gap compared to aromatic compounds. A small HOMO-LUMO gap is expected to facilitate charge transfer in the systems. Here we report the ground and excited-state properties of two model nanohoops that are nitrogen-doped analogs of recently synthesized [4]cyclodibenzopentalenes - tetramers of benzene-fused aromatic 1,4-dihydropyrrolo[3,2-b]pyrrole ([4]DHPP) and antiaromatic pyrrolo[3,2-b]pyrrole ([4]PP). Their complexes with C60 fullerene show different behavior upon photoexcitation, depending on the degree of aromaticity. [4]DHPP acts as an electron donor, whereas [4]PP is a stronger electron acceptor than C60. The ultrafast charge separation combined with the slow charge recombination that we found for [4]PP⊃C60 indicates a long lifetime of the charge transfer state.

Evaluating effect modification by HIV testing history to understand the mechanisms behind the impact of announcing HIV self-testing availability in a clinic system in Kenya

Background

In sub-Saharan Africa, truckers and female sex workers (FSWs) have high HIV risk and face challenges accessing HIV testing. Adding HIV self-testing (HIVST) to standard of care (SOC) programs increases testing rates. However, the underlying mechanisms are not fully understood. HIVST may decrease barriers (inconvenient clinic hours, confidentiality concerns) and thus we would expect a greater impact among those not accessing SOC testing (barriers prevented previous testing). As a new biomedical technology, HIVST may also be a cue to action (the novelty of a new product motivates people to try it), in which case we might expect the impact to be similar by testing history.

Methods

We used data from two randomized controlled trials evaluating the announcement of HIVST availability via text-message to male truckers (n = 2,260) and FSWs (n = 2,196) in Kenya. Log binomial regression was used to estimate the risk ratio (RR) for testing ≤ 2 months post-announcement in the intervention vs. SOC overall and by having tested in the previous 12-months (12m-tested); and we assessed interaction between the intervention and 12m-tested. We also estimated risk differences (RD) per 100 and tested additive interaction using linear binomial regression.

Results

We found no evidence that 12m-tested modified the HIVST impact. Among truckers, those in the intervention were 3.1 times more likely to test than the SOC (p < 0.001). Although testing was slightly higher among those not 12m-tested (RR = 3.5, p = 0.001 vs. RR = 2.7, p = 0.020), the interaction was not significant (p = 0.683). Among FSWs, results were similar (unstratified RR = 2.6, p < 0.001; 12m-tested: RR = 2.7, p < 0.001; not 12m-tested: RR = 2.5, p < 0.001; interaction p = 0.795). We also did not find significant interaction on the additive scale (truckers: unstratified RD = 2.8, p < 0.001; 12m-tested RD = 3.8, p = 0.037; not 12m-tested RD = 2.5, p = 0.003; interaction p = 0.496. FSWs: unstratified RD = 9.7, p < 0.001; 12m-tested RD = 10.7, p < 0.001, not 12m-tested RD = 9.1, p < 0.001; interaction p = 0.615).

Conclusion

The impact of HIVST was not significantly modified by 12m-tested among truckers and FSWs on the multiplicative or additive scales. Announcing the availability of HIVST likely served primarily as a cue to action and testing clinics might maximize the HIVST benefits by holding periodic HIVST events to maintain the cue to action impact rather than making HIVST continually available.

Improving educational and reproductive outcomes for adolescent mothers in South Africa: A cross-sectional analysis towards realising policy goals

Adolescent mothers face numerous challenges. This study aimed to address the operationalisation of the new South African national policy for young mothers by testing the associations of potential protective provisions with three policy goals: School return, grade promotion, and pregnancy/HIV prevention. Adolescent mothers aged 12-24 from rural and urban communities of South Africa's Eastern Cape completed study questionnaires between 2017-2019. Using multivariate multi-level analysis, we simultaneously estimated associations between hypothesized provisions and protective variables and all policy-aligned goals. School return was associated with using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Grade promotion was associated with greater exposure to friendly and respectful health staff, using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Pregnancy/HIV prevention (condom use) was moderately associated with greater exposure to friendly and respectful health staff. There was evidence of synergies of provisions whereby a combination of protective characteristics showed larger positive effects than receipt of any single factor alone. This study provides essential evidence for operationalising South Africa's new policy on the Prevention and Management of Learner Pregnancy in Schools, and points to implementation strategies that provide low-cost opportunities to promote educational and health outcomes for adolescent mothers.

HIV incidence and associated risk factors in adolescent girls and young women in South Africa: A population-based cohort study

BACKGROUND

In sub-Saharan Africa, high HIV incidence rates in adolescent girls and young women (AGYW) persist despite extensive HIV prevention efforts.

METHODS

A prospective cohort of 2,710 HIV-negative AGYW (15-24 years) in KwaZulu-Natal, South Africa were interviewed at baseline and followed-up approximately 18 months later (2014-2017). Associations between HIV seroconversion and socio-demographic and behavioural variables measured at baseline and follow-up were examined using Cox regression and a proximate determinants framework. Inter-relationships between determinants were measured using logistic regression. Separate models were built for 15-19 and 20-24-year-olds.

RESULTS

Weighted HIV incidence was 3.92 per 100 person-years (95% confidence interval: 3.27-4.69; 163 seroconversions over 4,016 person-years). Among 15-19-year-olds, absence of family support (adjusted hazards ratio (aHR): 3.82 (1.89-7.72)), having a circumcised partner (aHR: 0.5 (0.27-0.94)) or one who was HIV-positive and not on antiretroviral therapy (ART) (aHR: 6.21 (2.56-15.06)) were associated with HIV incidence. Those reporting an absence of family support were also more likely to report >1 partner during follow-up (odds ratio (OR): 2.7(1.11-6.57)). Among 20-24-year-olds, failure to complete secondary school (aHR: 1.89 (1.11-3.21)), inconsistent condom use (aHR: 3.01 (1.14-7.96)) and reporting partner(s) who were HIV-positive and not on ART (aHR: 7.75 (3.06-19.66)) were associated with HIV incidence. Failure to complete secondary school among 20-24-year-olds was associated with inconsistent condom use (OR: 1.82 (1.20-2.77)) and reporting an HIV-positive partner not on ART (OR: 3.53(1.59-7.82)) or an uncircumcised partner (OR: 1.39 (1.08-1.82).

CONCLUSION

Absence of family support and incomplete schooling are associated with risky sexual behaviours and HIV acquisition in AGYW. In addition, partner-level prevention-condom use, medical circumcision, and viral suppression-continue to play an important role in reducing HIV risk in AGYW. These findings support the use of combination HIV prevention programs that consider structural as well as biological and behavioural HIV risk factors in their design.

Macro-economic determinants, maternal and infant SDG targets in Nigeria: Correlation and predictive modeling

Objectives

Unambiguously, Nigeria is off-track in achieving the health-related SDGs. Consequentially, this study aligns with SDG 3 which calls for "good health and wellbeing for people by ensuring healthy lives and promoting wellbeing for all at all ages". This article examines the combined effect of health expenditure and other key macro-economic factors on health indices such as maternal and newborn and child mortality in Nigeria. Contrary to existing literature, we formulated a model that predicts the level of macro-economic determinants needed to achieve the SDG targets for maternal and newborn and child mortality in Nigeria by 2030.

Methodology

The study used Autoregressive Distributed Lag (ARDL), which is usually used for large T models. The study period spans from 1995 to 2020.

Results

We found a significant negative relationship between health outcomes and macro-economic determinants namely, household consumption, total health expenditure, and gross fixed capital while we determined a significant positive relationship between health outcomes and unemployment. Our findings are further supported by out-of-sample forecast results suggesting a reduction in unemployment to 1.84 percent and an increase in health expenditure, gross fixed capital, household consumption, control of corruption to 1,818.87 billon (naira), 94.46 billion (naira), 3.2 percent, and -4.2 percent respectively to achieve SDG health targets in Nigeria by 2030.

Policy implication

The outcome of this result will give the Nigerian government and stakeholders a deeper understanding of the workings of the macro-economic factors, concerning health performance and will help position Nigeria, and other SSA countries by extension, toward reducing maternal mortality to 70 per 100,000 and newborn and child mortality to 25 per 1,000 births by 2030. The African leaders should consider passing into law the need for improvement in macro-economic factors for better health in Africa. We also recommend that the Nigerian government should steadily increase health expenditure to reach and move beyond the forecast level for improvement in maternal and infant mortality, given the present low and unimpressive funding for the health sector in the country.

Cancer care for Ukrainian refugees: Strategic impact assessments in the early days of the conflict

BACKGROUND

The invasion of Ukraine by Russia in February 2022 has resulted in destruction of healthcare infrastructure and triggered the largest wave of internally displaced populations and refugees since World War Two. Conflicts in transitioned countries such as Ukraine create new non-communicable disease (NCD) challenges, especially for cancer care for refugees and humanitarian assistance in host countries. In the early days, rapid attempts were made to model possible impacts.

METHODS

By evaluating open source intelligence used in the first three months of the conflict through snowball search methods, we aimed to address: (i) burden of cancer in Ukrainian population, specifically considering translating to the refugees population, and its cancer care capacity; ii) baseline capacity/strengths of cancer systems in initial host countries. Moreover, using a baseline scenario based on crude cancer incidence in Ukraine, and considering data from UNHCR, we estimated how cancer cases would be distributed across host countries. Finally, a surveillance assessment instrument was created, intersecting health system's capacity and influx of internally displaced populations and refugees.

FINDINGS AND CONCLUSIONS

The total new cancer patients per month in pre-conflict Ukraine was estimated as 13,106, of which < 1 % are paediatric cases. The estimated cancer cases in the refugee population (combining prevalent and incident), assuming 7.5 million refugees by July 2022 and a female:male ratio of 9:1, was 33,121 individuals (Poland: 19284; Hungary: 3484; Moldova: 2651; Slovakia: 2421; Romania: 5281). According to our assessments, Poland is the only neighbouring country classified as green/yellow for cancer capacity, i.e. sufficient ablility to absorb additional burden into national health system; Slovakia we graded as yellow, Hungary and Romania as yellow/red and Moldova as red.

Preferences, beliefs, and attitudes about oral fluid and blood-based HIV self-testing among truck drivers in Kenya choosing not to test for HIV

Introduction

Clinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs.

Methods

Participants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs.

Results

The final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal.

Conclusion

We found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.

Sustainable thresholds, health outcomes, health expenditures and education nexus in selected African countries: quadratic and moderation modelling

Background

This study aligns with Sustainable Development Goal 3 which borders on “good health and well-being for people by ensuring healthy lives and promoting well-being for all at all ages”. It contributes to the health literature by evaluating the roles of health expenditures and educational quality on three health outcomes (infant mortality, maternal mortality and life expectancy at birth).

Methods

The study uses the panel spatial correlation consistent (PSCC) approach on balanced panel data on 25 selected sub-Saharan African countries from 2000 to 2020 to interrogate the nexus.

Results

The following findings are documented. First, health expenditures reveal significant asymmetric quadratic effects on health outcomes. Second, the interactions between health expenditures and educational quality reduce infant and maternal mortalities while enhancing life expectancy. Third, the threshold points from the interaction effects indicate that enhancing educational quality beyond some critical thresholds of 1.51 and 1.49 can induce a drop in maternal and child mortalities while a point beyond 1.84 exerts an improvement in life expectancy.

Conclusions

Hence, policy makers should ensure that both health expenditures and educational quality exceed the established thresholds for sustainable health outcomes.

The longitudinal loss of islet autoantibody responses from diagnosis of type 1 diabetes occurs progressively over follow-up and is determined by low autoantibody titres, early-onset, and genetic variants

The clinical usefulness of post-diagnosis islet autoantibody levels is unclear and factors that drive autoantibody persistence are poorly defined in type 1 diabetes (T1D). Our aim was to characterise the longitudinal loss of islet autoantibody responses after diagnosis in a large, prospectively sampled UK cohort. Participants with T1D [n = 577] providing a diagnosis sample [range -1.0 to 2.0 years] and at least one post-diagnosis sample (<32.0 years) were tested for autoantibodies to glutamate decarboxylase 65 (GADA), islet antigen-2 (IA-2A), and zinc transporter 8 (ZnT8A). Select HLA and non-HLA SNPs were considered. Non-genetic and genetic factors were assessed by multivariable logistic regression models for autoantibody positivity at initial sampling and autoantibody loss at final sampling. For GADA, IA-2A, and ZnT8A, 70.8%, 76.8%, and 40.1%, respectively, remained positive at the final sampling. Non-genetic predictors of autoantibody loss were low baseline autoantibody titres (P < 0.0001), longer diabetes duration (P < 0.0001), and age-at-onset under 8 years (P < 0.01--0.05). Adjusting for non-genetic covariates, GADA loss was associated with low-risk HLA class II genotypes (P = 0.005), and SNPs associated with autoimmunity RELA/11q13 (P = 0.017), LPP/3q28 (P = 0.004), and negatively with IFIH1/2q24 (P = 0.018). IA-2A loss was not associated with genetic factors independent of other covariates, while ZnT8A loss was associated with the presence of HLA A*24 (P = 0.019) and weakly negatively with RELA/11q13 (P = 0.049). The largest longitudinal study of islet autoantibody responses from diagnosis of T1D shows that autoantibody loss is heterogeneous and influenced by low titres at onset, longer duration, earlier age-at-onset, and genetic variants. These data may inform clinical trials where post-diagnosis participants are recruited.

The frictional layer in the observed momentum budget of the trades

Profiles of eddy momentum flux divergence are calculated as the residual in the momentum budget constructed from airborne circular dropsonde arrays ( ∼ 220 km) for 13 days during the EUREC 4 A/ATOMIC field campaign. The observed dynamical forcing averaged over all flights agrees broadly with European Centre for Medium-Range Weather Forecasts (ECMWF) Integrated Forecasting System (IFS) forecasts. In the direction of the flow, a mean flux divergence (friction) exists over a 1.5-km deep Ekman layer, and a mean flux convergence (acceleration) is present near cloud tops. The friction is countergradient between 1 and 1.5 km, where vertical wind shear exceeds the observed thermal wind. From the frictional profile, a 10-m momentum flux of ∼ 0.1 N · m - 2 is derived, in line with Saildrone turbulence measurements. A momentum flux divergence in the cross-wind direction is pronounced near the surface and acts to veer the wind, opposing the friction-induced cross-isobaric wind turning. Weaker friction and upper-level acceleration of easterly flow are observed when stronger winds and more vigorous convection prevail. Turbulence measurements on board the SAFIRE ATR-42 aircraft and the Uncrewed Aircraft System (UAS) RAAVEN reveal pronounced spatial variability of momentum fluxes, with a non-negligible contribution of mesoscales (5-30 km). The findings highlight the nontrivial impact of turbulence, convection, and mesoscale flows in the presence of diverse cloud fields on the depth and strength of the frictional layer.

'Eventually I wanted something more': sexual self-reflections of South African women engaged in transactional sexual relationships with blessers

The term 'blesser' emerged from social media in South Africa, typically denoting an older man who provides a younger woman with money and/or luxury items in exchange for sex. Within an increasingly consumerist culture, such transactional sexual relationships hold powerful appeal, and remain highly prevalent. An estimated one in three Black South African women have engaged in transactional sex. While these liaisons are associated with negative health outcomes for women, especially in high HIV prevalence settings, attention to how they affect Black women's sexuality is under-studied-especially with respect to emotional and sexual development-an important part of sexual rights and wellbeing. We used qualitative methods to investigate 22 women's experiences with blessers. A sexual rights framework was utilised to explore human rights dimensions. We found women's rights to engage in consensual sex, pursue sexual pleasure and ensure their bodily integrity were compromised. Many participants recognised the psychological costs and limitations of engaging in blesser relationships. Women communicated that they realised such partnerships failed to meet their emotional and relationship needs. Against the backdrop of structural gender inequality, Black South African women's narratives should inform research, programmes and educational interventions aimed at advancing women's sexual development, rights and wellbeing.

Role of Schooling and Comprehensive Sexuality Education in Reducing HIV and Pregnancy Among Adolescents in South Africa

BACKGROUND

Comprehensive sexuality education (CSE) seeks to reduce risky sexual behaviour and subsequent incidence of unintended pregnancy and HIV among schoolgoing adolescents. This study estimates the association between exposure to CSE and key biomedical and behavioural indicators among adolescent girls in South Africa.

SETTING

Four DREAMS implementation districts in Gauteng and KwaZulu-Natal provinces in South Africa.

METHODS

Data from a household-based representative sample of adolescent girls (between the ages 12-18 years) (n = 9673) was collected. Independent variables included school attendance and exposure to CSE, with outcome variables measuring prevalence of HIV, pregnancy, and sexual risky behaviour, including condom use, incidence of age-disparate relationships, and transactional sex.

RESULTS

Adolescent girls in school and who had attended CSE classes in the previous 12 months were associated with reduced adjusted odds of being HIV-positive [full sample: adjusted odds ratios (AOR): 0.76, 95% confidence interval [CI]: 0.61 to 0.95, P < 0.05; sexually active sample: AOR: 0.62, 95% CI: 0.40 to 0.96, P < 0.05]. Those in school who attended CSE in the previous 12 months were also more likely to get tested for HIV (AOR: 1.48, 95% CI: 1.32 to 1.65, P < 0.001).

CONCLUSIONS

The results indicate that school attendance and exposure to CSE is associated with a reduction in risky sexual behaviour. Exposure to CSE is also associated with increased access to HIV testing for adolescent girls both in and out of school. Keeping adolescent girls in school produces the greatest positive sexual behavioural effect; this, coupled with the delivery of quality CSE, is a key strategy for reducing HIV risk.

Determining HIV risk for Adolescent Girls and Young Women (AGYW) in relationships with "Blessers" and age-disparate partners: a cross-sectional survey in four districts in South Africa

BACKGROUND

HIV incidence among adolescent girls and young women (AGYW) remains high, with their male partners a prominent factor in sustaining these elevated rates. Partnership characteristics remain important metrics for determining HIV risk, with evidence indicating that AGYW engaged in transactional and age-disparate relationships face greater HIV exposure. This study examines the risk posed to AGYW in a relationship with a "Blesser", defined as male who provides his female partner with their material needs or desires in exchange for a sexual relationship, an age-disparate (5 or more years older) partner, and the potential compounded risk of being a relationship with a partner or partners who are considered both a "Blesser" and age-disparate.

METHODS

A cross -sectional household based representative sample of AGYW (aged between 12-24 years) were enrolled in the study (n = 18 926) from the districts of City of Johannesburg and Ekurhuleni in the Gauteng province and the Districts of eThekwini and uMgungundlovu in the province of KwaZulu-Natal (KZN) in South Africa between March 13, 2017 to June 22, 2018. Participants completed a structured questionnaire and provided finger-prick blood samples for laboratory measurements. Our analysis used descriptive statistics and multiple binary logistic regressions accounting for survey weights, clustering and stratification.

FINDINGS

The median age of the sample was 21 years old (Interquartile range: 19-23) and nearly three quarters (73.7%) were currently attending school. Whilst all relationships exposed AGYW to potential HIV risk, multiple binary logistic regression analysis revealed that AGYW in a relationship with both a Blesser and an age-disparate partner were more likely to be HIV positive (AOR: 3.12, 95% CI: 1.76-5.53, p < 0.001), diagnosed with an STI (AOR: 4.60, 95% CI: 2.99-7.08, p < 0.001), had 2 or more sexual partners in the previous 12 months (AOR: 6.37, 95% CI: 3.85-10.54, p < 0.001), engaged in sexual activity at age 15 or younger (AOR: 3.67, 95% CI: 2.36-5.69, p < 0.001) and more likely to have ever been pregnant (AOR: 2.60, 95% CI: 1.24-5.45, p < 0.05) than those not in a relationship with either a Blesser or age-disparate partner.

CONCLUSION

Different relationships present different HIV risk to AGYW. AGYW who had engaged in relationships with both a Blesser and an age-disparate partner were at greater HIV risk when examined against these relationships independent of one another. The data reveals the compounded HIV risk of being in both a transactional and age-disparate relationship.

Association of HIV Intervention Uptake With HIV Prevalence in Adolescent Girls and Young Women in South Africa

IMPORTANCE

In South Africa, adolescent girls and young women aged 15 to 24 years are among the most high-risk groups for acquiring HIV. Progress in reducing HIV incidence in this population has been slow.

OBJECTIVE

To describe HIV prevalence and HIV risk behaviors among a sample of adolescent girls and young women and to model the association between exposure to multiple or layered interventions and key HIV biological and behavioral outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey was conducted between March 13, 2017, and June 22, 2018, in 2 districts in Gauteng province and in 2 districts in KwaZulu-Natal province in South Africa. A stratified cluster random sampling method was used. Participants included adolescent girls and young women aged 12 to 24 years who lived in each sampled household. Overall, 10 384 participants were enrolled in Gauteng province and 7912 in KwaZulu-Natal province. One parent or caregiver was interviewed in each household. Data analysis was performed from March 12, 2021, to March 1, 2022.

EXPOSURES

DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe)-like interventions.

MAIN OUTCOMES AND MEASURES

The primary outcome was HIV prevalence. HIV status was obtained from laboratory-based testing of peripheral blood samples. Secondary outcomes included HIV testing and antiretroviral therapy uptake as well as numerous HIV risk variables that the DREAMS program sought to improve, such as pregnancy, sexually transmitted infection, intimate partner violence, and age-disparate sex.

RESULTS

The final sample included 18 296 adolescent girls and young women (median [IQR] age, 19 [15-21] years) in 10 642 households. Approximately half of participants (49.9%; n = 8414) reported engaging in sexual activity, and 48.1% (n = 3946) reported condom use at the most recent sexual encounter. KwaZulu-Natal province had a higher HIV prevalence than Gauteng province (15.1% vs 7.8%; P < .001). Approximately one-fifth of participants (17.6%; n = 3291) were not exposed to any interventions, whereas 43.7% (n = 8144) were exposed to 3 or more interventions. There was no association between exposure to DREAMS-like interventions and HIV status. Adolescent girls and young women who accessed 3 or more interventions were more likely to have undergone HIV testing (adjusted odds ratio, 2.39; 95% CI, 2.11-2.71; P < .001) and to have used condoms consistently in the previous 12 months (adjusted odds ratio, 1.68; 95% CI, 1.33-2.12; P < .001) than those who were not exposed to any interventions.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that self-reported exposures to multiple or layered DREAMS-like interventions were associated with favorable behavioral outcomes. The beneficial aspects of layering HIV interventions warrant further research to support the sexual and reproductive health of adolescent girls and young women.

Giving condoms to school children: educators' views on making condoms available in South African schools

One of the policy goals of the South African Department of Basic Education's National Policy on HIV, STIs and TB of 2017 is to reduce the incidence of HIV and pregnancy among learners. This is expected to be achieved by improving access to prevention services, including the provision of condoms in schools. This study uses street- level bureaucracy theory to explain how educators can play a more productive role in ensuring that policy goals are achieved. Educators provide their views on their role as condom promotion agents, their perception of demand and utilisation among learners, as well as their insights on suitable distribution mechanisms in the school setting. Trepidation exists among educators about their roles in the promotion and education of condoms. Educator statements suggest that they see the value in their policy-ascribed role to deliver sexual health messages and are also open to performing a role in the distribution of condoms at schools. However, our findings reveal that their role as policy communicators or "street-level bureaucrats" is complicated by inadequate policy guidance. We therefore conclude that to achieve optimal outcomes in terms of safer sexual practices among learners, condom messaging and distribution mechanisms in school settings require evidence-informed implementation strategies.

Resistance Testing for Management of HIV Virologic Failure in Sub-Saharan Africa : An Unblinded Randomized Controlled Trial

BACKGROUND

Virologic failure in HIV predicts the development of drug resistance and mortality. Genotypic resistance testing (GRT), which is the standard of care after virologic failure in high-income settings, is rarely implemented in sub-Saharan Africa.

OBJECTIVE

To estimate the effectiveness of GRT for improving virologic suppression rates among people with HIV in sub-Saharan Africa for whom first-line therapy fails.

DESIGN

Pragmatic, unblinded, randomized controlled trial. (ClinicalTrials.gov: NCT02787499).

SETTING

Ambulatory HIV clinics in the public sector in Uganda and South Africa.

PATIENTS

Adults receiving first-line antiretroviral therapy with a recent HIV RNA viral load of 1000 copies/mL or higher.

INTERVENTION

Participants were randomly assigned to receive standard of care (SOC), including adherence counseling sessions and repeated viral load testing, or immediate GRT.

MEASUREMENTS

The primary outcome of interest was achievement of an HIV RNA viral load below 200 copies/mL 9 months after enrollment.

RESULTS

The trial enrolled 840 persons, divided equally between countries. Approximately half (51%) were women. Most (72%) were receiving a regimen of tenofovir, emtricitabine, and efavirenz at enrollment. The rate of virologic suppression did not differ 9 months after enrollment between the GRT group (63% [263 of 417]) and SOC group (61% [256 of 423]; odds ratio [OR], 1.11 [95% CI, 0.83 to 1.49]; P = 0.46). Among participants with persistent failure (HIV RNA viral load ≥1000 copies/mL) at 9 months, the prevalence of drug resistance was higher in the SOC group (76% [78 of 103] vs. 59% [48 of 82]; OR, 2.30 [CI, 1.22 to 4.35]; P = 0.014). Other secondary outcomes, including 9-month survival and retention in care, were similar between groups.

LIMITATION

Participants were receiving nonnucleoside reverse transcriptase inhibitor-based therapy at enrollment, limiting the generalizability of the findings.

CONCLUSION

The addition of GRT to routine care after first-line virologic failure in Uganda and South Africa did not improve rates of resuppression.

PRIMARY FUNDING SOURCE

The President's Emergency Plan for AIDS Relief and the National Institute of Allergy and Infectious Diseases.

Who's slipping through the cracks? A comprehensive individual, clinical and health system characterization of people with virological failure on first-line HIV treatment in Uganda and South Africa

OBJECTIVES

HIV virological failure remains a major threat to programme success in sub-Saharan Africa. While HIV drug resistance (HIVDR) and inadequate adherence are the main drivers of virological failure, the individual, clinical and health system characteristics that lead to poor outcomes are not well understood. The objective of this paper is to identify those characteristics among people failing first-line antiretroviral therapy (ART).

METHODS

We enrolled a cohort of adults in HIV care experiencing virological failure on first-line ART at five sites and used standard statistical methods to characterize them with a focus on three domains: individual/demographic, clinical, and health system, and compared each by country of enrolment.

RESULTS

Of 840 participants, 51% were women, the median duration on ART was 3.2 years [interquartile range (IQR) 1.1, 6.4 years] and the median CD4 cell count prior to failure was 281 cells/µL (IQR 121, 457 cells/µL). More than half of participants [53%; 95% confidence interval (CI) 49-56%] stated that they had > 90% adherence and 75% (95% CI 72-77%) took their ART on time all or most of the time. Conversely, the vast majority (90%; 95% CI 86-92%) with a completed genotypic drug resistance test had any HIV drug resistance. This population had high health system use, reporting a median of 3 (IQR 2.6) health care visits and a median of 1 (IQR 1.1) hospitalization in the preceding 6 months.

CONCLUSIONS

Patients failing first-line ART in sub-Saharan Africa generally report high rates of adherence to ART, have extremely high rates of HIV drug resistance and utilize significant health care resources. Health systems interventions to promptly detect and manage treatment failure will be a prerequisite to establishing control of the HIV epidemic.

Paediatric tuberculosis preventive treatment preferences among HIV-positive children, caregivers and healthcare providers in Eswatini: a discrete choice experiment

OBJECTIVE

Isoniazid preventive therapy initiation and completion rates are suboptimal among children. Shorter tuberculosis (TB) preventive treatment (TPT) regimens have demonstrated safety and efficacy in children and may improve adherence but are not widely used in high TB burden countries. Understanding preferences regarding TPT regimens' characteristics and service delivery models is key to designing services to improve TPT initiation and completion rates. We examined paediatric TPT preferences in Eswatini, a high TB burden country.

DESIGN

We conducted a sequential mixed-methods study utilising qualitative methods to inform the design of a discrete choice experiment (DCE) among HIV-positive children, caregivers and healthcare providers (HCP). Drug regimen and service delivery characteristics included pill size and formulation, dosing frequency, medication taste, treatment duration and visit frequency, visit cost, clinic wait time, and clinic operating hours. An unlabelled, binary choice design was used; data were analysed using fixed and mixed effects logistic regression models, with stratified models for children, caregivers and HCP.

SETTING

The study was conducted in 20 healthcare facilities providing TB/HIV care in Manzini, Eswatini, from November 2018 to December 2019.

PARTICIPANTS

Ninety-one stakeholders completed in-depth interviews to inform the DCE design; 150 children 10-14 years, 150 caregivers and 150 HCP completed the DCE.

RESULTS

Despite some heterogeneity, the results were fairly consistent among participants, with palatability of medications viewed as the most important TPT attribute; fewer and smaller pills were also preferred. Additionally, shorter waiting times and cost of visit were found to be significant drivers of choices.

CONCLUSION

Palatable medication, smaller/fewer pills, low visit costs and shorter clinic wait times are important factors when designing TPT services for children and should be considered as new paediatric TPT regimens in Eswatini are rolled out. More research is needed to determine the extent to which preferences drive TPT initiation, adherence and completion rates.

Simple models for strictly non-ergodic stochastic processes of macroscopic systems

We investigate simple models for strictly non-ergodic stochastic processes [Formula: see text] (t being the discrete time step) focusing on the expectation value v and the standard deviation [Formula: see text] of the empirical variance [Formula: see text] of finite time series [Formula: see text]. [Formula: see text] is averaged over a fluctuating field [Formula: see text] ([Formula: see text] being the microcell position) characterized by a quenched spatially correlated Gaussian field [Formula: see text]. Due to the quenched [Formula: see text]-field [Formula: see text] becomes a finite constant, [Formula: see text], for large sampling times [Formula: see text]. The volume dependence of the non-ergodicity parameter [Formula: see text] is investigated for different spatial correlations. Models with marginally long-ranged [Formula: see text]-correlations are successfully mapped on shear stress data from simulated amorphous glasses of polydisperse beads.

The Impact on HIV Testing Over 6 Months When Free Oral HIV Self-Test Kits Were Available to Truck Drivers in Kenya: A Randomized Controlled Trial

Background: Studies suggest that offering HIV self-testing (HIVST) increases short-term HIV testing rates, but few have looked at long-term outcomes. Methods: We conducted a randomized controlled trial (RIDIE 55847d64a454f) on the impact of offering free oral HIVST to 305 truck drivers recruited from two clinics in Kenya. We previously reported that those offered HIVST were more likely to accept testing. Here we report on the 6-month follow-up during which intervention participants could pick-up HIVST kits from eight clinics. Results: There was no difference in HIV testing during 6-month follow-up between participants in the intervention and the standard of care (SOC) arms (OR = 1.0, p = 0.877). The most common reasons given for not testing were lack of time (69.6%), low risk (27.2%), fear of knowing HIV status (20.8%), and had tested recently (8.0%). The null association was not modified by having tested at baseline (interaction p = 0.613), baseline risk behaviors (number of partners in past 6 months, interaction p = 0.881, had transactional sex in past 6 months, interaction p = 0.599), nor having spent at least half of the past 30 nights away from home for work (interaction p = 0.304). Most participants indicated a preference for the characteristics associated with the SOC [preference for blood-based tests (69.4%), provider-administered testing (74.6%) testing in a clinic (70.1%)]. However, those in the intervention arm were more likely to prefer an oral swab test than those in the SOC (36.6 vs. 24.6%, p = 0.029). Conclusions: Offering HIVST kits to truck drivers through a clinic network had little impact on testing rates over the 6-month follow-up when participants had to return to the clinic to access HIVST. Clinic-based distribution of HIVST kits may not address some major barriers to testing, such as lack of time to go to a clinic, fear of knowing one's status and low risk perception. Preferred HIV testing attributes were consistent with the SOC for most participants, but oral swab preference was higher among those in the intervention arm, who had seen the oral HIVST and had the opportunity to try it. This suggests that preferences may change with exposure to different testing modalities.

Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin

Background

COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies.

Methods

Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with “classical” HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination.

Results

All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation.

Conclusion

Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.

Employment preferences of healthcare workers in South Africa: Findings from a discrete choice experiment

There is a maldistribution of human resources for health globally, with many Lower- and Middle-Income Countries experiencing significant shortages. We examined healthcare workers' job preferences in South Africa to identify factors which potentially influence employment decisions. A discrete choice experiment was conducted among 855 South African healthcare workers critical to its national HIV testing and treatment programs. Job characteristics included workload, workplace culture, availability of equipment, training opportunities, sector and facility type, location, salary and benefits. Main effects analysis was conducted using fixed effects logistic regression. Interaction effects identified divergence in preferences. Heavy workload (OR = 0.78; 95% C.I. 0.74-0.83), poor workplace culture (odds ratio 0.66; 95% C.I. 0.62-0.69), insufficient availability of equipment (OR = 0.67; 95% C.I. 0.63-0.70) and infrequent training opportunities (OR = 0.75; 95% C.I. 0.71-0.80) had large, significant effects on worker preferences. An increase in salary of 20% (OR = 1.29; 95% C.I. 1.16-1.44) had a positive effect on preferences, while a salary decrease of 20% (OR = 0.55; 95% C.I. 0.49-0.60) had a strong negative effect. Benefits packages had large positive effects on preferences: respondents were twice as likely to choose a job that included medical aid, pension and housing contributions worth 40% of salary (OR = 2.06; 95% C.I. 1.87-2.26), holding all else constant. Although salary was important across all cadres, benefits packages had larger effects on job preferences than equivalent salary increases. Improving working conditions is critical to attracting and retaining appropriate health cadres responsible for the country's HIV services, especially in the public sector and underserved, often rural, communities. Crucially, our evidence suggests that factors amenable to improvement such as workplace conditions and remuneration packages have a greater influence on healthcare workers employment decisions than employment sector or location.

Fluctuations of non-ergodic stochastic processes

We investigate the standard deviation [Formula: see text] of the variance [Formula: see text] of time series [Formula: see text] measured over a finite sampling time [Formula: see text] focusing on non-ergodic systems where independent "configurations" c get trapped in meta-basins of a generalized phase space. It is thus relevant in which order averages over the configurations c and over time series k of a configuration c are performed. Three variances of [Formula: see text] must be distinguished: the total variance [Formula: see text] and its contributions [Formula: see text], the typical internal variance within the meta-basins, and [Formula: see text], characterizing the dispersion between the different basins. We discuss simplifications for physical systems where the stochastic variable x(t) is due to a density field averaged over a large system volume V. The relations are illustrated for the shear-stress fluctuations in quenched elastic networks and low-temperature glasses formed by polydisperse particles and free-standing polymer films. The different statistics of [Formula: see text] and [Formula: see text] are manifested by their different system-size dependences.

Ensemble fluctuations matter for variances of macroscopic variables

Extending recent work on stress fluctuations in complex fluids and amorphous solids we describe in general terms the ensemble average [Formula: see text] and the standard deviation [Formula: see text] of the variance [Formula: see text] of time series [Formula: see text] of a stochastic process x(t) measured over a finite sampling time [Formula: see text]. Assuming a stationary, Gaussian and ergodic process, [Formula: see text] is given by a functional [Formula: see text] of the autocorrelation function h(t). [Formula: see text] is shown to become large and similar to [Formula: see text] if [Formula: see text] corresponds to a fast relaxation process. Albeit [Formula: see text] does not hold in general for non-ergodic systems, the deviations for common systems with many microstates are merely finite-size corrections. Various issues are illustrated for shear-stress fluctuations in simple coarse-grained model systems.

Optimizing Differentiated HIV Treatment Models in Urban Zimbabwe: Assessing Patient Preferences Using a Discrete Choice Experiment

Differentiated service delivery holds great promise for streamlining the delivery of health services for HIV. This study used a discrete choice experiment to assess preferences for differentiated HIV treatment delivery model characteristics among 500 virally suppressed adults on antiretroviral therapy in Harare, Zimbabwe. Treatment model characteristics included location, consultation type, healthcare worker cadre, operation times, visit frequency and duration, and cost. A mixed effects logit model was used for parameter estimates to identify potential preference heterogeneity among participants, and interaction effects were estimated for sex and age as potential sources of divergence in preferences. Results indicated that participants preferred health facility-based services, less frequent visits, individual consultations, shorter waiting times, lower cost and, delivered by respectful and understanding healthcare workers. Some preference heterogeneity was found, particularly for location of service delivery and group vs. individual models; however, this was not fully explained by sex and age characteristics of participants. In urban areas, facility-based models, such as the Fast Track model requiring less frequent clinic visits, are likely to better align with patient preferences than some of the other community-based or group models that have been implemented. As Zimbabwe scales up differentiated treatment models for stable patients, a clear understanding of patient preferences can help in designing services that will ensure optimal utilization and improve the efficiency of service delivery.

Depression symptoms, HIV testing, linkage to ART, and viral suppression among women in a high HIV burden district in KwaZulu-Natal, South Africa: A cross-sectional household study

Achieving the UNAIDS 90-90-90 targets by 2020 is contingent on identifying and addressing mental health challenges that may affect HIV testing and treatment-related behaviors. This study is based on survey data from KwaZulu-Natal, South Africa (2014–2015). HIV positive women who reported higher depression scores had a lower odds of having tested previously for HIV (15–25 years: AOR = 0.90, 95% CI [0.83, 0.98]; 26–49 years: AOR = 0.90, 95% CI [0.84, 0.96]). Because HIV testing behavior represents a gateway to treatment, the findings suggest mental health may be one challenge to attaining the UNAIDS 90-90-90 targets.

Applying a social-ecological lens to opinions about HIV self-testing among Kenyan truckers who declined to test: a qualitative study

HIV prevalence among truckers in Africa is high and testing rates suboptimal. With numerous African countries having approved HIV self-testing kits, more information on how to design acceptable and accessible self-testing programs for high-risk populations is necessary. We explored views about self-testing via in-depth interviews with 24 truckers participating in a randomised controlled trial who refused HIV testing. A social-ecological lens was used to guide data analysis and frame study findings. While most participants said that they would use an HIV self-test, perceived barriers and facilitators were identified at multiple levels. Many participants noted lack of time to test or obtain a self-test kit as a major barrier (intrapersonal) and varied in their views about self-testing with a partner (interpersonal). Participants offered programmatic/policy recommendations, suggesting that they preferred accessing self-test kits in settings where training could be provided. Participants believed they should be able to pick up multiple test kits at the same time and that the test kits should be free or low cost. These study findings will help guide the design of self-testing programs for truckers and other mobile populations.

Population prevalence of sexually transmitted infections in a high HIV burden district in KwaZulu-Natal, South Africa: Implications for HIV epidemic control

BACKGROUND

Sexually transmitted infections (STIs) and Human immunodeficiency virus (HIV) share a complex bidirectional relationship, however, population prevalence and the association between the presence of STIs and HIV in a high HIV burden district in KwaZulu-Natal, South Africa is not known.

METHODS

A total of 9812 participants aged 15-49 years were enrolled in a cross-sectional population-based household survey. Participants completed a structured questionnaire and provided first-pass urine (males) or self-collected vulvo-vaginal swabs (females) for the detection of STIs.

RESULTS

Prevalence of herpes simplex virus type-2 (HSV-2) was 57.8%, syphilis was 1.6%, Neisseria gonorrhoeae was 2.8%, Chlamydia trachomatis was 7.1%, Trichomonas vaginalis was 9.0%, Mycoplasma genitalium was 5.5% and HIV was 36.3%. HIV positive status was associated with an increased probability of having M. genitalium (aPR = 1.49, 95% CI 1.02-2.19) among males and syphilis (aPR = 2.54, 95% CI 1.32-4.86), N. gonorrhoeae (aPR = 2.39, 95% CI 1.62-3.52), T. vaginalis (aPR = 1.70, 95% CI 1.43-2.01) and M. genitalium (aPR = 1.60, 95% CI 1.15-2.22) among females. HIV viral load ≥400 copies per mL was associated with an increased probability of N. gonorrhoeae (aPR = 1.91, 95% CI 1.36-2.70), C. trachomatis (aPR = 1.52, 95% CI 1.12-2.05) and M. genitalium (aPR = 1.83, 95% CI 1.27-2.63).

CONCLUSIONS

The high prevalence of STIs and the association between STIs and HIV, and HIV viral load underscores the public health implications of sustained transmission risk of STIs and HIV. These findings highlight the urgent need for expanding STI surveillance and implementing interventions to monitor and reduce the STI burden.

Comparative analyses of published cost effectiveness models highlight critical considerations which are useful to inform development of new models

Background: Comparative analyses of published cost effectiveness models provide useful insights into critical issues to inform the development of new cost effectiveness models in the same disease area.Objective: The purpose of this study was to describe a comparative analysis of cost-effectiveness models and highlight the importance of such work in informing development of new models. This research uses genotypic antiretroviral resistance testing after first line treatment failure for Human Immunodeficiency Virus (HIV) as an example.Method: A literature search was performed, and published cost effectiveness models were selected according to predetermined eligibility criteria. A comprehensive comparative analysis was undertaken for all aspects of the models.Results: Five published models were compared, and several critical issues were identified for consideration when developing a new model. These include the comparator, time horizon and scope of the model. In addition, the composite effect of drug resistance prevalence, antiretroviral therapy efficacy, test performance and the proportion of patients switching to second-line ART potentially have a measurable effect on model results. When considering CD4 count and viral load, dichotomizing patients according to higher cost and lower quality of life (AIDS) versus lower cost and higher quality of life (non-AIDS) status will potentially capture differences between resistance testing and other strategies, which could be confirmed by cross-validation/convergent validation. A quality adjusted life year is an essential outcome which should be explicitly explored in probabilistic sensitivity analysis, where possible.Conclusions: Using an example of GART for HIV, this study demonstrates comparative analysis of previously published cost effectiveness models yields critical information which can be used to inform the structure and specifications of new models.

The cost of the training and supervision of community health workers to improve exclusive breastfeeding amongst mothers in a cluster randomised controlled trial in South Africa

Background

Interventions targeting community health workers (CHWs) aim to optimise the delivery of health services to underserved rural areas. Whilst interventions are evaluated against their objectives, there remains limited evidence on the economic costs of these interventions, and the practicality and value of scale up. The aim of this paper is to undertake a cost analysis on a CHW training and supervision intervention using exclusive breastfeeding rates amongst mothers as an outcome measure.

Methods

This is a retrospective cost analysis, from an implementer’s perspective, of a cluster randomised controlled trial investigating the effectiveness of a continuous quality improvement (CQI) intervention aimed at CHWs providing care and support to pregnant women and women with babies aged < 1 year in South Africa.

Results

One of the outcomes of the RCT revealed that the prevalence of exclusive breastfeeding (EBF) significantly improved, with the cost per mother EBF in the control and intervention arm calculated at US$760,13 and US$1705,28 respectively. The cost per additional mother practicing EBF was calculated to be US$7647, 88, with the supervision component of the intervention constituting 64% of the trial costs. In addition, women served by the intervention CHWs were more likely to have received a CHW visit and had significantly better knowledge of childcare practices.

Conclusion

Whilst the cost of this intervention is high, adapted interventions could potentially offer an economical alternative for achieving selected maternal and child health (MCH) outcomes. The results of this study should inform future programmes aimed at providing adapted training and supervision to CHWs with the objective of improving community-level health outcomes.

Optimizing differentiated treatment models for people living with HIV in urban Zimbabwe: Findings from a mixed methods study

INTRODUCTION

Zimbabwe is scaling up HIV differentiated service delivery (DSD) to improve treatment outcomes and health system efficiencies. Shifting stable patients into less-intensive DSD models is a high priority in order to accommodate the large numbers of newly-diagnosed people living with HIV (PLHIV) needing treatment and to provide healthcare workers with the time and space needed to treat people with advanced HIV disease. DSD is also seen as a way to improve service quality and enhance retention in care. National guidelines support five differentiated antiretroviral treatment models (DART) for stable HIV-positive adults, but little is known about patient preferences, a critical element needed to guide DART scale-up and ensure person-centered care. We designed a mixed-methods study to explore treatment preferences of PLHIV in urban Zimbabwe.

METHODS

The study was conducted in Harare, and included 35 health care worker (HCW) key informant interviews (KII); 8 focus group discussions (FGD) with 54 PLHIV; a discrete choice experiment (DCE) in which 500 adult DART-eligible PLHIV selected their preferences for health facility (HF) vs. community location, individual vs. group meetings, provider cadre and attitude, clinic operation times, visit frequency, visit duration and cost to patient; and a survey with the 500 DCE participants exploring DART knowledge and preferences.

RESULTS

Patient preferences were consistent in the FGDs, DCE and survey. Participants strongly preferred respectful HCWs, HF-based services, individual DART models, and less costly services. Patients also preferred less frequent visits and shorter wait times. They were indifferent to variations in HCW cadre and distances from home to HF. These preferences were mostly homogenous, with only minor differences between male vs. female and older vs. younger patients. HCWs in the KII correctly characterized facility-based individual models as the one most favored by patients; HCWs also preferred this model, which they felt decongested HFs and reduced their workload.

CONCLUSIONS

DART-eligible PLHIV in Harare found it relatively easy to access HFs, and preferred attributes associated with facility-based individual models. Prioritizing these for scale-up in urban areas may be the most efficient way to sustain positive patient outcomes and increase health system performance.

Evaluating DREAMS HIV prevention interventions targeting adolescent girls and young women in high HIV prevalence districts in South Africa: protocol for a cross-sectional study

BACKGROUND

Young women in sub-Saharan Africa remain at the epicentre of the HIV epidemic, with surveillance data indicating persistent high levels of HIV incidence. In South Africa, adolescent girls and young women (AGYW) account for a quarter of all new HIV infections. Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) is a strategy introduced by the United States President's Emergency Plan for AIDS Relief (PEPFAR) aimed at reducing HIV incidence among AGYW in 10 countries in sub-Saharan Africa by 25% in the programme's first year, and by 40% in the second year. This study will assess the change in HIV incidence and reduction in risk associated behaviours that can be attributed to the DREAMS initiative in South Africa, using a population-based cross-sectional survey.

METHODS

Data will be collected from a household-based representative sample of AGYW (between the ages 12-24 years) in four high prevalence districts (more than 10% of the population have HIV in these districts) in South Africa in which DREAMS has been implemented. A stratified cluster-based sampling approach will be used to select eligible participants for a cross-sectional survey with 18,500, to be conducted over 2017/2018. A questionnaire will be administered containing questions on sexual risk behaviour, selected academic and developmental milestones, prevalence of gender based violence, whilst examining exposure to DREAMS programmes. Biological samples, including two micro-containers of blood and self-collected vulvovaginal swab samples, are collected in each survey to test for HIV infection, HIV incidence, sexually transmitted infections (STIs) and pregnancy. This study will measure trends in population level HIV incidence using the Limiting antigen (LAg) Avidity Enzyme Immuno-Assay (EIA) and monitor changes in HIV incidence.

DISCUSSION

Ending the HIV/AIDS pandemic by 2030 requires the continual monitoring and evaluation of prevention programmes, with the aim of optimising efforts and ensuring the achievement of epidemic control. This study will determine the impact DREAMS interventions have had on HIV incidence among AGYW in a 'real world, non-trial setting'.

Recently formed age-disparate partnerships are associated with elevated HIV-incidence among young women in South Africa

OBJECTIVE

Cross-sectional and cohort studies draw different conclusions on whether age-disparate partnerships increase HIV-acquisition risk for young women. We investigated whether age-disparities were associated with HIV-infection risk early in relationships. This could result in the exclusion of women who seroconverted during high-risk age-disparate partnerships from cohort studies of HIV incidence - which exclude HIV-positive women - and explain null findings in these studies.

DESIGN

Prospective cohort study.

METHODS

We used data on 15-24-year-old, HIV-negative women in heterosexual partnerships (N = 830) in KwaZulu-Natal, South Africa. The association between age-disparate partnering (i.e., male partner ≥5 years older) and subsequent HIV seroconversion was assessed using Cox hazard models. We examined heterogeneity in HIV-acquisition risk by duration of partnership (defined by quartiles) at cohort enrolment.

RESULTS

During 1139 person-years (mean: 1.4 years) of follow-up, 54 (6.5%) women seroconverted, a weighted HIV-incidence estimate of 4.41/100 person-years [95% confidence interval (CI): 3.30-6.06]. HIV-acquisition risk did not differ significantly between women in age-disparate vs. age-similar partnerships (adjusted hazard ratios: 1.10, 95% CI: 0.55-2.21). However, for women in the shortest partnership quartile (<1.09 years) at baseline, risk of HIV seroconversion was higher for women in age-disparate partnerships (adjusted hazard ratios: 3.13, 95% CI: 1.02-9.65, P = 0.047). HIV acquisition was not statistically different by partnership type among women in longer partnerships.

CONCLUSION

The association between age-disparate partnerships and HIV-acquisition risk is evident early in young women's relationships. Results provide a potential explanation for null findings in cohort studies, whose research designs may exclude women in such partnerships, and affirms the elevated risk of HIV acquisition for young women in age-disparate relationships.

Factors associated with HIV in younger and older adult men in South Africa: findings from a cross-sectional survey

OBJECTIVE

This study investigated the behavioural, psychosocial and biological factors associated with HIV in a younger group of men (15 to 24 years) compared with an older group of men (25 to 35 years).

DESIGN

A household-based, cross-sectional study was conducted.

SETTING

Men were randomly selected using a two-stage random sampling method in KwaZulu-Natal, South Africa, between June 2014 and June 2015.

PARTICIPANTS

Overall, we interviewed 1472 younger men and 1138 older men. Only participants who could speak English or Zulu, were able to provide informed consent and who were expected to be living in the study area for the next 12 months were enrolled into the study.

PRIMARY AND SECONDARY OUTCOMES

HIV status was the primary outcome for the study. Men's HIV status was derived from blood samples collected in the study which were tested for HIV antibodies.

RESULTS

HIV prevalence was higher among older men (35.4%, 95% CI: 31.7 to 39.1) than younger men (7.6%, 95% CI: 6.2 to 9.4, p<0.01). Older men, who completed secondary school had a lower likelihood of being HIV positive (adjusted OR (AOR): 0.41, 95% CI: 0.27 to 0.63, p<0.001) and those with greater food insecurity had a higher likelihood of being HIV positive (AOR: 1.57, 95% CI: 1.05 to 2.34, p=0.04). Younger men with a higher number of lifetime sexual partners had a higher likelihood of being HIV positive (AOR: 1.04, 95% CI: 0.99 to 1.09, p=0.09).

CONCLUSION

Given that the HIV prevalence is higher in the older men, community based interventions need to target older men for medical circumcision and support HIV positive men to improve their material conditions early. For younger men intervening to reduce HIV risk behaviours at a young age before these behaviours become entrenched should be central to HIV prevention programmes.

HIV testing preferences among pregnant women attending antenatal care and their male partners: a discrete choice experiment in Uganda

HIV testing rates remain stubbornly low among men - a crucial target population for reaching the ambitious global and regional goals of the HIV programme. In an era of declining donor funding, identifying cost-effective strategies to increase testing rates amongst men remains paramount. Antenatal care is an effective entry-point for the delivery of HIV testing services for women, and partner testing presents an important opportunity to reach their male partners. We present the results of a discrete choice experiment in Uganda, examining preferences among 824 pregnant women and 896 male partners regarding service delivery characteristics of HIV testing. Both men and women preferred nurse administered testing to self-testing (OR = 0.835; p < 0.001), oral testing over a finger-prick test (OR = 1.176; p < 0.001) and testing with a partner over testing alone (OR = 1.230; p < 0.001). Men had a preference for testing at home compared to testing at a clinic (OR = 1.099; p = 0.024), but women were indifferent regarding the testing location. The cost of testing had the biggest effect on preferences. Free testing was preferred over a cost of US$2.90 (OR = 0.781; p < 0.001) or US$2.00 (OR = 0.670; p < 0.001). Offering an incentive of US$3.40 increased men's preferences compared to a free test (OR = 1.168; p < 0.001), although this did not affect women's preferences. Partner testing linked to antenatal care is a potential strategy to increase testing coverage among men, particularly given the preference for partner testing - provided costs to clients remain low. Future cost-effectiveness evaluations should investigate the economic impact of reaching men using these strategies.