'If you are found taking medicine, you will be called names and considered less of a man': young men's engagement with HIV treatment and care during ulwaluko (traditional initiation and circumcision) in the Eastern Cape Province of South Africa

This paper explores how HIV-positive abakhwetha (young male initiates) undergoing ulwaluko (traditional Xhosa initiation and circumcision) engage with HIV-related biomedical care and treatment. Health-focused life history narratives (n = 36), semi-structured interviews (n = 32) and analysis of health facility files (n = 41) with adolescent boys and young men (ages 13-24) living with HIV, and semi-structured interviews with traditional and biomedical health practitioners (n = 14) were conducted in 2017 and 2018. This research was part of the Mzantsi Wakho study, a longitudinal, mixed methods study of adolescents living with HIV (n = 1060). Findings demonstrate that ulwaluko rules of not engaging with biomedical care and treatment pose a challenge for initiates who are taking chronic medicine. Fears of inadvertent disclosure of their HIV-positive status collide with the pressure to successfully complete ulwaluko in order to be legitimised as men. In response to this dilemma, they engage a variety of strategies - including taking medicine in secret by hiding them, having a trusted person deliver them discretely, and stopping medicine-taking altogether. The three months following ulwaluko also pose a challenge in accessing biomedical treatment and care. In this time of high surveillance, amakrwala (new men) do not present at health facilities for fear of being thought to have had a botched circumcision or to have contravened 'manhood rules' and left ulwaluko before having healed properly. To get around this, those who continued taking medicine engaged caregiver pick-ups. Beyond suggesting that ulwaluko is a high-risk time for disengagement from biomedical treatment and care, this paper builds on a robust scholarship on the importance of locality and context in gender and health research. It documents the creativity, agency and resilience of initiates and their families as they subvert and re-signify health-related masculine norms.

Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa?

Low ART-adherence amongst adolescents is associated with morbidity, mortality and onward HIV transmission. Reviews find no effective adolescent adherence-promoting interventions. Social protection has demonstrated benefits for adolescents, and could potentially improve ART-adherence. This study examines associations of 10 social protection provisions with adherence in a large community-based sample of HIV-positive adolescents. All 10–19-year-olds ever ART-initiated in 53 government healthcare facilities in a health district of South Africa’s Eastern Cape were traced and interviewed in 2014–2015 (n = 1175 eligible). About 90% of the eligible sample was included (n = 1059). Social protection provisions were “cash/cash in kind”: government cash transfers, food security, school fees/materials, school feeding, clothing; and “care”: HIV support group, sports groups, choir/art groups, positive parenting and parental supervision/monitoring. Analyses used multivariate regression, interaction and marginal effects models in SPSS and STATA, controlling for socio-demographic, HIV and healthcare-related covariates. Findings showed 36% self-reported past-week ART non-adherence (<95%). Non-adherence was associated with increased opportunistic infections (p = .005, B .269, SD .09), and increased likelihood of detectable viral load at last test (>75 copies/ml) (aOR 1.98, CI 1.1–3.45). Independent of covariates, three social protection provisions were associated with reduced non-adherence: food provision (aOR .57, CI .42–.76, p < .001); HIV support group attendance (aOR .60, CI .40–.91, p < .02), and high parental/caregiver supervision (aOR .56, CI .43–.73, p < .001). Combination social protection showed additive benefits. With no social protection, non-adherence was 54%, with any one protection 39–41%, with any two social protections, 27–28% and with all three social protections, 18%. These results demonstrate that social protection provisions, particularly combinations of “cash plus care”, may improve adolescent adherence. Through this they have potential to improve survival and wellbeing, to prevent HIV transmission, and to advance treatment equity for HIV-positive adolescents.

Cutting edge: antigen-dependent regulation of telomerase activity in murine T cells

Telomeres, structures on the ends of linear chromosomes, function to maintain chromosomal integrity. Telomere shortening occurs with cell division and provides a mechanism for limiting the replicative potential of normal human somatic cells. Telomerase, a ribonucleoprotein enzyme, synthesizes telomeric repeats on chromosomal termini, potentially extending the capacity for cell division. The present study demonstrates that resting T cells express little/no activity, and optimal Ag-specific induction of telomerase activity in vitro requires both TCR and CD28-B7 costimulatory signals. Regulation of telomerase in T cells during in vivo Ag-dependent activation was also assessed by adoptive transfer of TCR transgenic T cells and subsequent Ag challenge. Under these conditions, telomerase was induced in transgenic T cells coincident with a phase of extensive clonal expansion. These findings suggest that telomerase may represent an adoptive response that functions to preserve replicative potential in Ag-reactive lymphocytes.

Cross-cultural medicine and diverse health beliefs. Ethiopians abroad

A large number of Ethiopians reside abroad as refugees, immigrants, or students. To provide adequate care, physicians must understand their beliefs about health and medicine. To Ethiopians, health is an equilibrium between the body and the outside. Excess sun is believed to cause mitch ("sunstroke"), leading to skin disease. Blowing winds are thought to cause pain wherever they hit. Sexually transmitted disease is attributed to urinating under a full moon. People with buda, "evil eye," are said to be able to harm others by looking at them. Ethiopians often complain of rasehn, "my head" (often saying it burns); yazorehnyal, "spinning" (not a true vertigo); and libehn, "my heart" (usually indicating dyspepsia rather than a cardiac problem). Most Ethiopians have faith in traditional healers and procedures. In children, uvulectomy (to prevent presumed suffocation during pharyngitis in babies), the extraction of lower incisors (to prevent diarrhea), and the incision of eyelids (to prevent or cure conjunctivitis) are common. Circumcision is performed on almost all men and 90% of women. Ethiopians do bloodletting for moygnbagegn, a neurologic disease that includes fever and syncope. Chest pain is treated by cupping. Ethiopians often prefer injections to tablets. Bad news is usually given to families of patients and not the patients themselves. Zar is a form of spirit possession treated by a traditional healer negotiating with the alien spirit and giving gifts to the possessed patient. Health education must address Ethiopian concerns and customs.

Meningococcal meningitis in patients with falciparum malaria

Between October 1994 and January 1995 a field hospital saw nine cases of falciparum malaria associated with meningococcal meningitis among Rwandan patients residing in Kibumba refugee camp in Goma, Zaire. All except one presented with signs and symptoms suggestive of meningeal irritation; all but one responded to intravenous quinine and chloramphenicol or ampicillin. Two had recrudescence of malaria and responded to treatment with pyrimethamine-sulphadoxine (Fansidar). There were no sequelae seen. Meningococcal meningitis is uncommon but frequently fatal if it occurs in patients with falciparum malaria. Early diagnosis and treatment are urgent to decrease morbidity and mortality.

Sensitivity of Plasmodium falciparum in vivo to chloroquine and pyrimethamine-sulfadoxine in Rwandan patients in a refugee camp in Zaire

Resistance of Plasmodium falciparum to available antimalarial drugs is now thought to be spreading progressively throughout sub-Sahara Africa. In this study we measured the susceptibility of P. falciparum to chloroquine and pyrimethamine-sulfadoxine in vivo in Rwandan patients living in Kibumba refugee camp in Goma, Zaire. Of the 39 cases treated with chloroquine, only 8 (20.5%) showed sensitive or RI (delayed) response and 31 (79.5%) demonstrated resistance at RI (30.8%), RII (33.3%( and RIII (15.4%) levels. Of the 38 individuals receiving pyrimethamine-sulfadoxine, 13 (34.2%) showed sensitive or RI (delayed) responses, and 25 (65.%) showed resistance at RI (26.3%), RII (36.8%) and RIII (2.6%) levels. Both chloroquine and pyrimethamine-sulfadoxine reduced parasite counts by at least 75% in the majority of the patients within 2 d of treatment. A greater proportion of children with malnutrition showed a higher mean geometric parasite density and slower parasite clearance in vivo than those without malnutrition. Moreover, the frequency and degree of resistance were more pronounced in children with malnutrition. Moreover, the frequency and degree of resistance were more pronounced in children with malnutrition. The results suggest the existence of resistance to chloroquine and pyrimethamine-sulfadoxine. However, the drugs are still effective in significantly reducing parasitaemia and they can still be used as drugs of first and second choice in the region, even in the face of some degree of resistance.

Cellular interaction in germinal centers. Roles of CD40 ligand and B7-2 in established germinal centers

Costimulatory interactions between T and B lymphocytes are crucial for T cell activation and B cell proliferation and differentiation. We have compared the roles of CD40L and B7-2 in the initiation and maturation of humoral immunity by administering anti-CD40 ligand (L) or anti-B7-2 Ab during the early (days -1 to 3) or late (days 6-10) phases of primary responses to thymus-dependent (Td) and -independent (Ti) Ags. Germinal center (GC) formation in response to a Td Ag was inhibited completely by the early administration of anti-CD40L or anti-B7-2 Abs. Later in the response, established GCs remained sensitive to anti-CD40L but were resistant to treatment with anti-B7-2. However, Ig hypermutation was reduced dramatically in GCs of anti-B7-2-treated mice and humoral memory was impaired. Early administration of anti-CD40L reduced serum Ab levels to approximately 10% of controls, whereas early treatment with anti-B7-2 reduced Ab production by only 50%. Later treatments with either Ab had no effect on Ab production. Response to a type II Ti Ag was more resistant than Td responses to interruption of costimulatory interactions. Our findings suggest that the costimulatory roles of CD40:CD40L and B7-2:CD28/CTLA-4 differ in the GC; administration of anti-CD40L abrogates an established GC reaction, whereas Ab to B7-2 suppresses Ig hypermutation and entry into the B cell memory compartment. Once B cells have entered the differentiation pathway to Ab production, neither CD40L nor B7-2 is necessary for their continued differentiation and persistence.

Cellular interaction in germinal centers. Roles of CD40 ligand and B7-2 in established germinal centers

Costimulatory interactions between T and B lymphocytes are crucial for T cell activation and B cell proliferation and differentiation. We have compared the roles of CD40L and B7-2 in the initiation and maturation of humoral immunity by administering anti-CD40 ligand (L) or anti-B7-2 Ab during the early (days -1 to 3) or late (days 6-10) phases of primary responses to thymus-dependent (Td) and -independent (Ti) Ags. Germinal center (GC) formation in response to a Td Ag was inhibited completely by the early administration of anti-CD40L or anti-B7-2 Abs. Later in the response, established GCs remained sensitive to anti-CD40L but were resistant to treatment with anti-B7-2. However, Ig hypermutation was reduced dramatically in GCs of anti-B7-2-treated mice and humoral memory was impaired. Early administration of anti-CD40L reduced serum Ab levels to approximately 10% of controls, whereas early treatment with anti-B7-2 reduced Ab production by only 50%. Later treatments with either Ab had no effect on Ab production. Response to a type II Ti Ag was more resistant than Td responses to interruption of costimulatory interactions. Our findings suggest that the costimulatory roles of CD40:CD40L and B7-2:CD28/CTLA-4 differ in the GC; administration of anti-CD40L abrogates an established GC reaction, whereas Ab to B7-2 suppresses Ig hypermutation and entry into the B cell memory compartment. Once B cells have entered the differentiation pathway to Ab production, neither CD40L nor B7-2 is necessary for their continued differentiation and persistence.

Expression of B7 costimulator molecules on mouse dendritic cells

Dendritic cells express most known accessory molecules [ICAM's, LFA's, B7's, and CD40] for binding and stimulating T cells. B7 is the most abundant of these, and B7-2 very much predominates relative to B7-1. B7 expression is regulated, not by LPS, but by some signal [s] that parallels maturation. B7 contributes to the T cell stimulatory function of dendritic cells, as do the other accessory molecules. B7-2 is expressed on dendritic cells and macrophages at several sites in situ, especially dendritic cells in the T cell areas.

Structure and expression of class I MHC genes in the miniature swine

The genome of the miniature swine, unlike other species, contains a relatively small class I MHC gene family, consisting of only seven members. This provides an excellent system in which to identify and characterize the regulatory mechanisms which operate to both coordinately and differentially regulate the expression of a multi-gene family. The structure of class I SLA genes, like other class I genes, consists of eight exons encoding a leader sequence, three extracytoplasmic domains, a transmembrane domain and intracytoplasmic domains. Despite the common structure, two sub-families of class I genes can be distinguished within the SLA family. One, containing the closely related PD1 and PD14 genes, encodes the classical transplantation antigens. Another contains the highly divergent PD6; the functions of the products of this subfamily, if any, are not known. The class I SLA genes share some common regulatory mechanisms, as evidenced by the fact that all three genes analyzed are transcribed in mouse L cells. Furthermore, interferon treatment of transfected mouse L cells enhances expression of all three genes. Both PD1 and PD6 are transcribed in vivo, where the highest levels of expression are observed in lymphoid tissues. Superimposed on the common patterns of class I gene expression are distinct ones, as evidenced by the findings that PD1 is preferentially expressed in B cells, whereas PD6 is preferentially expressed in T cells. These differences may reflect the extensive divergence of the 5' flanking sequences of these genes. Future studies will be aimed at elucidating the precise molecular interactions and mechanisms which give rise to the observed differential expression.

Secretory processes in lymphocyte function

The secretion of immunoglobulin by plasma cells has been considered a classical example of the "non-regulated" pathway of protein secretion, in which newly synthesized protein is processed by the Golgi, packaged into small vesicles, and immediately secreted without intracellular storage. In the case of lymphokine secretion by T lymphocytes, it is generally not clear whether this non-regulated pathway is also being used, as opposed to the "regulated" pathway which has been proposed to operate in the cytotoxic lymphocyte mechanism. In this case, as in mast cells and endocrine cells, proteins are synthesized and then stored in cytoplasmic granules. The secretion is triggered (regulated) by a membrane receptor-ligand interaction, which for the cytotoxic lymphocytes is part of the target cell binding process. In cytotoxic T lymphocytes, this secretion process can be measured by following the appearance of a granule serine protease in the medium, and it has been shown to be triggered by target cells or by immobilized antibodies which bind the T cell receptor complex. In addition to cytotoxic lymphocytes, cloned T helper cells contain this serine protease in cytoplasmic granules with a low internal pH. Helper lymphocytes secrete this enzyme in response to (1) soluble antigen which has been processed by cells bearing the appropriate MHC antigens; (2) immobilized antibodies against the T cell receptor complex; (3) a combination of phorbol ester and calcium ionophore. Thus in both helper and cytotoxic lymphocytes, the regulated pathway of protein secretion clearly operates after triggering by the T cell antigen receptor.

Use of biofeedback training in treatment of Raynaud's disease and phenomenon

To assess biofeedback training in Raynaud's, we retrospectively reviewed 23 patients' records. Eleven had Raynaud's disease and 12 had Raynaud's phenomenon; 9 had recurrent digital ulcers. Patients demonstrated lower baseline digital temperatures than controls (p less than or equal to 0.001), patients with Raynaud's and scleroderma manifesting the lowest. After biofeedback training all patients elevated baseline temperatures. Patients with scleroderma and systemic lupus erythematosus had the greatest elevations. Improvement, both subjective (57%) and ulcers (44%), persisted one year after treatment. Four of 7 patients were capable of elevating digital temperatures within 5 min, 18 months after their last training session. These findings support biofeedback training as beneficial therapy in Raynaud's.

Strategies of arousal control: biofeedback, meditation, and motivation

A series of four experiments assessed the effects of instructions to lower heart rate on heart rate change and general arousal reduction. Various conditions of biofeedback, cognitive load, incentive, knowledge of results, and the experimenter-subject relationship were tested. Experiment 1 compared physiological responses to the delivery of direct organ feedback (i.e., heart rate) with responses to electromyographic biofeedback from the frontalis muscle area and with responses to a nonfeedback tracking task. The results suggest that neither heart rate nor muscle tension feedback is an especially powerful method for achieving sustained reductions in heart rate. Furthermore, although some specificity of physiologic pattern is apparent, biofeedback is no more effective in lowering general activation level than simple instructions to relax accompanied by a general knowledge of results. The second experiment was designed to assess the role of cognitive load in arousal reduction. Heart rate biofeedback was compared with a procedure involving minimal external information processing--the secular meditation exercise of Wallace and Benson. The results indicated a clear superiority for the meditation strategy in effecting reductions in cardiac rate and lowering activation. However, in a third experiment, meditation subjects lowered heart rate much less than observed in the previous study, and this time the reduction did not exceed that achieved by feedback subjects. Subsequent analysis suggested that the quality of the subject-experimenter relationship (active-supportive vs. formal-distant) was a significant variable in accounting for outcome differences. The above hypothesis was supported by a fourth experiment. Under conditions of high subject-experimenter involvement, the superior meditation performance of Experiment 2 was reproduced; under low-involvement conditions the Experiment 3 result of no difference between training groups was obtained. The findings suggest that the effectiveness of any method for achieving relaxation (or physiological control) rests on a complex interaction between informational and motivational imperatives of the stimulus context and definable aspects of the interpersonal exchange between subject and experimenter. This research raises serious questions about the effectiveness of the usual biofeedback paradigm as an aid to arousal reduction and the cost efficiency of its applications in the clinical situation. Furthermore, these results demonstrate the great power in relaxation experiments of psychosocial and other moderator variables, and signal the practical difficulty of their control when these variables appear to be as potent in changing physiology as the primary training methods.