Challenges faced by medical officers in providing healthcare services at upazila health complexes and district hospitals in Bangladesh - a qualitative study.

Background: Upazila Health Complexes (UHCs) and District Hospitals (DHs) play a crucial role in the healthcare delivery system of Bangladesh. But very few research has been conducted to find out the prevailing challenges of the medical officers working in these tiers. The objective of the study was to identify the challenges faced by medical officers in providing healthcare services at UHCs and DHs. Methods: In-depth interviews of 51 medical officers from 17 UHCs and nine DHs were done between March and April 2021. All participants were purposively sampled. Data were transcribed verbatim and analysed using thematic analysis. Findings: Inadequate service rooms, unavailability of proper medical equipment, poor housing conditions, lack of public amenities, shortage of health workforce, lack of laboratory services, and excessive workload were the common challenges mentioned by the medical officers in providing healthcare services in UHCs and DHs. Lack of workplace safety, security, and undue pressure from local political leaders and journalists made the work environment fearful. The absence of proper implementation of policy related to higher education, posting, transfer, and promotion was also stated as challenge for the medical officers. Interpretation: Infrastructural improvements along with increased safety and security of the doctors at their workplace and transparent implementation of reformed policies are essential to reduce the workplace challenges of medical officers in UHCs and DHs of Bangladesh. Funding: The study was funded by Hospital Services Management, Directorate General Of Health Services (DGHS), Mohakhali, Dhaka, and Bangabandhu Sheikh Mujib Medical University.

Switching to Dolutegravir/Lamivudine Two-Drug Regimen: Durability and Virologic Outcomes by Age, Sex, and Race in Routine US Clinical Care.

Purpose: Two-drug regimens (2DR) may address drug-drug interactions and toxicity concerns. Dolutegravir/lamivudine (DTG/3TC) 2DR was approved in the US for both treatment-naïve and treatment-experienced individuals with a viral load <50 copies/mL. This study describes real-world DTG/3TC 2DR treatment outcomes among treatment-experienced individuals, stratified by age, sex, and race. Methods: From the OPERA® cohort, people with HIV with a viral load <50 copies/mL who switched from a commonly used three-drug regimen to DTG/3TC 2DR as per the label between April 8, 2019 and April 30, 2021 were included. Incidence rates (Poisson regression) for loss of virologic control (first viral load ≥50 copies/mL), confirmed virologic failure (2 viral loads ≥200 copies/mL or discontinuation after 1 viral load ≥200 copies/mL), and DTG/3TC 2DR discontinuation were estimated overall and stratified by age, sex, and race. Results: The 787 individuals included were followed for a median of 13.6 months (IQR: 8.2, 22.3). Confirmed virologic failure occurred in ≤5 individuals. Loss of virologic control occurred at a rate of 14.0 per 100 person-years (95% CI: 11.7, 16.8). DTG/3TC 2DR discontinuation occurred at a rate of 17.5 per 100 person-years (95% CI: 15.0, 20.3); 4% discontinued for treatment-related reasons (viremia, adverse diagnosis, side effect, lab abnormality). For all outcomes, incidence rates were comparable across strata of age, sex, and race. Conclusion: This descriptive study demonstrates that DTG/3TC 2DR is an effective and well-tolerated treatment option for people with HIV with a viral load <50 copies/mL at switch, regardless of their age, sex, or race.

Willingness and preferences for long-acting injectable PrEP among US men who have sex with men: a discrete choice experiment.

INTRODUCTION: Cabotegravir long-acting injectable HIV pre-exposure prophylaxis (LA-PrEP) was shown to be safe and effective in multiple clinical trials. Increasing uptake and persistence among populations with elevated risk for HIV acquisition, especially among men who have sex with men (MSM), is critical to HIV prevention. OBJECTIVE: This analysis aims to understand potential users' preferences for LA-PrEP, with audience segmentation. DESIGN: Willingness to use and preferences for LA-PrEP were measured in HIV-negative, sexually active MSM in the 2020 American Men's Internet Survey. Respondents answered a discrete choice experiment with paired profiles of hypothetical LA-PrEP characteristics with an opt-out option (no LA-PrEP). Conditional and mixed logit models were run; the final model was a dummy-coded mixed logit that interacted with the opt-out. SETTING: US national online sample. RESULTS: Among 2506 MSM respondents, most (75%) indicated a willingness to use LA-PrEP versus daily oral PrEP versus no PrEP. Respondents were averse to side effects and increasing costs and preferred increasing levels of protection. Respondents preferred a 2-hour time to obtain LA-PrEP vs 1 hour, with a strong aversion to 3 hours. Overall, there was an aversion to opting out of LA-PrEP, with variations: those with only one partner, no/other insurance or who were Black, Indigenous or People of Colour were significantly less likely to prefer LA-PrEP, while those who were Hispanic/Latino, college educated and <40 years significantly preferred LA-PrEP. CONCLUSIONS: A large proportion of MSM expressed a preference for LA-PrEP over daily oral pills. Most respondents chose LA-PrEP regardless of cost, clinic time, side effects or protection level; however, preferences varied by sociodemographics. These varied groups likely require tailored intervention strategies to achieve maximum LA-PrEP uptake and persistence.

Evaluation of feasibility phase of adaptive version of locally made bubble continuous positive airway pressure oxygen therapy for the treatment of COVID-19 positive and negative adults with severe pneumonia and hypoxaemia.

Background: Bubble continuous positive airway pressure (bCPAP) oxygen therapy has been shown to be safe and effective in treating children with severe pneumonia and hypoxaemia in Bangladesh. Due to lack of adequate non-invasive ventilatory support during coronavirus disease 2019 (COVID-19) crisis, we aimed to evaluate whether bCPAP was safe and feasible when adapted for use in adults with similar indications. Methods: Adults (18-64 years) with severe pneumonia and moderate hypoxaemia (80 to <90% oxygen saturation (SpO2) in room air) were provided bCPAP via nasal cannula at a flow rate of 10 litres per minute (l/min) oxygen at 10 centimetres (cm) H2O pressure, in two tertiary hospitals in Dhaka, Bangladesh. Qualitative interviews and focus group discussions, using a descriptive phenomenological approach, were performed with patients and staff (n = 39) prior to and after the introduction (n = 12 and n = 27 respectively) to understand the operational challenges to the introduction of bCPAP. Results: We enrolled 30 adults (median age 52, interquartile range (IQR) 40-60 years) with severe pneumonia and hypoxaemia and/or acute respiratory distress syndrome (ARDS) irrespective of coronavirus disease 2019 (COVID-19) test results to receive bCPAP. At baseline mean SpO2 on room air was 87% (±2) which increased to 98% (±2), after initiation of bCPAP. The mean duration of bCPAP oxygen therapy was 14.4 ± 24.8 hours. There were no adverse events of note, and no treatment failure or deaths. Operational challenges to the clinical introduction of bCPAP were lack of functioning pulse oximeters, difficult nasal interface fixation among those wearing nose pin, occasional auto bubbling or lack of bubbling in water-filled plastic bottle, lack of holder for water-filled plastic bottle, rapid turnover of trained clinicians at the hospitals, and limited routine care of patients by hospital clinicians particularly after official hours. Discussion: If the tertiary hospitals in Bangladesh are supplied with well-functioning good quality pulse oximeters and enhanced training of the doctors and nurses on proper use of adapted version of bCPAP, in treating adults with severe pneumonia and hypoxaemia with or without ARDS, the bCPAP was found to be safe, well tolerated and not associated with treatment failure across all study participants. These observations increase the confidence level of the investigators to consider a future efficacy trial of adaptive bCPAP oxygen therapy compared to WHO standard low flow oxygen therapy in such patients. Conclusion: s Although bCPAP oxygen therapy was found to be safe and feasible in this pilot study, several challenges were identified that need to be taken into account when planning a definitive clinical trial.

Variation in Preferences for Long-Acting Injectable Pre-Exposure Prophylaxis Among US Men Who Have Sex with Men: A Latent Class Analysis.

Cabotegravir long-acting injectable HIV pre-exposure prophylaxis (LA PrEP) is efficacious, with a good safety profile, and was approved by the US Food and Drug Administration in December 2021. Understanding variations in potential user preferences for LA PrEP may inform implementation and subsequently improve uptake and community-level effectiveness. HIV-negative, sexually active men who have sex with men (MSM) aged ≥15 years were recruited online for the 2019 American Men's Internet Survey, before LA PrEP approval. Respondents completed a discrete-choice experiment (DCE) with hypothetical LA PrEP attributes (out-of-pocket cost, perceived side effects, injection frequency, perceived stigma, service location). Latent class analysis segmented respondents into groups based on their preferences for the attributes presented, and relative importance of preference weights and willingness-to-pay were calculated. While the majority had never used daily oral PrEP, 73% of the 2489 respondents were very or somewhat likely to use LA PrEP. Three latent classes were identified from 2241 respondents in the DCE. The "side effects-averse" class was the largest group (64% of respondents) and placed 61% relative importance on side effects. The "ambivalent" class (20% of respondents) placed higher importance on stigma (17% of relative importance) than other classes. The "cost-conscious" class (16% of respondents) placed higher relative importance (62%) on cost compared with other attributes and classes. Perceived side effects were an important hypothetical barrier for LA PrEP uptake among a large proportion of potential MSM users. Minimizing out-of-pocket costs is likely to increase uptake and may be important to equitable access. Tailored communication strategies are recommended for the different groups of potential LA PrEP users.

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method.

Background: Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh. Methods: We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh. Results: Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh. Conclusions: This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Feasibility and acceptability of bubble continuous positive airway pressure oxygen therapy for the treatment of childhood severe pneumonia and hypoxaemia in Bangladeshi children.

Background: Effective management of hypoxaemia is key to reducing pneumonia deaths in children. In an intensive care setting within a tertiary hospital in Bangladesh, bubble continuous positive airway pressure (bCPAP) oxygen therapy was beneficial in reducing deaths in this population. To inform a future trial, we investigated the feasibility of introducing bCPAP in this population in non-tertiary/district hospitals in Bangladesh. Methods: We conducted a qualitative assessment using a descriptive phenomenological approach to understand the structural and functional capacity of the non-tertiary hospitals (Institute of Child and Mother Health and Kushtia General Hospital) for the clinical use of bCPAP. We conducted interviews and focus group discussions (23 nurses, seven physicians, 14 parents). We retrospectively (12 months) and prospectively (three months) measured the prevalence of severe pneumonia and hypoxaemia in children attending the two study sites. For the feasibility phase, we enrolled 20 patients with severe pneumonia (age two to 24 months) to receive bCPAP, putting in place safeguards to identify risk. Results: Retrospectively, while 747 of 3012 (24.8%) children had a diagnosis of severe pneumonia, no pulse oxygen saturation information was available. Of 3008 children prospectively assessed with pulse oximetry when attending the two sites, 81 (3.7%) had severe pneumonia and hypoxaemia. The main structural challenges to implementation were the inadequate number of pulse oximeters, lack of power generator backup, high patient load with an inadequate number of hospital staff, and inadequate and non-functioning oxygen flow meters. Functional challenges were the rapid turnover of trained clinicians in the hospitals, limited post-admission routine care for in-patients by hospital clinicians due to their extreme workload (particularly after official hours). The study implemented a minimum of four hourly clinical reviews and provided oxygen concentrators (with backup oxygen cylinders), and automatic power generator backup. Twenty children with a mean age of 6.7 (standard deviation (SD) = 5.0)) months with severe pneumonia and hypoxaemia (median (md) SpO2 = 87% in room air, interquartile range (IQR) = 85-88)) with cough (100%) and severe respiratory difficulties (100%) received bCPAP oxygen therapy for a median of 16 hours (IQR = 6-16). There were no treatment failures or deaths. Conclusions: Implementation of low-cost bCPAP oxygen therapy is feasible in non-tertiary/district hospitals when additional training and resources are allocated.

Emerging Strategies in Stimuli-Responsive Silk Architectures.

The utilization of implantable devices beseeches highly invasive surgeries considering the adversaries in the insertion of large, impliable devices through the body channels, which necessitate the development of implantable devices using biocompatible shape memory polymers. Silk displays prodigious heterogeneity in its genetic structure and physical properties in accordance with the spinning and storage process, where proteins undergo folding and unfolding. The stimuli-responsive nature of silk can be explained with the help of the structural morphology and composition of the material, where the hydrogen bonds in ß-sheet domains and amorphous region act as switch points and net points, respectively. This review provides a primary attempt to enswathe all the literature available to date on the stimuli-responsive nature of silk and silk-based materials as a natural and biodegradable alternative for commercially used synthetic shape memory materials taking their elastomeric nature and reduction in glass transition temperature into account. Further constitutive model using the continuum approach has been utilized to explain the anisotropic elasticity damping effect and plastic deformation based on the α-helix chains, ß-sheets, and ß-spiral structures. The practicability to develop biomedical devices such as patient-specific-injectable scaffolds, drug carriers, and artificial muscles has been encompassed in this article.

Epidemiology beyond its limits.

In 1995, journalist Gary Taubes published an article in Science titled "Epidemiology faces its limits," which questioned the utility of nonrandomized epidemiologic research and has since been cited more than 1000 times. He highlighted numerous examples of research topics he viewed as having questionable merit. Studies have since accumulated for these associations. We systematically evaluated current evidence of 53 example associations discussed in the article. Approximately one-quarter of those presented as doubtful are now widely viewed as causal based on current evaluations of the public health consensus. They include associations between alcohol consumption and breast cancer, residential radon exposure and lung cancer, and the use of tanning devices and melanoma. This history should inform current debates about the reproducibility of epidemiologic research results.

Influence of yellow gypsum on nutrient uptake and yield of groundnut in different acid soils of Southern India.

Yellow gypsum (YG), a synthetic product from Linz-Donawitz slag containing high iron (Fe) (5.41%), zinc (Zn) (0.37%) and silicon (Si) (3.41%) can be used as a source of these nutrients along with calcium (Ca) and sulphur (S) for groundnut production. Three field experiments were conducted to know the effect of different rates (500 and 625 kg YG ha-1) and time of application (basal alone and basal + split) of YG on growth, yield and economic returns of groundnut, and micronutrient and Si availability and their uptake in comparison with basal application of 500 kg natural gypsum (NG) ha-1. Basal alone and basal + split application of YG significantly increased the growth, yield and economic returns of groundnut. Further, it increased the soil pH, availability of micronutrients, Si and their uptake by haulm and kernel of groundnut over NG. Irrespective of the location, YG application recorded higher plant available nutrient (PAN) coefficient of micronutrients, while NG application recorded higher PAN recovery coefficient of Si. Basal + split application of YG resulted in better growth and yield of groundnut than basal application of YG. In conclusion, YG can be a potential alternative for NG as a source of Fe, Zn and Si along with Ca and S for groundnut production.

Algal treatment of membrane rejects: a unique approach towards zero liquid discharge.

A major concern in membrane-based water purification system is generation of huge concentrate stream and wastage of water. A typical Reverse osmosis (RO) or Nanofiltration (NF) system generates 20-25% reject containing high amount of dissolved salts and other contaminants. Contrary to popular belief, this reject water cannot be used without removing the contaminants or cannot be discharged anywhere. Main goal of this project is to find a cheapest and green way for treatment of RO/NF reject. Algal evaporation technique was explored in laboratory scale, to find its suitability for treatment of chloride-rich membrane reject in actual scenario and based on the results obtained, a pilot plant of 48KL was established on Hooghly Met Coke division (HMC), Tata Steel. Particular species of microalgae was selected, to take up minerals from reject water. There are several types of bacteria and symbiotic algae associated with selected micro algae survive in high TDS. A unique slope roof system, connected with algae growth tank, helps in efficient evaporation of water ensuring a Zero discharge. A markedly improved performance was achieved when algal evaporation followed solar evaporation. A total evaporation of 11 L/m2/day was observed, which was almost five times faster than Solar evaporation.

Algae based evaporation technology was explored to find its suitability for treatment of high chloride-based membrane reject. Specific Species of microalgae, which can take up minerals from reject water was selected.Based on algal evaporation, a pilot plant of 48 KL was established on Hooghly Met Coke division (HMC), Tata Steel India site.Rate of evaporation 11 L/m²/day was observed, which was almost five times faster than solar evaporation.

Application of coke breeze for removal of colour from coke plant wastewater.

Treatment of coking waste water has always been a challenge because of its complex and toxic nature. Numbers of technologies like biological treatment, advanced oxidation processes, activated carbon treatment etc. are available for removal of color and organic contaminants from wastewater. However, challenges and problems associated with application of biological, advanced oxidation methods for removal of color, chemical oxygen demand (COD), cyanides led to thrust for the development of new promising technologies. In this study, the application of coke breeze for the treatment of wastewater through adsorption has been demonstrated. A pseudo second order reaction kinetics has been observed through batch process adsorption study. Furthermore, adsorption data has found to be best fitted with the Freundlich adsorption isotherm model. Color removal efficiency of 80-90% along with COD removal efficiency of 40-50% was observed within 30 min by 120 g/L dosage of the adsorbent. The removal of phenolic and other organic compounds from coking wastewater has been measured through UV-Vis spectroscopy. The morphological changes of the adsorbent coke breeze have been captured through scanning electron microscopy (SEM) and energy dispersive X-ray (EDX) analysis. However, because of the significant abundance in the steel plant, cost effectiveness and applicability of the post-treated coke breeze in sintered plant as fuel, turn it into a suitable adsorbent despite of having much lower specific surface area compared to commercial activated carbon (AC). Therefore, application of the coke breeze turns it into a very promising material and the technique is sustainable towards the coke quenching effluent treatment.

Comparative characterization of cyanide-containing steel industrial wastewater.

In the steel industry, cyanide in the wastewater is a major environmental concern. There are several chemical, physical, and biological treatment processes available for the removal of cyanide from industrial wastewater. But the efficacy of every treatment process depends on the complex elemental matrix of wastewater and the interference associated with them. Thus, water characterization plays a vital part in finding a suitable cyanide treatment process for any wastewater. Characterization data can give a clear overview of the complexity of cyanide in the wastewater, which ultimately helps in selecting the right remediation process. The present work includes comparative characterization of coke plant and blast furnace wastewater collected from an integrated steel plant. Three months of data for physico-chemical properties of the two different sources were analysed and compared. Pearson's correlation analysis of physico-chemical properties with free cyanide was also studied. The different forms of cyanide in coke plant and blast furnace water were also characterised, along with interference associated with them. It was observed that the water matrix of coke plant and blast furnace effluents are totally different. It was also evident that free cyanide concentration is much more affected in coke plant wastewater than in blast furnace water.

Projected Impact of Concurrently Available Long-Acting Injectable and Daily-Oral Human Immunodeficiency Virus Preexposure Prophylaxis: A Mathematical Model.

BACKGROUND: Long-acting injectable (LAI) human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) is reportedly efficacious, although full trial results have not been published. We used a dynamic network model of HIV transmission among men who have sex with men to assess the population impact of LAI-PrEP when available concurrently with daily-oral (DO) PrEP. METHODS: The reference model represents the current HIV epidemiology and DO-PrEP coverage (15% among those with behavioral indications for PrEP) among men who have sex with men in the southeastern United States. Primary analyses investigated varied PrEP uptake and proportion selecting LAI-PrEP. Secondary analyses evaluated uncertainty in pharmacokinetic efficacy and LAI-PrEP persistence relative to DO-PrEP. RESULTS: Compared with the reference scenario, if 50% chose LAI-PrEP, 4.3% (95% simulation interval, -7.3% to 14.5%) of infections would be averted over 10 years. The impact of LAI-PrEP is slightly greater than that of the DO-PrEP-only regimen, based on assumptions of higher adherence and partial protection after discontinuation. If the total PrEP initiation rate doubled, 17.1% (95% simulation interval, 6.7%-26.4%) of infections would be averted. The highest population-level impact occurred when LAI-PrEP uptake and persistence improved. CONCLUSIONS: If LAI-PrEP replaces DO-PrEP, its availability will modestly improve the population impact. LAI-PrEP will make a more substantial impact if its availability drives higher total PrEP coverage, or if persistence is greater for LAI-PrEP.

Impact along the HIV pre-exposure prophylaxis "cascade of prevention" in western Kenya: a mathematical modelling study.

INTRODUCTION: Over one hundred implementation studies of HIV pre-exposure prophylaxis (PrEP) are completed, underway or planned. We synthesized evidence from these studies to inform mathematical modelling of the prevention cascade for oral and long-acting PrEP in the setting of western Kenya, one of the world's most heavily HIV-affected regions. METHODS: We incorporated steps of the PrEP prevention cascade - uptake, adherence, retention and re-engagement after discontinuation - into EMOD-HIV, an open-source transmission model calibrated to the demography and HIV epidemic patterns of western Kenya. Early PrEP implementation research from East Africa was used to parameterize prevention cascades for oral PrEP as currently implemented, delivery innovations for oral PrEP, and future long-acting PrEP. We compared infections averted by PrEP at the population level for different cascade assumptions and sub-populations on PrEP. Analyses were conducted over the 2020 to 2040 time horizon, with additional sensitivity analyses for the time horizon of analysis and the time when long-acting PrEP becomes available. RESULTS: The maximum impact of oral PrEP diminished by over 98% across all prevention cascades, with the exception of long-acting PrEP under optimistic assumptions about uptake and re-engagement after discontinuation. Long-acting PrEP had the highest population-level impact, even after accounting for possible delays in product availability, primarily because its effectiveness does not depend on drug adherence. Retention was the most significant cascade step reducing the potential impact of long-acting PrEP. These results were robust to assumptions about the sub-populations receiving PrEP, but were highly influenced by assumptions about re-initiation of PrEP after discontinuation, about which evidence was sparse. CONCLUSIONS: Implementation challenges along the prevention cascade compound to diminish the population-level impact of oral PrEP. Long-acting PrEP is expected to be less impacted by user uptake and adherence, but it is instead dependent on product availability in the short term and retention in the long term. To maximize the impact of long-acting PrEP, ensuring timely product approval and rollout is critical. Research is needed on strategies to improve retention and patterns of PrEP re-initiation.

Cost-effectiveness of integrated HIV prevention and family planning services for Zambian couples.

OBJECTIVE: To present the incremental cost from the payer's perspective and effectiveness of couples' family planning counseling (CFPC) with long-acting reversible contraception (LARC) access integrated with couples' voluntary HIV counseling and testing (CVCT) in Zambia. This integrated program is evaluated incremental to existing individual HIV counseling and testing and family planning services. DESIGN: Implementation and modelling. SETTING: Fifty-five government health facilities in Zambia. SUBJECTS: Patients in government health facilities. INTERVENTION: Community health workers and personnel promoted and delivered integrated CVCT+CFPC from March 2013 to September 2015. MAIN OUTCOME MEASURES: We report financial costs of actual expenditures during integrated program implementation and outcomes of CVCT+CFPC uptake and LARC uptake. We model primary outcomes of cost-per-: adult HIV infections averted by CVCT, unintended pregnancies averted by LARC, couple-years of protection against unintended pregnancy by LARC, and perinatal HIV infections averted by LARC. Costs and outcomes were discounted at 3% per year. RESULTS: Integrated program costs were $3 582 186 (2015 USD), 82 231 couples received CVCT+CFPC, and 56 409 women received LARC insertions. The program averted an estimated 7165 adult HIV infections at $384 per adult HIV infection averted over a 5-year time horizon. The program also averted 62 265 unintended pregnancies and was cost-saving for measures of cost-per-unintended pregnancy averted, cost-per-couple-year of protection against unintended pregnancy, and cost-per-perinatal HIV infection averted assuming 3 years of LARC use. CONCLUSION: Our intervention was cost-savings for CFPC outcomes and CVCT was effective and affordable in Zambia. Integrated couples-focused HIV and family planning was feasible, affordable, and leveraged HIV and unintended pregnancy prevention.

In situ photodecyanation of steel industry wastewater in a pilot scale.

The photodegradation of cyanide from steel industry wastewater was explored in pilot plant scale using hydrogen peroxide (H2O2) under UV irradiation. However, it was interesting to notice that only H2O2 or only UV was inefficient to degrade the cyanide from industrial wastewater. There was a synergy between H2O2 and UV radiation for the degradation of cyanide. The generated hydroxyl radicals from irradiated H2O2 were responsible for the efficient degradation of cyanide. Besides, the dissolved oxygen had a significant role on the degradation process. The photodecyanation rate was faster initially and decreased gradually thereafter ensuring the industrial viability of the process. The dozing rate of H2O2 and the UV lamp power were systematically optimized and they were found to be 8 l/m3 and 640 W, respectively. The photodecyanation kinetics was also explored simultaneously and the rate constant was found to be 3.21 × 10-2 min-1 at the selected dosage of 8 l/m3. This work demonstrates a scalable and facile decyanation technique from steel plant effluent without generation of toxic by-products.

A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural Zambia.

BACKGROUND: Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia. OBJECTIVE: The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples. STUDY DESIGN: A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted. RESULTS: A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%). CONCLUSION: Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.

Tertiary treatment of coke plant effluent by indigenous material from an integrated steel plant: a sustainable approach.

Biological process is an important and integral part of the coke plant wastewater treatment. Increasing pressure to meet more stringent discharge limits has led to adopt tertiary treatment for biologically treated coke plant (BTCP) effluent which contains intense colour along with many residual toxic pollutants like phenol, cyanide, thio-cyanate and COD. A sustainable process has been developed to remove these pollutants from BTCP effluent by using an indigenous material coke breeze which is abundantly available in integrated steel plant. Based on the developed process, a full-scale (200 m3/h) treatment plant has been designed for installation. The designed data has been obtained from a continuous demo plant treating 10 m3/h BTCP effluents. The utilised coke breeze is entirely used for sinter making. The process is highly efficient for the removal of colour above 95% and other residual pollutants like phenol, cyanide and COD to a safe level for discharge or reuse. This process neither incurs any additional chemical cost nor generates any secondary pollutants or products. Moreover, the developed process is very sustainable as it has some great advantages like less investment and low maintenance cost; therefore, the method is good in economics. The treated wastewater contains very less amount of chemical residues therefore meets the standards for reuse as industrial water resource. Hence, this developed technology has significant economic, social and environmental benefits. Graphical Abstract .

Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review.

BACKGROUND: Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources. METHODS: We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist. FINDINGS: 60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk. INTERPRETATION: The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.