Correction: Assessment of lung function in successfully treated tuberculosis reveals high burden of ventilatory defects and COPD.

[This corrects the article DOI: 10.1371/journal.pone.0217289.].

Assessment of lung function in successfully treated tuberculosis reveals high burden of ventilatory defects and COPD.

BACKGROUND: Burden, phenotype and risk-factors of lung function defects in successfully treated tuberculosis cases are unclear. METHODS: We performed spirometry with bronchodilators in new drug-sensitive adult (≥18 years) pulmonary tuberculosis cases during the 12 months following successful treatment in India. Airflow obstruction was defined as pre-bronchodilator FEV1/FVC<5th percentile of Global Lung Initiative mixed-ethnicity reference (lower limit of normal [LLN]). Chronic obstructive pulmonary disease (COPD) was defined as post-bronchodilator FEV1/FVC

Challenges and opportunities for outreach workers in the Prevention of Mother to Child Transmission of HIV (PMTCT) program in India.

BACKGROUND: The Prevention of Mother-to-Child Transmission of HIV (PMTCT) program in India is one of the largest in the world. It uses outreach workers (ORWs) to facilitate patient uptake of services, however, the challenges faced by the ORWs, and their views about the effectiveness of this program are unknown. METHODS: The COMmunity-Home Based INDia (COMBIND) Prevention of Mother to Child Transmission of HIV study evaluated an integrated mobile health and behavioral intervention to enhance the capacity of ORWs in India. To understand the challenges faced by ORWs, and their perceptions of opportunities for program improvement, four group discussions were conducted among 60 ORW from four districts of Maharashtra, India, as part of the baseline assessment for COMBIND. Data were qualitatively analyzed using a thematic approach. RESULTS: Numerous personal-, social-, and structural-level challenges existed for ORW as they engaged with their patients. Personal-level challenges for ORWs included disclosure of their own HIV status and travelling costs for home visits. Personal-level challenges for patients included financial costs of travelling to ART centers, non-adherence to ART, loss of daily wages, non-affordability of infant formula, lack of awareness of the baby's needs, financial dependence on family, four time points (6weeks, 6 months, 12 months and 18 months) for HIV tests, and need for nevirapine (NVP) prophylaxis. Social-level challenges included lack of motivation by patients and/or health care staff, social stigma, and rude behavior of health care staff and their unwillingness to provide maternity services to women in the PMTCT programme. Structural-level challenges included cultural norms around infant feeding, shortages of HIV testing kits, shortages of antiretroviral drugs and infant NVP prophylaxis, and lack of training/knowledge related to PMTCT infant feeding guidelines by hospital staff. The consensus among ORWs was that there was a critical need for tools and training to improve their capacity to effectively engage with patients, and deliver appropriate care, and for motivation through periodic feedback. CONCLUSIONS: Given the significant challenges in PMTCT programme implementation reported by ORW, novel strategies to address these challenges are urgently needed to improve patient engagement, and access to and retention in care.

Developing an Assessment Framework for Essential Internal Medicine Subspecialty Topics.

BACKGROUND: Assessing residents by direct observation is the preferred assessment method for infrequently encountered subspecialty topics, but this is logistically challenging. OBJECTIVE: We developed an assessment framework for internal medicine (IM) residents in subspecialty topics, using tuberculosis diagnosis for proof of concept. METHODS: We used a 4-step process at 8 academic medical centers that entailed (1) creating a 10-item knowledge assessment tool; (2) pilot testing on a sample of 129 IM residents and infectious disease fellow volunteers to evaluate validity evidence; (3) implementing the final tool among 886 resident volunteers; and (4) assessing outcomes via retrospective chart review. Outcomes included tool score, item performance, and rates of obtaining recommended diagnostics. RESULTS: Following tool development, 10 infectious disease experts provided content validity. Pilot testing showed higher mean scores for fellows compared with residents (7 [SD = 1.8] versus 3.8 [SD = 1.7], respectively, P < .001) and a satisfactory Kuder-Richardson Formula 20 (0.72). Implementation of the tool revealed a 14-minute (SD = 2.0) mean completion time, 61% (541 of 886) response rate, 4.4 (SD = 1.6) mean score, and ≤ 57% correct response rate for 9 of 10 items. On chart review (n = 343), the rate of obtaining each recommended test was ≤ 43% (113 of 261), except for chest x-rays (96%, 328 of 343). CONCLUSIONS: Our assessment framework revealed knowledge and practice gaps in tuberculosis diagnosis in IM residents. Adopting this approach may help ensure assessment is not limited to frequently encountered topics.

Gender-based violence screening methods preferred by women visiting a public hospital in Pune, India.

BACKGROUND: Gender-based violence (GBV) is a major global public health concern and is a risk factor for adverse health outcomes. Early identification of GBV is crucial for improved health outcomes. Interactions with health care providers may provide a unique opportunity for routine GBV screening, if a safe, confidential environment can be established. METHODS: Between November 2014 and February 2015, a cross-sectional, observational study was conducted where women were interviewed about their opinions concerning GBV screening in a tertiary health care setting in Pune, India. Trained counsellors interviewed 300 women at different out-patient and in-patient departments using a semi-structured questionnaire. RESULTS: Twenty-three percent of these women reported experiencing GBV in their life. However, 90% of women said they had never been asked about GBV in a health care setting. Seventy-two percent expressed willingness to be asked about GBV by their health care providers, with the preferred provider being nurses or counsellors. More than half (53%) women reported face-to-face interview as the most preferred method for screening. There were no major differences in these preferences by GBV history status. CONCLUSIONS: Our study provides evidence for preferred GBV screening methods and optimal provider engagement as perceived by women attending a public hospital.

Maternal Syphilis: An Independent Risk Factor for Mother to Infant Human Immunodeficiency Virus Transmission.

Syphilis is associated with increased human immunodeficiency virus acquisition and sexual transmission; we examined impact on human immunodeficiency virus mother-to-child transmission among mother-infant pairs enrolled in the India Six-Week Extended-Dose Nevirapine study. Maternal syphilis, diagnosed serologically using Venereal Disease Research Laboratory titer plus Treponema Pallidum Hemagglutination Assay, was associated with 2.5-fold greater risk.

Ecological Momentary Assessment of Illicit Drug Use Compared to Biological and Self-Reported Methods.

BACKGROUND: The use of mHealth methods for capturing illicit drug use and associated behaviors have become more widely used in research settings, yet there is little research as to how valid these methods are compared to known measures of capturing and quantifying drug use. OBJECTIVE: We examined the concordance of ecological momentary assessment (EMA) of drug use to previously validated biological and audio-computer assisted self-interview (ACASI) methods. METHODS: The Exposure Assessment in Current Time (EXACT) study utilized EMA methods to assess drug use in real-time in participants' natural environments. Utilizing mobile devices, participants self-reported each time they used heroin or cocaine over a 4-week period. Each week, PharmChek sweat patch samples were collected for measurement of heroin and cocaine and participants answered an ACASI-based questionnaire to report behaviors and drug using events during the prior week. Reports of cocaine and heroin use captured through EMA were compared to weekly biological or self-report measures through percent agreement and concordance correlation coefficients to account for repeated measures. Correlates of discordance were obtained from logistic regression models. RESULTS: A total of 109 participants were a median of 48.5 years old, 90% African American, and 52% male. During 436 person-weeks of observation, we recorded 212 (49%) cocaine and 103 (24%) heroin sweat patches, 192 (44%) cocaine and 161 (37%) heroin ACASI surveys, and 163 (37%) cocaine and 145 (33%) heroin EMA reports. The percent agreement between EMA and sweat patch methods was 70% for cocaine use and 72% for heroin use, while the percent agreement between EMA and ACASI methods was 77% for cocaine use and 79% for heroin use. Misreporting of drug use by EMA compared to sweat patch and ACASI methods were different by illicit drug type. CONCLUSIONS: Our work demonstrates moderate to good agreement of EMA to biological and standard self-report methods in capturing illicit drug use. Limitations occur with each method and accuracy may differ by type of illicit drugs used.

Development of global health education at Johns Hopkins University School of Medicine: a student-driven initiative.

Global health is increasingly present in the formal educational curricula of medical schools across North America. In 2008, students at Johns Hopkins University School of Medicine (JHUSOM) perceived a lack of structured global health education in the existing curriculum and began working with the administration to enhance global health learning opportunities, particularly in resource-poor settings. Key events in the development of global health education have included the introduction of a global health intersession mandatory for all first-year students; required pre-departure ethics training for students before all international electives; and the development of a clinical global health elective (Global Health Leadership Program, GHLP). The main challenges to improving global health education for medical students have included securing funding, obtaining institutional support, and developing an interprofessional program that benefits from the resources of the Schools of Medicine, Public Health, and Nursing. Strategies used included objectively demonstrating the need for and barriers to more structured global health experiences; obtaining guidance and modifying existing resources from other institutions and relevant educational websites; and harnessing institution-specific strengths including the large Johns Hopkins global research footprint and existing interprofessional collaborations across the three schools. The Johns Hopkins experience demonstrates that with a supportive administration, students can play an important and effective role in improving global health educational opportunities. The strategies we used may be informative for other students and educators looking to implement global health programs at their own institutions.

Feasibility and Acceptability of Smartphone-Based Ecological Momentary Assessment of Alcohol Use Among African American Men Who Have Sex With Men in Baltimore.

BACKGROUND: Alcohol use is a risk factor for the acquisition of human immunodeficiency virus (HIV) among African American men who have sex with men (MSM). Mobile phone-based ecological momentary assessments (EMA) could minimize bias due to retrospective recall and thus provide a better understanding of the social and structural context of alcohol use and its relationship with HIV-related risk behaviors in this population as well as other highly stigmatized populations. OBJECTIVE: We describe the study design and the implementation, feasibility, reactivity, and acceptability of an EMA study of alcohol use and HIV-related behaviors among African American MSM in Baltimore. METHODS: Participants were recruited through flyers and word-of-mouth in Baltimore from September 2013 to November 2014. Each participant was loaned an Android smartphone and instructed to respond to multiple prompts from the mobile app for 4 weeks. Data were collected through (1) random prompts delivered three times daily assessing participants' location, activity, mood, and social context, (2) daily prompts capturing drinking and sex events occurring in the past 24 hours, and (3) event-contingent responses collecting participants' self-reported episodes of drinking. RESULTS: A total of 16 participants enrolled in the study. The current analyses focused on 15 participants who completed at least 24 days of follow-up (mean follow-up time 29 days; range 24-35 days). Study participants (N=15) were a median 38 years of age (range 27-62 years) with low levels of income and educational attainment. Ten individuals self-reported living with HIV/AIDS, over half reported drinking alcohol at least 2-3 times a week, and a third reported binge drinking (ie, 6 or more drinks on one occasion) on a weekly basis. Based on the Alcohol Use Disorders Identification Test (AUDIT) score, nearly half were classified as hazardous drinkers (score 8-15) and a fifth were likely dependent (score ≥16). A total of 140 participant-initiated events were reported, and 75% of 1308 random prompts and 81% of 436 daily prompts delivered were answered. Of seven devices used during the study, five were reported lost by participants. We did not observe strong reactivity effects, and self-reported acceptability to study procedures was uniformly favorable. CONCLUSIONS: This study provides evidence to support the feasibility and acceptability of using EMA methods for collecting data on alcohol use among African American men who have sex with men living in urban settings. These data provide the basis for future studies of EMA-informed mHealth interventions to promote the reduction of substance use and HIV risk-taking behaviors among African American MSM living in urban settings.

Utilizing mHealth methods to identify patterns of high risk illicit drug use.

INTRODUCTION: We assessed patterns of illicit drug use using mobile health (mHealth) methods and subsequent health care indicators among drug users in Baltimore, MD. METHODS: Participants of the EXposure Assessment in Current Time (EXACT) study were provided a mobile device for assessment of their daily drug use (heroin, cocaine or both), mood and social context for 30 days from November 2008 through May 2013. Real-time, self-reported drug use events were summed for individuals by day. Drug use risk was assessed through growth mixture modeling. Latent class regression examined the association of mHealth-defined risk groups with indicators of healthcare access and utilization. RESULTS: 109 participants were a median of 48.5 years old, 90% African American, 52% male and 59% HIV-infected. Growth mixture modeling identified three distinct classes: low intensity drug use (25%), moderate intensity drug use (65%) and high intensity drug use (10%). Compared to low intensity drug users, high intensity users were younger, injected greater than once per day, and shared needles. At the subsequent study visit, high intensity drug users were nine times less likely to be medically insured (adjusted OR: 0.10, 95%CI: 0.01-0.88) and at greater risk for failing to attend any outpatient appointments (aOR: 0.13, 95%CI: 0.02-0.85) relative to low intensity drug users. CONCLUSIONS: Real-time assessment of drug use and novel methods of describing sub-classes of drug users uncovered individuals with higher-risk behavior who were poorly utilizing healthcare services. mHealth holds promise for identifying individuals engaging in high-risk behaviors and delivering real-time interventions to improve care outcomes.

Capturing illicit drug use where and when it happens: an ecological momentary assessment of the social, physical and activity environment of using versus craving illicit drugs.

AIMS: To understand the environmental and contextual influences of illicit cocaine and heroin use and craving using mobile health (mHealth) methods. DESIGN: Interactive mHealth methods of ecological momentary assessment (EMA) were utilized in the Exposure Assessment in Current Time (EXACT) study to assess drug use and craving among urban drug users in real time. Participants were provided with mobile devices and asked to self-report every time they either craved (without using) or used heroin or cocaine for 30 days from November 2008 through May 2013. SETTING: Baltimore, MD, USA. PARTICIPANTS: A total of 109 participants from the AIDS Linked to the IntraVenous Experience (ALIVE) study. MEASUREMENTS: For each drug use or craving event, participants answered questions concerning their drug use, current mood and their social, physical and activity environments. Odds ratios (OR) of drug use versus craving were obtained from logistic regression models with generalized estimating equations of all reported events. FINDINGS: Participants were a median of 48.5 years old, 90% African American, 52% male and 59% HIV-infected. Participants were significantly more likely to report use rather than craving drugs if they were with someone who was using drugs [adjusted odds ratio (aOR) = 1.45, 95% confidence interval (CI) = 1.13, 1.86), in an abandoned space (aOR = 6.65, 95% CI = 1.78, 24.84) or walking/wandering (aOR = 1.68, 95% CI = 1.11, 2.54). Craving drugs was associated with being with a child (aOR = 0.26, 95% CI = 0.12, 0.59), eating (aOR = 0.54, 95% CI = 0.34, 0.85) or being at the doctor's office (aOR = 0.31, 95% CI = 0.12, 0.80). CONCLUSIONS: There are distinct drug using and craving environments among urban drug users, which may provide a framework for developing real-time context-sensitive interventions.

The exposure assessment in current time study: implementation, feasibility, and acceptability of real-time data collection in a community cohort of illicit drug users.

Objective. We describe the study design and evaluate the implementation, feasibility, and acceptability of an ecological momentary assessment (EMA) study of illicit drug users. Design. Four sequential field trials targeting observation of 30 individuals followed for a four week period. Participants. Participants were recruited from an ongoing community-cohort of current or former injection drug users. Of 113 individuals enrolled, 109 completed study procedures during four trials conducted from November 2008 to May 2013. Methods. Hand-held electronic diaries used in the initial trials were transitioned to a smartphone platform for the final trial with identical data collection. Random-prompts delivered five times daily assessed participant location, activity, mood, and social context. Event-contingent data collection involved participant self-reports of illicit drug use and craving. Main Outcome Measures. Feasibility measures included participant retention, days of followup, random-prompt response rates, and device loss rate. Acceptability was evaluated from an end-of-trial questionnaire. Sociodemographic, behavioral, clinical, and trial characteristics were evaluated as correlates of weekly random-prompt response rates ≥80% using logistic regression with generalized estimating equations. Results. Study participants were a median of 48.5 years old, 90% African American, 52% male, and 59% HIV-infected with limited income and educational attainment. During a median followup of 28 days, 78% of 11,181 random-prompts delivered were answered (mean of 2.8 responses daily), while 2,798 participant-initiated events were reported (30% drug use events; 70% craving events). Self-reported acceptability to study procedures was uniformly favorable. Device loss was rare (only 1 lost device every 190 person-days of observation). Higher educational attainment was consistently associated with a higher response rate to random-prompts, while an association of HIV infection with lower response rates was not observed after accounting for differences in trial recruitment procedures. Conclusion. Near real-time EMA data collection in the field is feasible and acceptable among community-dwelling illicit drug users. These data provide the basis for future studies of EMA-informed interventions to prevent drug relapse and improve HIV treatment outcomes in this population.

Cost analyses of peer health worker and mHealth support interventions for improving AIDS care in Rakai, Uganda.

A cost analysis study calculates resources needed to deliver an intervention and can provide useful information on affordability for service providers and policy-makers. We conducted cost analyses of both a peer health worker (PHW) and a mHealth (mobile phone) support intervention. Excluding supervisory staffing costs, total yearly costs for the PHW intervention was $8475, resulting in a yearly cost per patient of $8.74, per virologic failure averted cost of $189, and per patient lost to follow-up averted cost of $1025. Including supervisory staffing costs increased total yearly costs to $14,991. Yearly costs of the mHealth intervention were an additional $1046, resulting in a yearly cost per patient of $2.35. In a threshold analysis, the PHW intervention was found to be cost saving if it was able to avert 1.50 patients per year from switching to second-line antiretroviral therapy. Other AIDS care programs may find these intervention costs affordable.

Building a global health education network for clinical care and research. The benefits and challenges of distance learning tools. Lessons learned from the Hopkins Center for Clinical Global Health Education.

Expanding the capacity for clinical care and health research is a global priority and a global challenge. The Johns Hopkins Center for Clinical Global Health Education (CCGHE) was established in 2005 to provide access to high-quality training to health care providers in resource-limited settings. The CCGHE made a strategic decision to develop, use, and evaluate distance learning platforms to achieve its mission. In the initial years of this new program, several lessons have been learned that may be helpful to other programs considering the use of distance learning programs to expand global health clinical and research capacity.

An assessment of Makerere University College of Health Sciences: optimizing health research capacity to meet Uganda's priorities.

BACKGROUND: Health research is critical to the institutional mission of the Makerere College of Health Sciences (MakCHS). Optimizing the alignment of health research capacity at MakCHS with the health needs and priorities of Uganda, as outlined in the country's Health Sector Strategic Plan (HSSP), is a deliberate priority, a responsibility, and a significant opportunity for research. To guide this strategic direction, an assessment of MakCHS's research grants and publication portfolio was conducted. METHODS: A survey of all new and ongoing grants, as well as all publications, between January 2005 and December 2009 was conducted. Research, training, and education grants awarded to MakCHS' constituent faculties and departments, were looked for through financial records at the college or by contact with funding organizations. Published manuscripts registered with PubMed, that included MakCHS faculty authors, were also analyzed. RESULTS: A total of 58 active grants were identified, of which 18 had been initiated prior to 2005 and there were an average of about eight new grants per year. Most grants funded basic and applied research, with major focus areas being HIV/AIDS (44%), malaria (19%), maternal and child health (14%), tuberculosis (11%), mental health (3%), and others (8%). MakCHS faculty were identified as Principal Investigators (PIs) in only 22 (38%) active grants. Grant funding details were only available for one third of the active grants at MakCHS. A total of 837 publications were identified, with an average of 167 publications per year, most of which (66%) addressed the country's priority health areas, and 58% had MakCHS faculty or students as first authors. CONCLUSIONS: The research grants and publications at MakCHS are generally well-aligned with the Ugandan Health Ministry priorities. Greater efforts to establish centralized and efficient grants management procedures are needed. In addition, greater efforts are needed to expand capacity for MakCHS faculty leadership of grants, as well as to continue to expand the contribution of MakCHS faculty to lead research publications.

High risk for occupational exposure to HIV and utilization of post-exposure prophylaxis in a teaching hospital in Pune, India.

BACKGROUND: The risk for occupational exposure to HIV has been well characterized in the developed world, but limited information is available about this transmission risk in resource-constrained settings facing the largest burden of HIV infection. In addition, the feasibility and utilization of post-exposure prophylaxis (PEP) programs in these settings are unclear. Therefore, we examined the rate and characteristics of occupational exposure to HIV and the utilization of PEP among health care workers (HCW) in a large, urban government teaching hospital in Pune, India. METHODS: Demographic and clinical data on occupational exposures and their management were prospectively collected from January 2003-December 2005. US Centers for Diseases Control guidelines were utilized to define risk exposures, for which PEP was recommended. Incidence rates of reported exposures and trends in PEP utilization were examined using logistic regression. RESULTS: Of 1955 HCW, 557 exposures were reported by 484 HCW with an incidence of 9.5 exposures per 100 person-years (PY). Housestaff, particularly interns, reported the greatest number of exposures with an annual incidence of 47.0 per 100 PY. Personal protective equipment (PPE) was used in only 55.1% of these exposures. The incidence of high-risk exposures was 6.8/100 PY (n = 339); 49.1% occurred during a procedure or disposing of equipment and 265 (80.0%) received a stat dose of PEP. After excluding cases in which the source tested HIV negative, 48.4% of high-risk cases began an extended PEP regimen, of whom only 49.5% completed it. There were no HIV or Hepatitis B seroconversions identified. Extended PEP was continued unnecessarily in 7 (35%) of 20 cases who were confirmed to be HIV-negative. Over time, there was a significant reduction in proportion of percutaneous exposures and high-risk exposures (p < 0.01) and an increase in PEP utilization for high risk exposures (44% in 2003 to 100% in 2005, p = 0.002). CONCLUSION: Housestaff are a vulnerable population at high risk for bloodborne exposures in teaching hospital settings in India. With implementation of a hospital-wide PEP program, there was an encouraging decrease of high-risk exposures over time and appropriate use of PEP. However, overall use of PPE was low, suggesting further measures are needed to prevent occupational exposures in India.

Telecommunications and health Care: an HIV/AIDS warmline for communication and consultation in Rakai, Uganda.

Hotlines and warmlines have been successfully used in the developed world to provide clinical advice; however, reports on their replicability in resource-limited settings are limited. A warmline was established in Rakai, Uganda, to support an antiretroviral therapy program. Over a 17-month period, a database was kept of who called, why they called, and the result of the call. A program evaluation was also administered to clinical staff. A total of 1303 calls (3.5 calls per weekday) were logged. The warmline was used mostly by field staff and peripherally based peer health workers. Calls addressed important clinical issues, including the need for urgent care, medication side effects, and follow-up needs. Most clinical staff felt that the warmline made their jobs easier and improved the health of patients. An HIV/AIDS warmline leveraged the skills of a limited workforce to provide increased access to HIV/AIDS care, advice, and education.