The Limits of Professional Identity: A Lesson From My Grandfather.

My grandfather was a prominent Jewish physician in Nazi Germany who escaped the Holocaust with his family but nevertheless came to a tragic end. As I, an American family physician, learned more about him, I was surprised by how much I identified with him. I was struck by how his success in his career had not been matched in other areas of his life, leaving him little to fall back on when his professional status was taken away. My grandfather's story has given me insights about him, my family, and myself and has taught me important lessons about the balance between professional and personal life.

Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here.

BACKGROUND: Strategies to control coronavirus 2019 disease (COVID-19) have often been based on preliminary and limited data and have tended to be slow to evolve as new evidence emerges. Yet knowledge about COVID-19 has grown exponentially, and the expanding rollout of vaccines presents further opportunity to reassess the response to the pandemic more broadly. MAIN TEXT: We review the latest evidence concerning 10 key COVID-19 policy and strategic areas, specifically addressing: 1) the expansion of equitable vaccine distribution, 2) the need to ease restrictions as hospitalization and mortality rates eventually fall, 3) the advantages of emphasizing educational and harm reduction approaches over coercive and punitive measures, 4) the need to encourage outdoor activities, 5) the imperative to reopen schools, 6) the far-reaching and long-term economic and psychosocial consequences of sustained lockdowns, 7) the excessive focus on surface disinfection and other ineffective measures, 8) the importance of reassessing testing policies and practices, 9) the need for increasing access to outpatient therapies and prophylactics, and 10) the necessity to better prepare for future pandemics. CONCLUSIONS: While remarkably effective vaccines have engendered great hope, some widely held assumptions underlying current policy approaches call for an evidence-based reassessment. COVID-19 will require ongoing mitigation for the foreseeable future as it transforms from a pandemic into an endemic infection, but maintaining a constant state of emergency is not viable. A more realistic public health approach is to adjust current mitigation goals to be more data-driven and to minimize unintended harms associated with unfocused or ineffective control efforts. Based on the latest evidence, we therefore present recommendations for refining 10 key policy areas, and for applying lessons learned from COVID-19 to prevent and prepare for future pandemics.

Contraception and abortion among migrant women in Changzhou, China.

OBJECTIVES: Migrant women in China's industrial cities face particular contraceptive challenges, which have changed in recent years as family planning policy has shifted. Little is known about recent trends in contraception and abortion among China's large internal migrant population. We conducted a survey to examine these issues among factory workers in a large Chinese city. METHODS: Married migrant women (N = 801) aged 20-39 years and working in Changzhou, China, completed an anonymous self-administered questionnaire giving details about their sociodemographic background, work and migration situations, and reproductive health. RESULTS: Current contraceptive use was reported by 86.6% of women. Condoms, which have largely replaced longer acting contraceptive methods in this population in recent years, were being used by 54.9% of contraceptive users. Only 41.2% used a longer acting method, mostly an intrauterine device (IUD). A lifetime history of abortion was reported by 40.4%. In the past year, 5.5% had had an unintended pregnancy and 5.2% had had an induced abortion. Older age, lower level of education, lower income, area of origin and husband's residency were associated with IUD use. Lower income, husband's residency and stronger fertility desire were associated with recent unintended pregnancy. CONCLUSION: The results of the study provide evidence that migrant women in China are relying more than ever on less effective methods of contraception. Unintended pregnancy and abortion are common. China's current informed choice model needs to be improved with the provision of better health education before and after migration and easy access to health and reproductive health care services.

Assessment of an HIV-prevention intervention for couples in peri-urban Uganda: pervasive challenges to relationship quality also challenge intervention effectiveness.

Reducing multiple and concurrent partnerships has been identified as a priority in generalised HIV epidemics, yet developing successful interventions to bring about such behaviour change has proven challenging. We offered a three-session intervention aimed to improve couple relationship quality and address HIV risk factors, particularly concurrent sexual partnerships (CSP), in a peri-urban community of Kampala, Uganda. Before launching the intervention, a different group of community members participated in eight single-gender focus group discussions (FGDs) which explored issues of couple relationship quality and satisfaction. Findings from the FGDs guided the intervention. All 162 couples invited to the intervention completed a survey pre- and post-intervention. In FGDs, women and men discussed challenges faced in their relationships, including pervasive dissatisfaction, financial constraints, deception and lack of trust, poor communication, lack of sexual satisfaction, and concurrent sexual partnerships. A difference-in-difference analysis showed no measurable impact of the intervention on relationship quality or sexual risk behaviours over a six-month follow-up among 183 individuals who participated in the intervention, although many stated in response to open-ended questions that they had experienced positive relationship changes. Qualitative findings suggest high demand for couple-focused interventions but also reveal many individual-, couple-, community- and structural-level factors which contribute to women and men seeking concurrent sexual partnerships. More intensive interventions may be needed to overcome these barriers to behaviour change and reduce HIV risk. These findings also raise questions about how to interpret divergent qualitative and quantitative data, a topic which has received little attention in the literature.

Couple Relationship Functioning as a Source or Mitigator of HIV Risk: Associations Between Relationship Quality and Sexual Risk Behavior in Peri-urban Uganda.

Despite evidence that a greater focus on couples could strengthen HIV prevention efforts, little health-related research has explored relationship functioning and relationship quality among couples in Africa. Using data from 162 couples (324 individuals) resident in a peri-urban Ugandan community, we assessed actor and partner effects of sexual risk behaviors on relationship quality, using psychometric measures of dyadic adjustment, sexual satisfaction, commitment, intimacy, and communication. For women and men, poor relationship quality was associated with having concurrent sexual partners and suspecting that one's partner had concurrent sexual partners (actor effects). Women's poor relationship quality was also associated with men's sexual risk behaviors (partner effects), although the inverse partner effect was not observed. These findings suggest that relationship quality is linked to HIV risk, particularly through the pathway of concurrent sexual partnerships, and that positive relationship attributes such as sexual satisfaction, intimacy, and constructive communication can help couples to avoid risk.

Risk Behaviors and Perceptions Among Self-identified Men Who Have Sex with Men (MSM), Bisexuals, Transvestites, and Transgender Women in Western Guatemala.

Guatemala has a concentrated HIV epidemic disproportionately affecting men who have sex with men (MSM) and transgender women. We recruited 205 self-identified MSM, bisexuals, transvestites, and transgender women in western Guatemala using long-chain peer referral, wherein "seed" participants were asked to invite as many as three acquaintances to participate in the study. Self-reported sexual or gender identity was MSM, 46%; bisexual, 28%; transvestite, 21%, and transgender woman, 5%. Median age of the participants was 23 years, and 36% self-identified as being indigenous. Indigenous persons were more likely to self-identity as transvestite (32.9% vs 13.8%, P = 0.04), strongly perceive themselves at risk for HIV (87.7% vs 51.5%, P = 0.001), have had an HIV test in the last 12 months and know the result (97.3% vs 85.4%, P = 0.008), and experience barriers to testing and treatment (86.3% vs 67.7%, P = 0.004). HIV prevention services for indigenous MSM should especially target transvestites and how to overcome stigmatization and barriers to care.

Prenatal care among rural to urban migrant women in China.

BACKGROUND: There is a very large population of internal migrants in China, and the majority of migrant women are of childbearing age. Little is known about their utilization of prenatal care and factors that influence this. We examined this using data from a large national survey of migrants. METHODS: 5372 married rural to urban migrant women aged 20-34 who were included in the 2014 National Dynamic Monitoring Survey on Migrants and who delivered a baby within the previous two years were studied. We examined demographic and migration experience predictors of prenatal care in the first trimester and of adequate prenatal visits. RESULTS: 12.6% of migrant women reported no examination in the first trimester and 27.6% had less than 5 prenatal visits during their latest pregnancy. Multivariate analysis indicated that demographic predictors of delayed and inadequate care included lower educational level, lower income and not having childbearing insurance. Migrating before pregnancy, longer time since migration, having migrated a greater distance, and not returning to their home town for delivery were correlated with better prenatal care. CONCLUSIONS: Many internal migrant women in China do not receive adequate prenatal care. While internal migration before pregnancy seems to promote adequate prenatal care, it also creates barriers to receiving care. Strategies to improve prenatal care utilization include expanding access to childbearing insurance and timely education for women before and after they migrate.

Health-related quality of life of among elders in rural China: the effect of widowhood.

PURPOSE: China has an enormous and rapidly growing population of widowed elders. Little is known about how losing a spouse affects elders' health-related quality of life (QOL), especially in the rural areas where most Chinese elders live. This article analyzes QOL data collected in 2014 among rural Chinese elders to address this question. METHODS: SF12 questionnaires and information about individual and household characteristics were collected from 3053 elders aged 60 and above in rural China. We compared the physical component summary (PCS) and mental component summary (MCS) scores between 1925 married elders and 1060 widowed elders in a bivariate model stratifying by gender and age group and in a general factorial ANOVA multivariate analysis that examined and controlled for other predictors of PCS and MCS scores including education, chronic disease, and family and household factors. RESULTS: Widowed male and female elders' physical health and mental health were in decline with age. Widowed men had lower PCS and MCS scores than married men. Widowed women also had lower PCS scores, but differences in MCS scores did not reach statistical significance. In multivariate analysis, widowhood was associated with lower PCS and MCS scores overall. Support from children was associated with better QOL and, based on interaction analysis, appeared to mitigate negative effects of widowhood. CONCLUSIONS: Widowed rural elders in China have lower physical and mental quality of life than their married counterparts. These elders rely on their children for care, and a supportive family is associated with better QOL.

Treating kleptomania: cross-cultural adaptation of the Kleptomania Symptom Assessment Scale and assessment of an outpatient program.

BACKGROUND: Kleptomania is characterized by repetitive stealing and has severe consequences for patients. Stigma, a lack of standardized therapy and a limited number of assessment tools hinder advances in treatment. This study provides preliminary data on the Portuguese-language version of the Kleptomania Symptom Assessment Scale (P-K-SAS) and preliminary data on an outpatient program. METHODS: Experts in the field analyzed an initial P-K-SAS version, produced through translation/back-translation, in order to arrive at a final version. Eight patients currently on cognitive-behavioral therapy (CBT) and 10 patients under maintenance CBT were initially assessed, then re-assessed 6months later. RESULTS: The mean P-K-SAS score was higher among patients initiating CBT than among those under maintenance CBT (21.1±8.0 vs. 11.3±7.5; Mann-Whitney U=15.0, P=.024). The final version of the P-K-SAS presented excellent reliability (Cronbach's alpha=0.980; inter-item correlation, 0.638-0.907). CONCLUSIONS: The P-K-SAS presented solid psychometrics and seems ready for use in assessing the effectiveness of treatments for kleptomania. The findings suggest that kleptomania patients need follow-up treatment that goes beyond the traditional 12-session structure.

Risk of sexually transmitted infections among Mayan women in rural Guatemala whose partners are migrant workers.

HIV and sexually transmitted infection (STI) are of concern in Mayan districts of Guatemala in which labor migration is common. This study assessed whether the migration status of men is associated with reported STI symptoms among their female primary partners. In a multivariate analysis of survey data taken from a larger Mayan sexual health study, the odds of reporting STI symptoms were twofold higher among women who reported that their partner migrated (OR 2.08, 95 % CI, 1.16-3.71), compared to women whose partners did not. Women from the Mam and Kaqchikel ethnolinguistic groups reported higher rates of STI symptoms after adjustment for their partners' migration status.

Impact of integrating HIV and TB care and treatment in a regional tuberculosis hospital in rural Guatemala.

Resource-limited settings have made slow progress in integrating TB and HIV care for co-infected patients. We examined the impact of integrated TB/HIV care on clinical and survival outcomes in rural western Guatemala. Prospective data from 254 newly diagnosed TB/HIV patients (99 enrolled in the pre-integrated program from August 2005 to July 2006, and 155 enrolled in the integrated program from February 2008 to January 2009) showed no significant baseline differences between clients in the two periods. They were principally male (65.5 %), Mayan (71 %), median age 33 years, and CD4 count averaged 111 cells/mm³. TB/HIV co-infected patients were more likely to receive antiretroviral therapy in the integrated program than in the pre-integrated program (72 vs. 22 %, respectively) and had lower mortality (HR 0.22, 95 % CI 0.14­0.33). This study shows how using a TB setting as the entry point for integrated TB/HIV care can improve health outcomes for HIV-positive patients in rural Guatemala.

Individual and household-level predictors of health related quality of life among middle-aged people in rural Mid-east China: a cross-sectional study.

BACKGROUND: China has an enormous and growing middle-aged population. Little is known about health-related quality of life (HRQOL) for this group, especially in rural areas. We examined HRQOL and its individual and household predictors among middle-aged people in rural Mid-east China. METHODS: HRQOL questionnaires and information about individual and household characteristics were collected from 428 subjects aged 45 to 65 in 12 villages in Mid-east China. We examined the eight dimensions of the SF-36 instrument, along with the Physical Component Summary (PCS) and Mental Component Summary (MCS) using a reference sample in Hong Kong for standardization. Individual and household predictors of PCS and MCS were examined by one-way ANOVA and binary logistic regression analysis. RESULTS: Self-reported HRQOL was similar to that seen in middle-aged populations elsewhere. Based on univariate analyses, PCS differed by age, education, occupation, household per capita income, drinking water supply, and frequency of household members caring about each other; MCS differed by education, household per capita income, drinking water supply, and frequency of caring about each other. Individual and household-level factors accounted for 12.5% and 8.2% of the variance in PCS, respectively, and for 3.1% and 10.7% of the variance in MCS. CONCLUSIONS: HRQOL among middle-aged people in rural China appears similar to that observed elsewhere, and varies by income, education, and other factors. Household factors, particularly the extent to which household members care about each other, are significant predictors of physical and mental health. In addition to improving general socioeconomic conditions, efforts to improve HRQOL for middle-aged people in rural China need to focus on the family environment.

Masking for COVID-19 and other respiratory viral infections: implications of the available evidence.

The use of face masks has been widely promoted and at times mandated to prevent coronavirus disease 2019 (COVID-19). The 2023 publication of an updated Cochrane review on mask effectiveness for respiratory viruses as well as the unfolding epidemiology of COVID-19 underscore the need for an unbiased assessment of the current scientific evidence. It appears that the widespread promotion, adoption, and mandating of masking for COVID-19 were based not primarily on the strength of evidence for effectiveness but more on the imperative of decision-makers to act in the face of a novel public health emergency, with seemingly few good alternatives. Randomized clinical trials of masking for prevention of COVID-19 and other respiratory viruses have so far shown no evidence of benefit (with the possible exception of continuous use of N95 respirators by hospital workers). Observational studies provide lower-quality evidence and do not convincingly demonstrate benefit from masking or mask mandates. Unless robust new evidence emerges showing the effectiveness of masks in reducing infection or transmission risks in either trials or real-world conditions, mandates are not warranted for future epidemics of respiratory viral infections.

Prevention messages and AIDS risk behavior in Kampala, Uganda.

Uganda was one of the first countries to substantially reduce HIV rates through behavior change, but these gains have not continued in recent years. Little is known about what messages Ugandans are currently hearing about AIDS prevention, what they themselves believe to be important prevention strategies, and how these beliefs are associated with behavior. We interviewed men and women aged between 20 and 39 in two poor peri-urban areas of Kampala, using a random sample, cross-sectional household survey design. Respondents provided detailed reports of sexual behavior over the past six months, the main prevention message they are currently hearing about AIDS, and their own ranking of the importance of prevention strategies. Condom use was the main AIDS prevention message that respondents reported hearing, followed by getting tested. These were also what respondents themselves considered most important, followed closely by faithfulness. Abstinence was the lowest ranked strategy, but a higher ranking for this prevention strategy was the only one consistently associated with less risky behavior. A higher ranking for condoms was associated with higher levels of risk behavior, while the ranking of testing made no difference in any behavior. These results present challenges for AIDS prevention strategies that rely primarily on promoting condoms and testing. HIV prevention programs need to assess their impact on behavior.

High occurrence of HIV-positive siblings due to repeated mother-to-child transmission in Brazil.

Pregnancies in women without knowledge of their HIV-positive status increase the risk of mother-to-child transmission, and of disease progression. This study aimed to characterize the frequency of multiple pregnancies and of HIV-positive children in the family, during HAART era. We analyzed data of a national multicenter cohort study among Brazilian children with AIDS diagnosed between 1999 and 2002. In total, 945 children and their 928 mothers were included. Five hundred and ninety (64.6%) women had a history of multiple pregnancies, and 49.5% attended prenatal care (mean: 3.5 consultations; SD 3.6). In 483 child cases, HIV status of the sibling was known; 130 (26.9%) of these were infected with HIV. In 38.5% of cases, the child with AIDS included in the cohort study was the first case in the family. Despite the overall positive results of the Brazilian control policy of HIV/AIDS, our study shows that HIV infection in pregnant women was often undetected and that consequently there was a high frequency of repeated HIV-infected children. There is a need to improve comprehensive prenatal and postnatal care of Brazilian women. HIV-affected families are most vulnerable and should be targeted by specific control programs, preventing additional HIV infections in other children.

Risk factors for delayed intrauterine device removal among menopausal women in rural China.

OBJECTIVE: More women in China have received intrauterine devices (IUDs) than in the rest of the world combined. Recent reports have recognized a growing problem of delayed removal of these IUDs after menopause, especially in rural China, but few studies have examined women's knowledge and other risk factors for delayed removal. METHODS: A total of 1,014 perimenopausal and postmenopausal women aged 45 to 64 years participating in a pilot program providing free IUD removal in rural China completed a questionnaire. We examined their knowledge about when IUDs should be removed and other demographic and reproductive health characteristics and the association of these factors with whether their IUD removal was on time or delayed using bivariate contingency analysis and multivariate logistic regression. RESULTS: A total of 40.2% of women were having their IUDs removed more than 2 years after menopause, and 67.9% did not know the correct time for IUD removal. Women who were older, less educated, had one child, had their IUD placed in a rural facility, and with no gynecological examination in the past 2 years were less likely to know when an IUD should be removed. In multivariate analysis, knowledge, the facility where the IUD was placed, and a recent gynecological examination were independent predictors of on-time removal. At least 170 women had received a gynecological examination after menopause without the IUD being removed at that time. CONCLUSIONS: Lack of knowledge about timing for IUD removal and structural barriers in health service organization must be addressed to improve care for millions of women with IUDs in rural China.

Opportunistic illnesses in Brazilian children with AIDS: results from two national cohort studies, 1983-2007.

BACKGROUND: HAART has significantly reduced AIDS-related morbidity in children. However, limited evidence is available from developing countries regarding patterns of opportunistic illnesses. We describe these events and their associated factors in children with AIDS in Brazil. METHODS: This study is based on two representative retrospective multi-center cohorts including a total 1,859 children with AIDS, infected via mother-to-child transmission (MTCT), between 1983-2002. Opportunistic illnesses were described and analyzed over time. The association of demographic, clinical and operational data with the occurrence of opportunistic diseases was assessed. RESULTS: In total, 1,218 (65.5%) had at least one event of an opportunistic disease. Variables significantly associated with occurrence of these events included: region of residence (OR 2.68-11.33, as compared to the Northern region), age < 1 year at diagnosis (OR 2.56, 95% CI 1.81-3.61, p < 0.001), and non-performance of MTCT prevention measures (OR 1.58, 95% CI 1.21-2.07, p < 0.001). Protective factors included year of HIV diagnosis in the HAART era (OR 0.34, 95% CI 0.15-0.76, p = 0.009) and ART use (OR 0.58, 95% CI 0.44-0.77, p < 0.001). In both periods bacterial infections represented the most common opportunistic events (58.6 vs. 34.7%; p < 0.001), followed by Pneumocystis jirovecii pneumonia (21.9 vs. 13.2%; p < 0.001), and bacterial meningitis/sepsis (16.8 vs. 7.4%; p < 0.001). CONCLUSIONS: Despite the significant reduction in recent years, opportunistic illnesses are still common in Brazilian children with AIDS in the HAART era, especially bacterial diseases. The data reinforce the need for scaling up prevention of MTCT, early diagnosis of infection, and improvement of comprehensive pediatric care.

[HIV prevention using the operative group approach among men who have sex with men in São Paulo, Brazil]. / Prevenção de infecção pelo HIV por intermédio da utilização do grupo operativo entre homens que fazem sexo com homens, São Paulo, Brasil.

This study aimed to evaluate the operative group as a preventive approach among men who have sex with men that use two public health services in the city of São Paulo, Brazil. One hundred volunteers were randomly allocated to two groups (intervention and control, with 50 each). All participants answered questionnaires in two phases: before the intervention and six months after its conclusion. Effect was measured by comparing the groups for the following outcomes: median number of anal sex acts without condoms and responses from the participants to questions about HIV infection. 69 participants completed the study (34 in the prevention group and 35 in the control group). Analysis showed a decrease in the number of unprotected anal sex acts (p = 0.029) and an increase in the number of answers favoring prevention in the intervention group. The results indicate that the study group was responsive to a safer sex operative group intervention. Further research is necessary to evaluate the feasibility of this prevention approach as a public health strategy, including other social groups.

AIDS by mother-to-child transmission: survival analysis of cases followed from 1983 to 2002 in different regions of Brazil.

Antiretroviral therapy contributes to decreasing morbidity and mortality, and ultimately to increasing survival. In Brazil, there are regional differences in HIV epidemiology regarding pregnant women and children with HIV/AIDS. This study evaluates survival time after AIDS diagnosis in 914 children infected by mother-to-child transmission, reported between 1983 and 1998 and followed until 2002, in Brazil's five regions. Time between birth and HIV diagnosis decreased over the years, mainly in the South and Southeast Regions. There was a significant improvement in survival; more than 75% of cases were still living four years after diagnosis in the 1997-1998 group. This Brazilian study demonstrates that even with regional inequalities in health care infrastructure it is possible for a developing country to establish an effective system of universal and free access to antiretroviral therapy that produces a significant increase in survival for children with AIDS.

Migration Experiences and Reported Sexual Behavior Among Young, Unmarried Female Migrants in Changzhou, China.

BACKGROUND: China has a large migrant population, including many young unmarried women. Little is known about their sexual behavior, contraceptive use, and risk of unintended pregnancy. METHODS: 475 unmarried female migrants aged 15-24, working in 1 of 6 factories in 2 districts of Changzhou city, completed an anonymous self-administered questionnaire in May 2012 on demographic characteristics, work and living situation, and health. We examined demographic and migration experience predictors of sexual and contraceptive behavior using bivariate and multivariate regressions. RESULTS: 30.1% of the respondents were sexually experienced, with the average age at first sex of 19 years (standard deviation=3). 37.8% reported using contraception at first sex, 58.0% reported using consistent contraception during the past year, and 28.0% reported having at least 1 unintended pregnancy with all unintended pregnancies resulting in abortion. Those who had had at least 1 abortion reported having on average 1.6 abortions [SD=1] in total. Migrating with a boyfriend and changing jobs fewer times were associated with being sexually experienced. Younger age, less education, and changing jobs more times were associated with inconsistent contraceptive use. CONCLUSION: These findings demonstrate there is an unmet need for reproductive health education and services where these women work as well as in their hometown communities. This education must begin early to reach young women before they migrate.