Increasing Preterm Delivery and Small for Gestational Age Trends in South Carolina during the COVID-19 Pandemic

Preterm delivery (PTD) complications are a major cause of childhood morbidity and mortality. We aimed to assess trends in PTD and small for gestational age (SGA) and whether trends varied between race-ethnic groups in South Carolina (SC). We utilized 2015-2021 SC vital records linked to hospitalization and emergency department records. PTD was defined as clinically estimated gestation less than (<) 37 weeks (wks.) with subgroup analyses of PTD < 34 wks. and < 28 wks. SGA was defined as infants weighing below the 10th percentile for gestational age. This retrospective study included 338,532 (243,010 before the COVID-19 pandemic and 95,522 during the pandemic) live singleton births of gestational age ≥ 20 wks. born to 260,276 mothers in SC. Generalized estimating equations and a change-point during the first quarter of 2020 helped to assess trends. In unadjusted analyses, pre-pandemic PTD showed an increasing trend that continued during the pandemic (relative risk (RR) = 1.04, 95% CI: 1.02-1.06). PTD < 34 wks. rose during the pandemic (RR = 1.07, 95% CI: 1.02-1.12) with a significant change in the slope. Trends in SGA varied by race and ethnicity, increasing only in Hispanics (RR = 1.02, 95% CI: 1.00-1.04) before the pandemic. Our study reveals an increasing prevalence of PTD and a rise in PTD < 34 wks. during the pandemic, as well as an increasing prevalence of SGA in Hispanics during the study period.

Xpert MTB/RIF Ultra versus mycobacterial growth indicator tube liquid culture for detection of Mycobacterium tuberculosis in symptomatic adults: a diagnostic accuracy study

BACKGROUND

Xpert MTB/RIF Ultra (Ultra) is an automated molecular test for the detection of Mycobacterium tuberculosis in sputum. We compared the sensitivity of Ultra to that of mycobacterial growth indicator tube (MGIT) liquid culture, considered the most sensitive assay in routine clinical use.

METHODS

In this prospective, multicentre, cross-sectional diagnostic accuracy study, we used a non-inferiority design to assess whether the sensitivity of a single Ultra test was non-inferior to that of a single liquid culture for detection of M tuberculosis in sputum. We enrolled adults (age ≥18 years) with pulmonary tuberculosis symptoms in 11 countries and each adult provided three sputum specimens with a minimum volume of 2 mL over 2 days. Ultra was done directly on sputum 1, and Ultra and MGIT liquid culture were done on resuspended pellet from sputum 2. Results of MGIT and solid media cultures done on sputum 3 were considered the reference standard. The pre-defined non-inferiority margin was 5·0%.

FINDINGS

Between Feb 18, 2016, and Dec 4, 2019, we enrolled 2906 participants. 2600 (89%) participants were analysed, including 639 (25%) of 2600 who were positive for tuberculosis by the reference standard. Of the 2357 included in the non-inferiority analysis, 877 (37%) were HIV-positive and 984 (42%) were female. Sensitivity of Ultra performed directly on sputum 1 was non-inferior to that of sputum 2 MGIT culture (MGIT 91·1% vs Ultra 91·9%; difference -0·8 percentage points; 95% CI -2·8 to 1·1). Sensitivity of Ultra performed on sputum 2 pellet was also non-inferior to that of sputum 2 MGIT (MGIT 91·1% vs Ultra 91·9%; difference -0·8 percentage points; -2·7 to 1·0).

INTERPRETATION

For the detection of M tuberculosis in sputum from adults with respiratory symptoms, there was no difference in sensitivity of a single Ultra test to that of a single MGIT culture. Highly sensitive, rapid molecular approaches for M tuberculosis detection, combined with advances in genotypic methods for drug resistance detection, have potential to replace culture.

FUNDING

US National Institute of Allergy and Infectious Diseases.

Neonatal Extracorporeal Membrane Oxygenation: Associations between Continuous Renal Replacement Therapy, Thrombocytopenia, and Outcomes

INTRODUCTION

The incidence of thrombocytopenia in neonates receiving extracorporeal membrane oxygenation (ECMO) with and without concurrent continuous renal replacement therapy (CRRT) and associated complications have not been well described. The primary aims of the current study were to (1) characterize thrombocytopenia in neonates receiving ECMO (including treated concurrently with CRRT) and (2) evaluate risk factors (including CRRT utilization) associated with severe thrombocytopenia. In a planned exploratory secondary aim, we explored the association of severe thrombocytopenia with outcomes in neonates receiving ECMO.

METHODS

We conducted a retrospective single-center chart review of neonates who received ECMO 07/01/14 - 03/01/20 and evaluated associations between CRRT, severe thrombocytopenia (platelet count <50,000/mm3), and outcomes (ECMO duration, length of stay, and survival).

RESULTS

Fifty-two neonates received ECMO; 35 (67%) received concurrent CRRT. Severe thrombocytopenia occurred in 27 (52%) neonates overall and in 21 (60%) neonates who received concurrent CRRT. Underlying diagnosis, ECMO mode, care unit, and moderate/severe hemolysis differed between those who did and did not receive CRRT. CRRT-receivers experienced shorter hospital stays than CRRT non-receivers, but ECMO duration, length of intensive care unit (ICU) stay, and survival did not differ between groups. CRRT receipt was associated with severe thrombocytopenia. Exploratory classification and regression tree (CART) analysis suggests CRRT use, birthweight, and ICU location are all predictors of interest for severe thrombocytopenia.

CONCLUSIONS

In our cohort, CRRT use during ECMO was associated with severe thrombocytopenia, and patients who received ECMO with CRRT experienced shorter hospital stays than those who did not receive CRRT. Exploratory CART analysis suggests CRRT use, birthweight, and ICU location are all predictors for severe thrombocytopenia and warrant further investigations in larger studies.

Outcomes in Primary Repair of Truncus Arteriosus with Significant Truncal Valve Insufficiency: A Systematic Review and Meta-analysis

Data regarding the effect of significant TVI on outcomes after truncus arteriosus (TA) repair are limited. The aim of this meta-analysis was to summarize outcomes among patients aged ≤ 24 months undergoing TA repair with at least moderate TVI. A systematic literature search was conducted in PubMed, Scopus, and CINAHL Complete from database inception through June 1, 2022. Studies reporting outcomes of TA repair in patients with moderate or greater TVI were included. Studies reporting outcomes only for patients aged > 24 months were excluded. The primary outcome was overall mortality, and secondary outcomes included early mortality and truncal valve reoperation. Random-effects models were used to estimate pooled effects. Assessment for bias was performed using funnel plots and Egger's tests. Twenty-two single-center observational studies were included for analysis, representing 1,172 patients. Of these, 232 (19.8%) had moderate or greater TVI. Meta-analysis demonstrated a pooled overall mortality of 28.0% after TA repair among patients with significant TVI with a relative risk of 1.70 (95% CI [1.27-2.28], p < 0.001) compared to patients without TVI. Significant TVI was also significantly associated with an increased risk for early mortality (RR 2.04; 95% CI [1.36-3.06], p < 0.001) and truncal valve reoperation (RR 3.90; 95% CI [1.40-10.90], p = 0.010). Moderate or greater TVI before TA repair is associated with an increased risk for mortality and truncal valve reoperation. Management of TVI in patients remains a challenging clinical problem. Further investigation is needed to assess the risk of concomitant truncal valve surgery with TA repair in this population.

Risky Sexual Behaviors and Condom Use Barriers in Iranian Women with Substance Use Disorders

Background

Scant information exists on Iranian women's protective behaviors mainly constant condom use. Inconsistent condom use seems prevalent among women with substance use problems. We aimed to investigate risky sexual behaviors (RSBs) and condom use barriers in Iranian women with substance use disorders (SUDs).

Methods

In our cross-sectional study, we recruited 300 women who sought treatments for their SUDs from the active outpatient drug free (ODF) and Methadone Maintenance Therapy (MMT) centers in Tehran, Iran during 2017-2021. We used three batteries including demographic questionnaire, the Risky Sexual Behavior Questionnaire (RSBQ); and the Condom Barriers Scale (CBS). The statistical software R, analysis of variance post hoc and multivariate analysis of variance (MANOVA) logistic regression tests were used in data analysis.

Results

The majority reported at least one lifetime experience of RSBs. Our results show that only 22% of the participants 'always' use condom in their sexual encounters. The lowest and highest subscale scores of the CBS were related to Sexual Experience (SE) (2.47 ± 0.86) and access/availability structure (3.52 ± 0.7), respectively. RSBs had negative significant association with Partner Barrier (PB) subscale scores (OR = 0.4; 95% CI: 0.22 to 0.73) and effect on SE subscale scores (OR= 0.54; 95% CI: 0.31 to 0.94).

Conclusion

RSBs was prevalent among our study population. RSBs and condom use barriers are significantly interwoven. The condom use barriers were highly associated with the types of sexual encounters such as group sex or casual sexual relations than specific mean of sexual performance (i.e. anal sex). Gender-specific RSBs, STIs/HIV/AIDS prevention program is recommended for women with SUDs.

Self-rated health and quality of life in female sex workers with substance use disorders in Tehran, Iran

BACKGROUND

While self-rated health (SRH) and quality of life (QoL) has been associated with substance use disorders (SUDs) in sex-working populations, little is known about this association in Iran. This study aimed to assess QoL and SRH in Iranian female sex workers (FSWs) in Tehran.

METHOD

FSWs were recruited using convenience sampling methods from substance abuse treatment centers in Tehran that exclusively provided services for women. Participants completed an interviewer-administered demographic questionnaire in Persian and the Iranian version of the Short Form Health Survey (SF-36). Descriptive analyses, means and standard deviations; frequency and percentages, t-test and one-way ANOVA, and Chi-square tests were utilized to analyze the data.

RESULTS

The mean age among 161 participants clinically diagnosed with SUD was 34.09 years (SD 7.97; range: 18-57). The total mean QoL score was 41.03 (SD: 12.92). The highest and lowest mean scores were observed in the physical functioning (52.23) and role emotional (26.64) dimensions, respectively. Significant differences (p < 0.05) in QoL were observed according to education and marital status, and the average QoL score was lower in women who reported permanent marriages and women who were illiterate. The average score of QoL was significantly higher in employed women. Overall, 51.6% of the women rated their health as sub-optimal, with divorced participants and women who were illiterate more likely to rate their health as sub-optimal (p < 0.05).

CONCLUSION

Results emphasize the need for mental, physical, and sexual health screening and gender-specific interventions to improve QoL in this population. Further investigation may elucidate the consequences of poor SRH and QoL on SUD treatment adherence, sexual risk behavior, and morbidity and mortality in FSWs.

Evaluation of Bayesian spatiotemporal infectious disease models for prospective surveillance analysis

BACKGROUND

COVID-19 brought enormous challenges to public health surveillance and underscored the importance of developing and maintaining robust systems for accurate surveillance. As public health data collection efforts expand, there is a critical need for infectious disease modeling researchers to continue to develop prospective surveillance metrics and statistical models to accommodate the modeling of large disease counts and variability. This paper evaluated different likelihoods for the disease count model and various spatiotemporal mean models for prospective surveillance.

METHODS

We evaluated Bayesian spatiotemporal models, which are the foundation for model-based infectious disease surveillance metrics. Bayesian spatiotemporal mean models based on the Poisson and the negative binomial likelihoods were evaluated with the different lengths of past data usage. We compared their goodness of fit and short-term prediction performance with both simulated epidemic data and real data from the COVID-19 pandemic.

RESULTS

The simulation results show that the negative binomial likelihood-based models show better goodness of fit results than Poisson likelihood-based models as deemed by smaller deviance information criteria (DIC) values. However, Poisson models yield smaller mean square error (MSE) and mean absolute one-step prediction error (MAOSPE) results when we use a shorter length of the past data such as 7 and 3 time periods. Real COVID-19 data analysis of New Jersey and South Carolina shows similar results for the goodness of fit and short-term prediction results. Negative binomial-based mean models showed better performance when we used the past data of 52 time periods. Poisson-based mean models showed comparable goodness of fit performance and smaller MSE and MAOSPE results when we used the past data of 7 and 3 time periods.

CONCLUSION

We evaluate these models and provide future infectious disease outbreak modeling guidelines for Bayesian spatiotemporal analysis. Our choice of the likelihood and spatiotemporal mean models was influenced by both historical data length and variability. With a longer length of past data usage and more over-dispersed data, the negative binomial likelihood shows a better model fit than the Poisson likelihood. However, as we use a shorter length of the past data for our surveillance analysis, the difference between the Poisson and the negative binomial models becomes smaller. In this case, the Poisson likelihood shows robust posterior mean estimate and short-term prediction results.

Acceptability and uptake of oral HIV self-testing among rural community members in Tanzania: a pilot study

New strategies are needed to improve HIV testing rates in Tanzania, particularly among adult men. We sought to investigate if HIV oral self-testing would increase HIV testing uptake in Tanzanian rural community homes. The study design was a prospective community-randomized pilot study, in two matched villages with similar characteristics (intervention and control villages) Before data collection, we trained village health workers and research assistants for one week. We recruited male and female adults from 50 representative households in each of two villages in eastern Tanzania. We collected data at baseline and we followed-up the enrolled households after a one-month period. There was a high interest in testing for HIV, with all participants from both arms (100%; n = 259) reporting that they would like to test for HIV. After the one-month follow-up, overall, 66.1% (162/245) of study participants reported to have tested for HIV in both arms. In the intervention arm, 97.6% (124/127) reported that they tested for HIV versus in the control arm, 32.2% (38/118) tested for HIV, p-value < 0.001. In Tanzania, we found that availability of HIV self-testing was associated with an enormous increase in HIV testing uptake in a rural population.

Hazard of substance abuse onset among adults diagnosed with epilepsy or migraine

OBJECTIVE

We investigated adult-onset epilepsy as a risk factor for the development of substance use disorder (SUD) by comparing the rate of SUD diagnosis among adults diagnosed with epilepsy with presumably healthy controls with lower extremity fractures (LEF). For additional comparison, we investigated the risk for adults with migraine only. Epilepsy and migraine are both episodic neurological disorders and migraine is frequently comorbid with epilepsy.

METHODS

We conducted a time-to-event analysis using a subset of surveillance data of hospital admissions, emergency department visits, and outpatient visits in South Carolina, USA from January 1, 2000, through December 31, 2011. Individuals aged 18 years or older were identified using the International Classification of Disease, 9thRevision Clinical Modification (ICD-9) with a diagnosis of epilepsy (n = 78,547; 52.7% female, mean age 51.3 years), migraine (n = 121,155; 81.5% female, mean age 40.0 years), or LEF (n = 73,911; 55.4% female, mean age 48.7 years). Individuals with SUD diagnosis following epilepsy, migraine, or LEF were identified with ICD-9 codes. We used Cox proportional hazards regression to model the time to SUD diagnosis comparing adults diagnosed with epilepsy, migraine, and LEF, adjusting for insurance payer, age, sex, race/ethnicity, and prior mental health comorbidities.

RESULTS

Compared to LEF controls, adults with epilepsy were diagnosed with SUD at 2.5 times the rate [HR 2.48 (2.37, 2.60)] and adults with migraine only were diagnosed with SUD at 1.12 times the rate [HR 1.12 (1.06, 1.18)]. We found an interaction between disease diagnosis and insurance payer, with hazard ratios comparing epilepsy to LEF of 4.59, 3.48, 1.97, and 1.44 within the commercial payer, uninsured, Medicaid, and Medicare strata, respectively.

SIGNIFICANCE

Compared to presumably healthy controls, adults with epilepsy had a substantially higher hazard of SUD, while adults with migraine only showed a small, but significant, increased hazard of SUD.

Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids

BACKGROUND

In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes.

METHODS

Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter.

RESULTS

Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity.

CONCLUSIONS AND RELEVANCE

This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.

Oral Janus kinase inhibitors in the treatment of atopic dermatitis: A systematic review and meta-analysis

Background

Janus kinase (JAK) inhibitors are being evaluated as promising upcoming treatments for atopic dermatitis (AD).

Objectives

To systematically assess the efficacy of oral JAK inhibitors in patients with AD and provide comparisons among JAK inhibitors.

Methods

A systematic literature review of JAK inhibitors in the treatment of AD was conducted and reported based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed, ClinicalTrials.gov, CENTRAL, MEDLINE/Ovid, Embase and sponsor websites from inception to 30 September 2021. References of relevant articles were reviewed by two authors. Only RCTs of JAK inhibitors for treating AD with more than one study were included. Data was extracted and the meta-analysis was performed using the metan procedure in STATA version 12.1. Risk of bias was assessed with the Cochrane Risk of Bias Tool. The four outcomes analysed included Eczema Area Severity Index (EASI)-75 response (≥75% improvement of EASI score from baseline), percent change in EASI score, percent of subjects achieving Investigator Global Assessment (IGA) of clear or almost clear (IGA 0/1), and ≥ 4-point improvement in pruritus numerical rating scale (NRS).

Results

Fourteen randomized controlled trials (7051 subjects) assessing three different oral JAK inhibitors (abrocitinib, baricitinib and upadacitinib) in patients with moderate-to-severe AD were included in the meta-analysis. Abrocitinib (100 and 200 mg), baricitinib (1, 2 and 4 mg) and upadacitinib (15 and 30 mg) were all found to be more efficacious compared to placebo in all four outcomes analysed. Upadacitinib 30 mg was more effective than all other dosages of JAK inhibitors in achieving EASI-75, decrease in percent change of EASI, IGA 0/1 response rate, and ≥ 4-point improvement in pruritus NRS.

Conclusions

JAK inhibitors were found to be an effective treatment for AD. Upadacitinib, at 30 mg, was found to be the most efficacious oral JAK inhibitor for AD. More clinical trial studies with comparisons among JAK inhibitors are needed to confirm these results as well as explore long-term efficacy and safety of these molecules.

Developing Sentinel Surveillance for Chlamydia and Gonorrhea Using Test Results From Routine Screening During Pregnancy

Background.

Interpretation of case-based surveillance of chlamydia and gonorrhea is limited by the lack of negative tests for comparison. We sought to develop a sustainable electronic health record (EHR)-based approach to disease surveillance in a sentinel population of pregnant persons.

Methods.

We conducted a one-year assessment of sexually transmitted infections (STIs) in persons receiving at least one pregnancy-related visit within our university medical center. Data were obtained using EHR analytic structured query language code (SQL). Patients were categorized by whether they had an STI test during pregnancy and if screened, by the STI test results (positive or negative). We assessed screening and positivity by demographic using bivariate analyses. Predictors of a positive STI test were determined using logistic regression.

Results.

We identified 4,553 persons who received pregnancy care from January 1 to December 31, 2021. Seventy-six percent (n, 3483) of persons were screened for an STI during pregnancy. Those who identified as white or had private insurance were less likely to have a chlamydia test. Among persons screened, Trichomonas was the most commonly detected STI (5%, 141/2,698) followed by chlamydia (4%, 135/3,456), and gonorrhea (0.7% 24/3,468). Predictors of a positive STI test during pregnancy were Black race [adjusted odds ratio (aOR) 6.0 (95% Confidence Interval 4.2–8.7)], age ≤ 25 [aOR 2.5 (1.9–3.3)], and public insurance [aOR 1.6 (1.2–2.1)].

Conclusions.

We demonstrated that EHRs can be utilized to assess gonorrhea and chlamydia positivity. These methods could potentially be applied in other jurisdictions to improve the understanding of national STI surveillance.

Electronic health records of a sentinel population of pregnant persons were queried to perform STI surveillance. This approach may improve the accuracy of national case estimates of STIs.

Geographical distribution of the health crisis of war in the Tigray region of Ethiopia

War destroys health facilities and displaces health workers. It has a devastating impact on population health, especially in vulnerable populations. We assess the geographical distribution of the impact of war on healthcare delivery by comparing the pre-November 2020 and the November to June 2021 status of health facilities in the Tigray region of Ethiopia. Data were collected from February 2021 to June 2021, during an active civil war and an imposed communication blackout in Tigray. Primary data were collected and verified by multiple sources. Data include information on health facility type, geocoding and health facility status (fully functional (FF), partially functional (PF), not functional, no communication). Only 3.6% of all health facilities (n=1007), 13.5% of all hospitals and health centres (n=266), and none of the health posts (n=741), are functional. Destruction varies by geographic location; only 3.3% in Western, 3.3% in South Eastern, 6.5% in North Western, 8% in Central, 14.6% in Southern, 16% in Eastern and 78.6% in Mekelle are FF. Only 9.7% of health centres, 43.8% of general hospitals and 21.7% of primary hospitals are FF. None of the health facilities are operating at prewar level even when classified as FF or PF due to lack of power and water or essential devices looted or destroyed, while they still continue operating. The war in Tigray has clearly had a direct and devastating impact on healthcare delivery. Restoration of the destroyed health facilities needs to be a priority agenda of the international community.

Spatial patterns of HPV and Tdap vaccine dose administration and the association of health department clinic access in Georgia counties

OBJECTIVE

To characterize counties in GA by quantifying administered doses of the HPV and Tdap vaccines collected by the state health department immunization registry and indicators of Health Department (HD) clinic access.

METHODS

Using a cross sectional study design, secondary data were collected from public health data sources for the years 2016 to 2018 for 159 counties of Georgia. The study population was male and female adolescents aged 13-17. The number of administered HPV and Tdap vaccine doses were modeled in relation to number of private and public HD clinics, number of HD clinics registered in the VFC program and the availability of public transportation using Poisson regression, negative binomial regression, and Bayesian spatial analysis.

RESULTS

Choropleth maps showed similar clustering patterns between administered doses of the HPV vaccine and Tdap vaccine and increased counts of administered vaccine doses in counties with both public and private clinics. Administered doses of HPV and Tdap vaccines were found to exhibit spatial dependence across counties. Accounting for spatial dependence, the availability of public transit had a significant positive effect on administered HPV vaccine doses, while the number of private HD clinics had a significant positive effect on administered Tdap vaccine doses.

CONCLUSIONS

Maps at the county level show vaccination variability, clustering patterns and provide additional insights on the access to health care. Bayesian spatial models are needed to accurately identify and estimate factors associated with administering doses of the HPV and Tdap vaccines. Future work is needed to further examine the utilization of HPV vaccination services among urban groupings.

Sexual health outcomes of PLISSIT-based counseling versus grouped sexuality education among Iranian women with breast cancer: A randomized clinical trial

In-person, individual counseling using the PLISSIT model is a well-known approach to help people with sexual problems. Evidence suggests that Grouped Sexuality Education (GSE) can be as effective as in-person sexuality education. The efficacy of PLISSIT versus GSE has not previously been evaluated in women with Breast Cancer (BC). In this paper, we report on the effect of PLISSIT versus GSE on self-reported sexual behaviors experienced by women after a BC diagnosis (n = 75). The women were randomly allocated into three groups, with 25 women in each arm. Data analysis of the intention-to-treat population (n = 65) revealed efficacy of both GSE and PLISSIT in improving sexual behaviors (p < 0.0001) with a positive change in sexual capacity, motivation and performance after 6- and 12-weeks post-intervention follow ups. We found the GSE model showed a greater efficacy than the PLISSIT model. Due to the substantial needs faced by women with cancer and the cost associated with implementing the PLISST model, GSE seems to be more effective. We recommend GSE for Iranian communities where management of sexual problems is at an early stage and where the sexuality of women with cancer is routinely overlooked.

Low acceptance of intimate partner violence by pregnant women in Uganda predicts higher uptake of HIV self-testing among their male partners

Introduction: Heterosexual couples are at high risk for HIV acquisition in sub-Saharan Africa, and HIV self-testing (HST) is an additional approach to expand access to HIV testing services. However, it is not well known how gender equality is associated with HST.Methods: We used intervention-arm data from a cluster-randomised controlled HST intervention trial (N = 1 618) conducted in Uganda to determine the association between attitudes towards intimate partner violence (IPV), decision-making power and male partner's uptake of HST among heterosexual couples expecting a child in south-central Uganda. The original study question was to assess the impact of providing pregnant women with HST kits to improve male partner's HIV testing rates. For this analysis, the primary exposures were gender equality (measured by male partner's and female partner's attitudes towards IPV and the female partner's household decision-making power), and the primary outcome was the male partner's uptake of HST. Multivariate logistic regression was used for analysis.Results: We found that male partner HST uptake did not vary depending on male partner's attitudes towards IPV or decision-making power; however, male partner HST uptake did depend on the female partner's attitude towards IPV, with 1.76 times more testing (95% CI 1.06-2.92) in couples where the woman had "medium" versus "high" acceptance of IPV, and 1.82 times more testing (95% CI 1.08-3.08) in couples where the woman had "low" versus "high" acceptance of IPV.Conclusions: This study shows the importance of appropriate negative attitudes by women to IPV in increasing male partner's HST uptake to integrate HST into national health care policies.

Measuring Sexual Performance: Development and Psychometric Properties of the Sexual Performance Questionnaire in Iranian People with Spinal Cord Injury

Sexual performance refers to activities served by sexual capacity and motivation. As a culturally sensitive issue, to date the scalar invariance of sexual performance has not been examined for Iranians with spinal cord injuries (SCIs). Aim: To develop and assess properties of an instrument evaluating sexual performance of an Iranian population with SCIs., in Brain and Spinal Cord Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Using multi-modal methods, we developed and assessed the Sexual Performance Questionnaire (SPQ). This included collecting expert opinions; engaging with patients with SCI referred to BASIR; pilot testing to assess the scale; and a formal investigation. Participants (men = 156, women = 58) completed the SPQ. Internal consistency and reliability were measured using Cronbach's α coefficient. Content and face validity were examined by academic experts. Construct validity was assessed by examining convergent and discriminant validity. Finally, exploratory factor analysis was used to extract the factor structure of the questionnaire. The Cronbach's α coefficient was 0.77. There was a significant (p = 0.04) correlation (r = - 0.23) between the SPQ score and age. Those with a partner scored higher (p = 0.001). We found three components: Spouse as initiator, self-initiation, and genital-oriented sex which accounted for 59% of the observed variance. The face and content validity was approved by an expert committee. The development and application of the 13-item SPQ provides a thorough understanding of sexual performance amongst persons with SCI. It facilitates the development of efficient sexual rehabilitation interventions and SCI-specific sexuality education programs.

Coping Mechanisms of Previously Diagnosed and New HIV-Discordant, Heterosexual Couples Enrolled in a Pilot HIV Self-Testing Intervention Trial in Central Uganda

Introduction: Learning that a couple has HIV-discordant results can create tensions in the relationship including separation. We explored the coping mechanisms of HIV-discordant, heterosexual couples enrolled in an HIV self-testing (HIVST) intervention trial in Central Uganda.

Materials and Methods: This qualitative study was nested within a pilot HIVST intervention trial targeting pregnant women and their male partners in central Uganda. In-depth interviews were conducted with 18 individuals from 13 HIV-discordant couples between July and September 2018; 18 months after the end of the main trial. Data were collected on the couples' initial reactions after learning about their HIV-discordant status, mechanisms adopted by couples to cope with HIV-discordance, and suggestions on how couples in similar situations can be supported. Interviews were transcribed verbatim and analysed manually following a thematic framework approach.

Findings: Of the 13 HIV-discordant couples, the female partner was HIV-positive (M–F+) in seven, while the male partner was HIV-positive (F–M+) in six. The mean (±SD) age of the participants was 32.6 (±6.4) years and participants had stayed together for an average of 5.5 (±3.6) years. Fourteen participants from nine couples already knew about their HIV-discordant status by the time they participated in the HIVST trial. After learning about their HIV-discordant status, most individuals (15) thought of abandoning their relationship; three (3) thought of committing suicide. To cope with HIV-discordance, some couples reported that they sought professional counselling support from healthcare providers, and this was particularly true for couples that were already aware of their HIV-discordant status by the time they participated in the HIVST trial. However, new couples that learnt about their HIV-discordant status after participating in the trial reported that they sought psycho-social support from friends or relatives. In the majority of cases, couples reported that they reduced the frequency of sex or abstained from sex. Some couples temporarily separated from their partners, while a few others resorted to using condoms to reduce HIV infection risk.

Conclusion: Couples used a variety of approaches to cope with HIV-discordance. Study findings underscore the importance of ongoing professional counselling and psycho-social support in helping couples to cope with HIV-discordance.

Absence of Antenatal Care and Antiretroviral Therapy Associated with Preterm Delivery in Women with HIV: An 11-Year Retrospective Cohort in South Carolina

PURPOSE

Our primary aim was to determine if combined antiretroviral therapy (cART) increased the risk of poor infant outcomes among women with HIV.

METHODS

Maternal antiretroviral regimens were classified as mono-(mARV), dual (dARV), cART, and no ARV. Differences in dichotomous outcomes were compared using χ2 tests and continuous outcomes were compared using Kruskal-Wallis tests. Predictors of preterm delivery (PTD), low birth weight, and perinatal HIV infection were determined using logistic regression.

RESULTS

During the 11-year study period, 643 mother-baby pairs with HIV exposure were eligible for analysis. Non-Hispanic, Black women were more likely to report mARV or no ARV use (p=.03). Women not taking ARVs were more likely to have PTD (p=.01). Prenatal care was associated with a reduction in PTD [aOR 0.12 (95% CI 0.03-0.5)] and perinatal HIV infection [aOR 0.1 (95% CI 0.01-0.7)].

CONCLUSIONS

Maternal cART and race were not associated with PTD. Rather, absence of prenatal care and lack of ARV use during pregnancy increased the risk of PTD and perinatal HIV infection.

HIV Self-Testing Uptake and Intervention Strategies Among Men in Sub-Saharan Africa: A Systematic Review

Background: HIV testing is an essential gateway to HIV prevention and treatment services. However, HIV testing uptake remains low among men due to stigma, discrimination, and confidentiality concerns. HIV self-testing (HIVST) is an alternative HIV testing method that can address many of these barriers for men. We conducted a systematic review to examine HIVST uptake and intervention strategies among Men in Sub-Saharan Africa.

Methods: We used a systematic approach to survey literature published from January 2010 to June 2020 using five electronic databases (PubMed-Medline, CINAHL Complete, PsychINFO, Google Scholar, and Web of Science) and a manual search. Studies were included if they were peer-reviewed, published in English, and examined HIVST willingness, uptake, and/or linkage to care and included men in Sub-Saharan Africa.

Results: Sixty-three articles related to HIVST were reviewed. Of the included articles, 37 discussed HIVST uptake/acceptability and 24 discussed intervention strategies. Both oral swab and finger-prick methods had high acceptability with ease of access and availability of the test cited as important by men. Free HIVST kits were preferred by men. Secondary distribution of kits via peers, sexual partners, and female sex workers were successful.

Conclusion: HIV self-testing is highly acceptable to men. More efforts are needed to develop policies to implement HIVST programs targeting men in Sub-Saharan Africa, including a focus on linkage to care in sub-Saharan Africa. Future interventions should directly target men independently in tandem with using peers and their romantic partners to promote self-testing among men in sub-Saharan Africa. HIVST kit distribution strategies should be combined with services that can offer confirmatory tests and counseling for men as well as linkage to care.

Ease of understanding and performing HIV self-tests by pregnant women and their male partners in Uganda: a cross-sectional study

INTRODUCTION

Understanding and following HIV self-testing (HIVST) instructions is a critical step in the use of HIVST kits. We analyzed data on pregnant women and their partners' self-assessment on the usability of kits delivered by their pregnant women.

METHODS

Quantitative data were collected on 399 pregnant women and 238 male partners enrolled in the intervention arm of a large cluster-randomized HIVST trial. Each pregnant woman received HIVST demonstrations, detailed pictorial instructions on how to use OraQuick HIVST kits, and two kits; for herself and her male partner. Follow-up was at one month (baseline for male partners) and 3 months. Descriptive statistics were conducted to compare understanding and following of HIVST instructions by age and education level.

RESULTS

The proportion of those who understood HIVST instructions was almost the same (98%) for women and their partners, although partners (26.5%) were nearly twice as likely than women (16.0%) to report needing pretest counseling (Odds ratio [OR] = 1.9, 95% CI: 1.27-2.79). Partners' understanding of the HIVST instructions did not vary by education level, but 4.4% of women with primary education reported difficulty in understanding HIVST instructions compared with 0.5% and 0% of those with secondary and university education, respectively (p = 0.05). However, 5.6% of women aged 30-68 years and 3.3% of partners aged 20-24 years found it more difficult to understand the HIVST instructions.

CONCLUSION

Both pregnant women and their male partners were correctly able to perform an HIVST without or (with minimal) support suggesting that this mode of delivery will help the national program reach more men. Because more male partners than women required HIVST pretest counseling support, male-targeted HIVST promotional messages may be needed to increase men's self-efficacy to perform HIVST unsupported.

Socio-demographic predictors of gender inequality among heterosexual couples expecting a child in south-central Uganda

BACKGROUND

Gender inequality is a pervasive problem in sub-Saharan Africa, and has negative effects on health and development.

OBJECTIVE

Here, we sought to identify socioeconomic predictors of gender inequality (measured by low decision-making power and high acceptance of intimate partner violence) within heterosexual couples expecting a child in south-central Uganda.

METHOD

We used data from a two-arm cluster randomized controlled HIV self-testing intervention trial conducted in three antenatal clinics in south-central Uganda among 1,618 enrolled women and 1,198 male partners. Analysis included Cochran Mantel-Haenzel, proportional odds models, logistic regression, and generalized linear mixed model framework to account for site-level clustering.

RESULTS

Overall, we found that 31.1% of men had high acceptance of IPV, and 15.9% of women had low decision-making power. We found religion, education, HIV status, age, and marital status to significantly predict gender equality. Specifically, we observed lower gender equality among Catholics, those with lower education, those who were married, HIV positive women, and older women.

CONCLUSION

By better understanding the prevalence and predictors of gender inequality, this knowledge will allow us to better target interventions (increasing education, reducing HIV prevalence in women, targeting interventions different religions and married couples) to decrease inequalities and improve health care delivery to underserved populations in Uganda.

Adherence Across FDA-Approved Medications for Alcohol Use Disorder in a Veterans Administration Population

OBJECTIVE

U.S. Food and Drug Administration (FDA)-approved medications exist for the treatment of alcohol use disorders. However, their effectiveness depends on proper adherence to the prescribed regimen. Differences in adherence across medications may have implications for clinical outcomes and may provide helpful information in considering treatment options. This study aims to identify significant differences in adherence if present.

METHOD

A retrospective chart review was conducted in the Veterans Integrated Service Networks (VISN)-7 region of Veterans Affairs hospital and community-based outpatient clinics within South Carolina and Georgia. Prescriptions of FDA-approved alcohol use disorder medications from 2010 through 2015 were reviewed. Adherence was determined by the proportion of days the veteran had oral or injectable medication available over a 6-month period as noted by medication fills (reported as 0%-100% medication availability). We compared adherence for specific medications using chi-square, t test, logistic regression for dichotomous outcomes, and linear regression for continuous outcomes.

RESULTS

A total of 715 subjects and 807 medication trials were included. Mean adherence (percentage of days that medication was available) was 41.3% for disulfiram, 44.7% for acamprosate, 49.8% for oral naltrexone, and 54.6% for extended-release injectable naltrexone. The mean adherence was significantly different between disulfiram and oral naltrexone (p = .002) as well as disulfiram and extended-release injectable naltrexone (p = .004). Adherence of 80% was achieved in 11.9%, 19.4%, 22.7%, and 24.4% of treatment courses with disulfiram, acamprosate, naltrexone, and extended-release injectable naltrexone, respectively. These differences were significant for disulfiram versus oral naltrexone (p = .004) and disulfiram versus extended-release injectable naltrexone (p = .05).

CONCLUSIONS

These results demonstrate that overall adherence to medication-assisted treatment for alcohol use disorder is low across all medications. When directly compared, disulfiram had significantly lower adherence than both oral and extended-release injectable naltrexone.

Timing is everything: assessing the impact of maternal HIV infection diagnosis timing on infant outcomes in a ten-year retrospective cohort study in South Carolina

The aims were to evaluate the impact of maternal HIV infection diagnosis timing on infant outcomes. The outcomes of interest included preterm delivery (PTD) and confirmed infant HIV infection. Data for all HIV-exposed infants from 2004-14 were obtained. Maternal HIV infection diagnosis timing was categorized as: perinatal (PHIV), adult infection before conception, and after conception. Infant outcomes were compared according to timing of maternal HIV diagnosis. Bivariate outcomes were compared using χ ² tests. Continuous variables were compared using Kruskal-Wallis tests. Logistic regression was used to determine predictors of PTD and infant HIV infection. Most women were diagnosed with HIV before conception: PHIV (21, 3%), before conception (431, 69%), and post-conception (176, 28%). Women diagnosed with HIV as an adult before conception were more likely to deliver preterm (P = 0.007). Prenatal care was associated with lower risk of PTD (aOR 0.1, 95% CI 0.04-0.5). Six infants contracted HIV. Infant HIV infection was more likely in women who did not take antiretroviral therapy (aOR 13.5, 95% CI 2.5-72.1) or delivered preterm (aOR 5.3, 95% 1.1-25.1). Women with PHIV were more likely to deliver at term, and there were no HIV infections among PHIV-exposed infants. These findings are reassuring to PHIV women who desire pregnancy.

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.

Repeat HIV testing of individuals with discrepant HIV self-test results in Central Uganda

Background

According to the user instructions from the manufacturer of OraQuick HIV self-test (HIVST) kits, individuals whose kits show one red band should be considered to be HIV-negative, no matter how weak the band is. However, recent reports show potential for a second false weak band after storage, thereby creating confusion in the interpretation of results. In this study, we re-tested individuals whose results were initially non-reactive but changed to weak reactive results to determine their true HIV status.

Methods

This study was nested within a large, cluster-randomized HIVST trial implemented among pregnant women attending antenatal care and their male partners in central Uganda between July 2016 and February 2017. Ninety-five initially HIV-negative respondents were enrolled into this study, including 52 whose kits developed a second weak band while in storage and 43 whose kits were interpreted as HIV-positive by interviewers at the next follow-up interview. Respondents were invited to return for repeat HIVST which was performed under the observation of a trained nurse counsellor. After HIVST, respondents underwent blood-based rapid HIV testing as per the national HIV testing algorithm (Determine (Abbot Laboratories), STAT-PAK (Chembio Diagnostic Systems Inc.) and Unigold (Trinity Biotech plc.) and dry blood spots were obtained for DNA/PCR testing. DNA/PCR was considered as the gold-standard HIV testing method.

Results

After repeat HIVST, 90 (94.7%) tested HIV-negative; 2 (2.1%) tested HIV-positive; and 3 (3.2%) had missing HIV test results. When respondents were subjected to blood-based rapid HIV testing, 97.9% (93/95) tested HIV-negative while 2.1% (2/95) tested HIV-positive. Finally, when the respondents were subjected to DNA/PCR, 99% (94/95) tested HIV-negative while 1.1% (1/95) tested HIV-positive.

Conclusions

Nearly all initially HIV-negative individuals whose HIVST kits developed a second weak band while in storage or were interpreted as HIV-positive by interviewers were found to be HIV-negative after confirmatory DNA/PCR HIV testing. These findings suggest a need for HIV-negative individuals whose HIVST results change to false positive while under storage or under other sub-optimal conditions to be provided with an option for repeat testing to determine their true HIV status.

Relationship Gender Equality and Couples' Uptake of Oral Human Immunodeficiency Virus Self-Testing Kits Delivered by Pregnant Women in Kenya

BACKGROUND

Higher gender equality is associated with many human immunodeficiency virus (HIV) preventive behaviors, including HIV testing. HIV self-testing is a relatively new testing technology that could assist with HIV prevention. However, there are no studies examining gender equality and HIV self-testing. We examined the associations between gender equality and couples' uptake of HIV self-testing among heterosexual couples expecting a child in central Kenya.

METHODS

This analysis used data from a HIV self-testing randomized intervention trial among pregnant women attending antenatal care and their male partners. The primary exposures were gender equality (measured by the male partner's attitudes toward intimate partner violence, and the woman's report on her household decision making power), and the primary outcome was couples' uptake of HIV self-testing. Generalized linear mixed models framework was used to account for site-level clustering.

RESULTS

In comparison to male partners reporting high acceptance of intimate partner violence, couples with male partners reporting medium acceptance (odds ratio, 2.36; 95% confidence interval, 0.99-5.63) or low acceptance (odds ratio, 2.50; 95% confidence interval, 1.20-5.21) were significantly more likely to use HIV self-testing. Gender equality measured by decision making power was not associated with couples' uptake of HIV self-testing.

CONCLUSIONS

This study is the first of its kind to examine the association between gender equality and couples' HIV self-testing. This holds important implications for HIV self-testing as we strive to achieve the United Nations Programme on HIV/acquired immune deficiency syndrome goal that 90% of individuals living with HIV should know their status.

Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial

IMPORTANCE

The effects of intensive care unit (ICU) visiting hours remain uncertain.

OBJECTIVE

To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium.

DESIGN, SETTING AND PARTICIPANTS

Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018.

INTERVENTIONS

Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation.

MAIN OUTCOMES AND MEASURES

Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory).

RESULTS

Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation.

CONCLUSIONS AND RELEVANCE

Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02932358.

HIV Self-Testing Knowledge and Attitudes at Sports-based HIV Prevention Tournaments in Nairobi, Kenya

HIV remains a major health problem in sub-Saharan Africa, and innovations - such as HIV self-testing (HST) - that break down barriers to testing are required to move toward elimination. Four anonymous cross-sectional surveys were conducted assessing HST knowledge and attitudes among sports-based HIV prevention tournament attendees in Nairobi, Kenya. Results suggest HST may increase testing rates in this population. Participants expressed interest in using HST and were willing to use HST as a tool to motivate others. This poses a unique opportunity for a community intervention aimed to increase knowledge of HST, and to increase HIV testing rates using HST kits.

Per- and polyfluoroalkyl substances (PFAS) in plasma of the West Indian manatee (Trichechus manatus)

Per- and polyfluoroalkyl substances (PFAS) are ubiquitous, synthetic anthropogenic chemicals known to infiltrate and persist in biological systems as a result of their stability and bioaccumulation potential. This study investigated 15 PFAS, including short-chain carboxylic and sulfonic acids, and their presence in a threatened herbivore, the West Indian manatee (Trichechus manatus). Seven of the 15 PFAS examined were detected in manatee plasma. Perfluorooctanesulfonic acid (PFOS) (ranging from 0.13 to 166 ng/g ww) and perfluorononanoic acid (PFNA) (ranging from 0.038 to 3.52 ng/g ww) were detected in every manatee plasma sample examined (n = 69), with differing medians across sampling sites in Florida, Crystal River (n = 39), Brevard County (n = 18), Everglades National Park (n = 8), and four samples (n = 4) from Puerto Rico. With an herbivorous diet and long life-span, the manatee provides a new perspective to monitoring PFAS contamination.

Social and Demographic Predictors of Gender Inequality Among Heterosexual Couples Expecting a Child in Central Kenya

Imbalance of power and equality in sexual relationships is linked to health in various ways, including (1) reduced ability to get information or take action, (2) increased violence between partners, and (3) influence on the reduced use of health services. While there has been research assessing multiple social and economic variables related to gender inequality, studies have used many different definitions of gender inequality, and there is a lack of this research within a pregnancy context. Here, we attempt to identify social and economic predictors of gender inequality (measured by decision-making power and acceptance of intimate partner violence) within heterosexual couples expecting a child in central Kenya. We ran a secondary data analysis using data from a three-arm individually randomized controlled HIV self-testing intervention trial conducted in 14 antenatal clinics in central and eastern Kenya among 1410 women and their male partners. The analysis included Cochran Mantel-Haenszel, logistic regression, proportional odds models, and generalized linear mixed model (GLMM) framework to account for site-level clustering. Overall, we show that there are significant social and economic variables associated with acceptance of intimate partner violence including higher age, being married, "other" religion, lower partner education, higher wealth status, and variables associated with decision-making power including lower partner education and lack of equality in earnings. This study contributes to the literature on the influence of social and economic factors on gender inequality, especially in Kenya which has a high burden of HIV/AIDS. Our results show some areas to improve these specific factors (including education and employment opportunities) or create interventions for targeted populations to potentially improve gender equality in heterosexual pregnant couples in Kenya.

'If I had not taken it [HIVST kit] home, my husband would not have come to the facility to test for HIV': HIV self-testing perceptions, delivery strategies, and post-test experiences among pregnant women and their male partners in Central Uganda

Background: HIV self-testing (HIVST) can improve HIV-testing rates in ‘hard-to-reach’ populations, including men. We explored HIVST perceptions, delivery strategies, and post-test experiences among pregnant women and their male partners in Central Uganda.

Methods: This was a qualitative study implemented as part of a pilot, cluster-randomized oral HIVST intervention trial among 1,514 pregnant women attending antenatal care services at three health facilities in Central Uganda. The qualitative component of the study was conducted between February and March 2017. We conducted 32 in-depth interviews to document women and men’s perceptions about HIVST, strategies used by women in delivering the kits to their male partners, male partners’ reactions to receiving kits from their female partners, and positive and negative social outcomes post-test. All interviews were audio-recorded, transcribed verbatim, and analyzed manually following a thematic framework approach.

Results: Women were initially anxious about their male partners’ reaction if they brought HIVST kits home, but the majority eventually managed to deliver the kits to them successfully. Women who had some level of apprehension used a variety of strategies to deliver the kits including placing the kits in locations that would arouse male partners’ inquisitiveness or waited for ‘opportune’ moments when their husbands were likely to be more receptive. A few (three) women lied about the purpose of the test kit (testing for syphilis and other illnesses) while one woman stealthily took a mucosal swab from the husband. Most men initially doubted the ability of oral HIVST kits to test for HIV, but this did not stop them from using them. Both men and women perceived HIVST as an opportunity to learn about each other’s HIV status. No serious adverse events were reported post-test.

Conclusion: Our findings lend further credence to previous findings regarding the feasibility of female-delivered HIVST to improve male partner HIV testing in sub-Saharan Africa. However, support for women in challenging relationships is required to minimize potential for deception and coercion.

How Do Iranian People with Spinal Cord Injury Understand Marriage?

Background: Spinal cord injury (SCI) is a life-altering experience. There is little information about the perspectives of people with SCI toward marriage. Purpose: To explore the understandings of Iranian adults with SCI about marriage. Methods: In this qualitative inquiry, using a semi-structured interview guide, we collected data from 53 single adults with SCI (41 men and 12 women) who were referred to the Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences in Tehran. Barun and Clarke's thematic analysis approach was applied for data analysis. Results: "Marriage" was thematized in outer and inner scenarios. The outer scenario was explored in terms of physical disability identified as a seminal determinant in successful marriage. "Attractiveness," "able body for breadwinning," "sexually active," and "reproduction" were dominant concepts extracted from the participants' narratives. The participants' inner scenarios revealed that marriage would be welcomed if a potential partner accepted them as a "whole person" regardless of their SCI condition. Conclusion: The findings suggest that adults with SCI do not ignore or reject marriage, however it was not their life priority due to major concerns that they had internalized. Considering the quality of care, people with SCI must be reassured about their potential to get married. SCI-based sexuality education and premarital counseling support the patients in their postmarital lives. Our findings will provide decision makers and health providers with significant insight for utilizing culturally appropriate services for people with SCI.

The Effects of Asthma and Bullying on Suicidal Behaviors Among US Adolescents

BACKGROUND

Positive associations between suicidal behaviors and asthma have been established in previous adolescent studies. Few studies consider social risk factors, such as bullying. This study involved an analysis of suicidal behaviors and asthma, but also includes an assessment of whether these relationships were modified by the co-occurrence of bullying.

METHODS

Data included 13,154 participants from the 2013 Youth Risk Behavior Survey (YRBS), collected by the US Centers for Disease Control and Prevention. Logistic regression models were constructed and summarized using odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

When comparing adolescents with asthma who were bullied at school to those who were not bullied at school, the odds of contemplating suicide were increased by nearly 2-fold (OR = 1.8, 95% CI = 1.5-2.3), and the odds of creating a suicide plan were 2.3 times higher (OR = 2.3, 95% CI = 1.7-3.1). The odds of a suicide attempt and incurring an injury from a suicide attempt were also substantially increased. Similarly, increased odds of suicidal behaviors were observed for adolescents with asthma who were bullied electronically.

CONCLUSION

Having asthma and being bullied are both associated with increased odds of suicidal behaviors.

Perfluorinated alkyl acids and fecundity assessment in striped mullet (Mugil cephalus) at Merritt Island national wildlife refuge

This study investigated wild caught striped mullet (Mugil cephalus) at Merritt Island National Wildlife Refuge (MINWR) for levels of 15 perfluoroalkyl acids (PFAA) in tandem with individual fecundity measurements (Oocyte sub-stage 2 late, n=42) and oocyte reproductive stages (Stages 1-5, n=128). PFAA measurements were quantified in striped mullet liver (n=128), muscle (n=49), and gonad (n=10). No significant negative impacts of liver PFAA burden on wild-caught, mullet fecundity endpoints were observed in this study; however, changes in PFAA were observed in the liver as mullet progressed through different sub-stages of oocyte development. Of the PFAA with significant changes by sub-stage of oocyte development, the carboxylic acids (perfluorooctanoic acid, perfluorononanoic acid, and perfluorotridecanoic acid) increased in the liver with increasing sub-stage while the sulfonic acid and its precursor (perfluorooctanesulfonic acid (PFOS) and perfluorooctanesulfonamide, respectively) decreased in the liver with increasing sub-stage of oocyte development. This is a unique find and suggests PFAA change location of compartmentalization as mullet progress towards spawning. Investigations also revealed higher than expected median muscle and gonad levels of PFOS in striped mullet collected at MINWR (9.01ng/g and 80.2ng/g, respectively).

Does change in readiness influence retention among African American women and men in substance abuse treatment?

African Americans are less likely than other racial groups to engage in and complete outpatient substance abuse treatment. The current study, conducted as a secondary analysis of a multisite randomized clinical trial, examined whether readiness to change (RTC) over time influences retention and whether gender moderates the relationship between changes in RTC and retention among 194 African American women and men. Participants completed the University of Rhode Island Change Assessment at baseline and at the end of the 16-week study. Findings revealed a significant relationship between RTC over time and retention. Specifically, the more RTC increased throughout the 16-week study, the longer participants remained in treatment. In addition, gender moderated the relationship between changes in RTC and retention, with a stronger association between changes in RTC and retention among men relative to women. One approach to improving substance abuse treatment retention rates is to focus on increasing RTC during treatment, especially among African American men.

A recommendation for timing of repeat Chlamydia trachomatis test following infection and treatment in pregnant and nonpregnant women

The objective of this study was to describe the time required to obtain a negative chlamydia test in pregnant and nonpregnant women following treatment to inform test-of-cure collection and recommend an abstinence period to avoid reinfection. Seventy-two women with Chlamydia trachomatis infection, 36 pregnant and 36 nonpregnant, were enrolled in a prospective cohort study. Women were excluded less than 18 years of age, if they had been treated for chlamydia, reported an allergy to macrolide antibiotics, or if they had Myasthenia Gravis. Women were treated for chlamydia with single-dose therapy and submitted weekly vaginal chlamydia nucleic acid amplification tests (NAATs). Once NAAT were negative, the participants completed the study. Forty-seven women completed the study per protocol. The primary outcome was to determine the time to a negative chlamydia NAAT following treatment, with secondary outcomes of determining the appropriate time to collect a test-of-cure following chlamydia treatment and to recommend an appropriate abstinence period following treatment to avoid reinfection. Results showed that the time to a negative chlamydia NAAT was significantly different between groups (log-rank p = 0.0013). The median number of days to obtain a negative chlamydia NAAT was 8 days (IQR 7-14) in pregnant and 7 days (IQR 6-10) in nonpregnant women (WRST p = 0.04). All participants had a negative chlamydia NAAT by day 29 post-treatment. Following single-dose treatment for chlamydia, both pregnant and nonpregnant women should test negative with NAAT by 30 days post-treatment. Clinicians should collect a test-of-cure in pregnant women no earlier than 1 month. To avoid reinfection, women should avoid condomless intercourse for at least 1 month.

Spinal cord injury and women's sexual life: case-control study

Study design :This is a case-control study.

OBJECTIVE

The objective of this study was to estimate the magnitude of association between spinal cord injury (SCI) and women's quality of sexual life and sexual function.

SETTING

This study was conducted in the Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran.

METHODS

From the referral university-based clinics, we used simple random sampling to recruit 62 women: 31 women with SCI and 31 women without SCI. Socio-demographic and reproductive traits questionnaire, Sexual Quality of life-Female (SQOL-F), Female Sexual Function Index (FSFI) and Spinal Cord Independence Measure (SCIM) were completed using telephone and face-to-face interviews in the cases and controls. After univariate analyses, multivariate linear and proportional odds regression models were conducted to investigate the relation between SCI and women's quality of sexual life, as well as sexual function.

RESULTS

The mean age of cases and controls was 35.42±6.51 and 33.77±4.02 years. Most women were high school-educated and housewives. Adjusting for probable confounders, the proportional odds regression model showed a significant relationship between the spinal cord injury (AOR=4.2, 95% CI: 1.8-9.2), non-college-educated (AOR=3.1, 95% CI: 1.2-5.9) and employed (AOR=1.8, 95% CI: 1.1-1.8) variables and being in one of the moderate or poor quality of life classes. Scores of SQOL-F and FSFI domains, except satisfaction, were significantly worse in cases versus controls (P<0.001).

CONCLUSION

Although our participants showed low sexual dysfunction, they tended to report moderate to poor quality of sexual life. Our findings support the implication that sexual rehabilitation must be provided for women with SCI soon after injury.

Psychometric properties of the Sexual Adjustment Questionnaire (SAQ) in the Iranian population with spinal cord injury

STUDY DESIGN

This is a cross-sectional study.

OBJECTIVES

The objective of this study was to examine the psychometric properties of the Sexual Adjustment Questionnaire (SAQ) for Iranian people with spinal cord injury.

SETTING

This study was conducted in the brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran.

METHODS

We assessed the psychometric properties of the SAQ, with 200 participants (men=146, women=54) completing the scale. An evaluation of its test-retest reliability was performed over a 2-weeks period, on a subsample of 30 patients recruited from the overall group. Cronbach's α-coefficient was computed for assessment of internal consistency reliability. In addition, content and face validity were examined by an expert committee. Construct validity was assessed by examining convergent and discriminant validity. Finally, exploratory factor analysis was used to extract the factor structure of the questionnaire.

RESULTS

The Cronbach's α and intraclass correlation coefficient were 0.77 and 0.72 retrospectively. With regard to construct validity, there was a significant (P=0.009) negative correlation (r=-0.28) between the SAQ score and age. Those with lower levels of educations scored significantly lower on the SAQ (P=0.04). The exploratory factor analysis indicated a four-factor structure for the questionnaire, accounting for 68.9% of the observed variance. The expert committee approved the face and content validity of the developed measure.

CONCLUSION

The SAQ is a valid measure for assessing sexual adjustment in people with spinal cord injury. The evaluation of sexual well-being may be useful in clinical trials and practical settings.

Increasing prevalence of diabetes during pregnancy in South Carolina

BACKGROUND

The objective of our study was to examine the prevalence of diabetes during pregnancy at the population level in SC from January 1996 through December 2008.

METHODS

The study included 387,720 non-Hispanic white (NHW), 232,278 non-Hispanic black (NHB), and 43,454 Hispanic live singleton births. Maternal inpatient hospital discharge codes from delivery (91.59%) and prenatal information (i.e., Medicaid [42.91%] and SC State Health Plan [SHP] [5.98%]) were linked to birth certificate data. Diabetes during pregnancy included gestational and preexisting, defined by prenatal and maternal inpatient International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes (i.e., 64801-64802, 64881-64882, or 25000-25092) or report on the birth certificate.

RESULTS

Diabetes prevalence from any source increased from 5.02% (95% confidence interval [CI]: 4.82-5.22) in 1996 to 8.37% (95% CI: 8.15-8.60) in 2008. Diabetes prevalence, standardized for maternal age and race/ethnicity from 1996 through 2008, increased from 3.38% (95% CI: 3.29-3.47) to 5.81% (95% CI: 5.71-5.91) using birth certificate data, from 3.99% (95% CI: 3.89-4.10) to 6.69% (95% CI: 6.58-6.80) using hospital discharge data, and from 4.74% (95% CI: 4.52-4.96) to 8.82% (95% CI: 8.61-9.03) using Medicaid data. Comparing birth certificate to hospital discharge, Medicaid, and SHP data, Cohen's kappa in 2008 was 0.73 (95% CI: 0.72-0.75), 0.64 (95% CI: 0.62-0.66), and 0.59 (95% CI: 0.54-0.65), respectively.

CONCLUSIONS

An increasing prevalence of diabetes during pregnancy is reported, as well as substantial lack of agreement in reporting of diabetes prevalence across administrative databases. Prevalence of reported diabetes during pregnancy is impacted by screening, diagnostic, and reporting practices across different data sources, as well as by actual changes in prevalence over time.

An association between Trichomonas vaginalis and high-risk human papillomavirus in rural Tanzanian women undergoing cervical cancer screening

OBJECTIVE

The goal of this study was to determine the prevalence of vaginitis and its association with high-risk human papillomavirus (HR HPV) in women undergoing cervical cancer screening in rural Tanzania.

METHODS

For the purpose of cervical cancer screening, cytology and HR HPV polymerase chain reaction data were collected from 324 women aged between 30 and 60 years. Microscopy and gram stains were used to detect yeast and bacterial vaginosis. Cervical nucleic acid amplification test specimens were collected for the detection of Trichomonas vaginalis (TV), Chlamydia trachomatis, and Neisseria gonorrhoeae.

RESULTS

The majority of women were married (320 of 324) and reported having a single sexual partner (270 of 324); the median age of participants was 41 years. HR HPV was detected in 42 participants. Forty-seven percent of women had vaginitis. Bacterial vaginosis was the most common infection (32.4%), followed by TV (10.4%), and yeast (6.8%). In multivariable logistic regression analysis, TV was associated with an increased risk of HR HPV (odds ratio, 4.2 [95% CI, 1.7-10.3]). Patients with TV were 6.5 times more likely to have HPV type 16 than patients negative for TV (50% vs 13.3%) (odds ratio, 6.5 [95% CI, 1.1-37]).

CONCLUSIONS

Among rural Tanzanian women who presented for cervical cancer screening, Trichomonas vaginitis was significantly associated with HR HPV infection (specifically type 16).

Invited commentary: Parental smoking as a risk factor for adult tobacco use: can maternal smoking during pregnancy be distinguished from the social environmental influence during childhood?

Parental smoking is known to have prenatal health effects on developing fetuses, and postnatal exposure to secondhand smoke causes adverse health effects during childhood and beyond. Further, there is solid evidence that parental smoking during childhood is a potent risk factor for smoking in offspring. In this issue of the Journal, Rydell et al. (Am J Epidemiol. 2014;179(12):1409-1417) add to a growing body of evidence showing that maternal smoking during pregnancy is statistically associated with the long-term risk of tobacco use in offspring. The data revealed a strong signal between maternal smoking during pregnancy and tobacco use in young adulthood, an association that was largely concentrated in snus use but not cigarette smoking. This new study adds to a growing body of epidemiologic evidence that consistently points toward maternal smoking during pregnancy being associated with an increased risk of offspring tobacco use in later life. There is also evidence from animal models indicating that fetal exposure to maternal nicotine use in utero can have a durable impact on the neural pathways that affect lifetime sensitivity to nicotine. This is an important research topic that continues to yield a consistent signal despite an array of inferential challenges.