Prioritizing Mental Health within HIV and Tuberculosis Services in PEPFAR.

Underprioritization of mental health is a global problem and threatens the decades-long progress of the US President's Emergency Plan for AIDS Relief (PEPFAR) program. In recent years, mental health has become globally recognized as a part of universal healthcare, making this an opportune moment for the global community to integrate mental health services into routine programming. PEPFAR is well positioned to lead by example. We conceptualized 5 key strategies that might help serve as a framework to support mental health programming as part of PEPFAR's current 5-year strategic plan. PEPFAR and the global community have an opportunity to identify mental health service gaps and interweave global mental health priorities with actions to end the HIV and TB epidemics by 2030.

Collect Once, Use Many Times: Attaining Unified Metrics for Tuberculosis Preventive Treatment for People Living With HIV.

The World Health Organization (WHO) recommends providing tuberculosis preventive treatment (TPT) to all persons living with HIV and to all household contacts of persons with bacteriologically confirmed pulmonary tuberculosis disease. Regrettably, the absence of a harmonized data collection and management approach to TPT indicators has contributed to programmatic challenges at local, national, and global levels. However, in April 2020, the WHO launched the Consolidated HIV Strategic Information Guidelines, with an updated set of priority indicators. These guidelines recommend that Ministries of Health collect, report, and use data on TPT completion in addition to TPT initiation. Both indicators are reflected in the WHO's list of 15 core indicators for program management and are also required by the US President's Emergency Plan for AIDS Relief's Monitoring, Evaluation, and Reporting (MER) guidance. Although not perfectly harmonized, both frameworks now share essential indicator characteristics. Aligned indicators are necessary for robust strategic and operational planning, resource allocation, and data communication. "Collect once, use many times" is a best practice for strategic information management. Building harmonized and sustainable health systems will enable countries to successfully maintain essential HIV, tuberculosis, and other health services while combatting new health threats.

Time from Start of Quarantine to SARS-CoV-2 Positive Test Among Quarantined College and University Athletes - 17 States, June-October 2020.

To safely resume sports, college and university athletic programs and regional athletic conferences created plans to mitigate transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Mitigation measures included physical distancing, universal masking, and maximizing outdoor activity during training; routine testing; 10-day isolation of persons with COVID-19; and 14-day quarantine of athletes identified as close contacts* of persons with confirmed COVID-19. Regional athletic conferences created testing and quarantine policies based on National Collegiate Athletic Association (NCAA) guidance (1); testing policies varied by conference, school, and sport. To improve compliance with quarantine and reduce the personal and economic burden of quarantine adherence, the quarantine period has been reduced in several countries from 14 days to as few as 5 days with testing (2) or 10 days without testing (3). Data on quarantined athletes participating in NCAA sports were used to characterize COVID-19 exposures and assess the amount of time between quarantine start and first positive SARS-CoV-2 test result. Despite the potential risk for transmission from frequent, close contact associated with athletic activities (4), more athletes reported exposure to COVID-19 at social gatherings (40.7%) and from roommates (31.7%) than they did from exposures associated with athletic activities (12.7%). Among 1,830 quarantined athletes, 458 (25%) received positive reverse transcription-polymerase chain reaction (RT-PCR) test results during the 14-day quarantine, with a mean of 3.8 days from quarantine start (range = 0-14 days) until the positive test result. Among athletes who had not received a positive test result by quarantine day 5, the probability of having a positive test result decreased from 27% after day 5 to <5% after day 10. These findings support new guidance from CDC (5) in which different options are provided to shorten quarantine for persons such as collegiate athletes, especially if doing so will increase compliance, balancing the reduced duration of quarantine against a small but nonzero risk for postquarantine transmission. Improved adherence to mitigation measures (e.g., universal masking, physical distancing, and hand hygiene) at all times could further reduce exposures to SARS-CoV-2 and disruptions to athletic activities because of infections and quarantine (1,6).

"Knock Knock": a qualitative study exploring the experience of household contacts on home visits and their attitude towards people living with TB in South Africa.

BACKGROUND: Household contract tracing (HHCT) is an important strategy for active tuberculosis case finding and offers an opportunity for testing of other diseases such as HIV. However, there is limited data on the patient-centered approach to HHCT. Our study aimed to describe experiences and preferences of household contacts (HHCs) for HHCT. METHODS: We conducted a qualitative study in Rustenburg, South Africa from September 2013 to March 2015. Twenty-four HHCs (≥18 years) had audio-recorded in-depth interviews. We used an inductive thematic analysis approach to develop themes. We made an a priori assumption that we would reach saturation with at least 20 interviews. RESULTS: There were 16 (66.7%) females (median age = 36 years) and eight (33.3%) males (median age = 34 years). Two themes developed: (i) Positive attitude of HHCs towards TB services provided at home and (ii) HHCs relationship to and acceptance of people living with TB (PLTB). The first main theme emphasized that HHCs appreciated the home visits. Participants preferred home visits because they had negative experiences at the clinic such as delayed waiting times and long queues. HHCs supported the screening of children for TB at home. Participants suggested that the research staff could expand their services by screening for diabetes and hypertension alongside TB screening. In the second main theme, there was a sense of responsibility from the HHCs towards accepting the diagnosis of PLTB and caring for them. A sub-theme that emerged was that as their knowledge on TB disease improved, they accepted the TB status of the PLTB empowering them to take care of the PLTB. CONCLUSIONS: HHCs are supportive of HHCT and felt empowered by receiving TB education that ultimately allowed them to better understand and care for PLTB. HHCs were supportive of screening children for TB at home. Future HHCT activities should consider raising community awareness on the benefits of TB contact tracing at households.

Effects of Supplemental Calcium and Vitamin D on Expression of Toll-Like Receptors and Phospho-IKKα/ß in the Normal Rectal Mucosa of Colorectal Adenoma Patients.

Chronic inflammation in the colorectum, a significant contributor to colorectal carcinogenesis, can be triggered by the activation of proinflammatory signaling pathways such as those initiated by Toll-like receptors (TLR) and nuclear factor κB (NF-κB). Although experimental evidence supports calcium and vitamin D potentially modifying these proinflammatory pathways in the colorectum, human data in these regards are scarce. We investigated supplemental calcium (1,200 mg daily) and/or vitamin D3 (1,000 IU daily) effects on inflammatory signaling pathway-related biomarkers in a subset of 105 participants from a colorectal adenoma recurrence chemoprevention clinical trial. We assessed expression of TLR4 and TLR5, which recognize the bacterial components lipopolysaccharides and flagellin, respectively, and phospho-IKKα/ß (pIKKα/ß), a biomarker of inflammation, in the normal-appearing rectal crypt epithelium and stroma using standardized, automated immunohistochemistry and quantitative image analysis. Following 1 year of treatment, TLR4, TLR5, and pIKKα/ß expression in the rectal mucosa did not statistically significantly change with vitamin D or calcium supplementation, taken alone or in combination. Several baseline participant characteristics, including body mass index, history of sessile serrated adenomas, high red/processed meat intake, and high levels of rectal epithelial cell proliferation (as measured by MIB-1/Ki-67), were associated with higher baseline expression of TLRs or pIKKα/ß. Our findings suggest that vitamin D and calcium may have no substantial effect on the investigated biomarkers. However, several modifiable lifestyle factors may be associated with TLRs and pIKKα/ß expression in the normal rectal mucosa, supporting their future investigation as potentially treatable, preneoplastic risk factors for colorectal neoplasms. Cancer Prev Res; 11(11); 707-16. ©2018 AACR.

Low Referral Rate for Genetic Testing in Racially and Ethnically Diverse Patients Despite Universal Colorectal Cancer Screening.

BACKGROUND & AIMS: Guidelines recommend that all colorectal tumors be assessed for mismatch repair deficiency, which could increase identification of patients with Lynch syndrome. This is of particular importance for minority populations, in whom hereditary syndromes are under diagnosed. We compared rates and outcomes of testing all tumor samples (universal testing) collected from a racially and ethnically diverse population for features of Lynch syndrome. METHODS: We performed a retrospective analysis of colorectal tumors tested from 2012 through 2016 at 4 academic centers. Tumor samples were collected from 767 patients with colorectal cancer (52% non-Hispanic white [NHW], 26% African American, and 17% Hispanic patients). We assessed rates of tumor testing, recommendations for genetic evaluation, rates of attending a genetic evaluation, and performance of germline testing overall and by race/ethnicity. We performed univariate and multivariate regression analyses. RESULTS: Overall, 92% of colorectal tumors were analyzed for mismatch repair deficiency without significant differences among races/ethnicities. However, minority patients were significantly less likely to be referred for genetic evaluation (21.2% for NHW patients vs 16.9% for African American patients and 10.9% for Hispanic patients; P = .02). Rates of genetic testing were also lower among minority patients (10.7% for NHW patients vs 6.0% for AA patients and 3.1% for Hispanic patients; P < .01). On multivariate analysis, African American race, older age, and medical center were independently associated with lack of referral for genetic evaluation and genetic testing. CONCLUSION: In a retrospective analysis, we found that despite similar rates of colorectal tumor analysis, minority patients are less likely to be recommended for genetic evaluation or to undergo germline testing for Lynch syndrome. Improvements in institutional practices in follow up after tumor testing could reduce barriers to diagnosis of Lynch diagnosis in minorities.