Nearly half of adults with symptoms of sexually transmitted infections (STIs) did not seek clinical care: A population-based study of treatment-seeking behavior among adults in Rakai, Uganda.

Understanding treatment-seeking behavior is critical to the treatment and control of sexually transmitted infections (STIs), yet current data on STI treatment seeking in low-resource settings is rare. This population-based study aimed to describe STI treatment-seeking behavior and identify factors associated with seeking treatment at a clinic among adults with STI-related symptoms in rural Uganda. The STI prevalence study (STIPS) conducted a survey and STI testing among all consenting adults aged 18-49 in two communities in rural south-central Uganda. Of 1,825 participants, 962 individuals self-reported STI symptoms in the past six months; we present descriptive data on treatment seeking and STI prevalence among these individuals. We used multivariable Poisson regressions with robust variance to determine the sociodemographic and symptom-related factors independently associated with seeking STI treatment at a clinic and assessed the association with previous clinic treatment seeking and current STI diagnosis. Forty-three percent of adults who reported STI-related symptoms in the past six months said they did not seek any treatment. Among those who did, 58% sought treatment at a private clinic, 28% at a government clinic, 9% at a pharmacy/drug store, 3% at a traditional healer, 2% at a market/shop, and 5% at another location. Among both males and females, having multiple STI related symptoms was positively associated with clinic treatment seeking (males = PRR: 1.73, 95%CI: 1.36-2.21; females = PR: 1.41, 95%CI: 1.12-1.78). Approximately one-third of males and females who reported previously seeking clinic treatment for their symptoms were diagnosed with a curable STI at the time of the survey. In this setting, nearly half of adults with STI-related symptoms are not seeking clinical care and many who report having sought treatment for recent STI symptoms have curable STIs. Future studies should explore barriers to care-seeking and strategies to improve STI services.

Integration of HIV testing services into family planning services: a systematic review.

BACKGROUND: Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously. METHODS: We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017. RESULTS: Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes. CONCLUSIONS: Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.

Global and local excitation and inhibition shape the dynamics of the cortico-striatal-thalamo-cortical pathway.

The cortico-striatal-thalamo-cortical (CSTC) pathway is a brain circuit that controls movement execution, habit formation and reward. Hyperactivity in the CSTC pathway is involved in obsessive compulsive disorder (OCD), a neuropsychiatric disorder characterized by the execution of repetitive involuntary movements. The striatum shapes the activity of the CSTC pathway through the coordinated activation of two classes of medium spiny neurons (MSNs) expressing D1 or D2 dopamine receptors. The exact mechanisms by which balanced excitation/inhibition (E/I) of these cells controls the network dynamics of the CSTC pathway remain unclear. Here we use non-linear modeling of neuronal activity and bifurcation theory to investigate how global and local changes in E/I of MSNs regulate the activity of the CSTC pathway. Our findings indicate that a global and proportionate increase in E/I pushes the system to states of generalized hyper-activity throughout the entire CSTC pathway. Certain disproportionate changes in global E/I trigger network oscillations. Local changes in the E/I of MSNs generate specific oscillatory behaviors in MSNs and in the CSTC pathway. These findings indicate that subtle changes in the relative strength of E/I of MSNs can powerfully control the network dynamics of the CSTC pathway in ways that are not easily predicted by its synaptic connections.

Interventions to address unequal gender and power relations and improve self-efficacy and empowerment for sexual and reproductive health decision-making for women living with HIV: A systematic review.

BACKGROUND: Many women living with HIV experience gendered power inequalities, particularly in their intimate relationships, that prevent them from achieving optimal sexual and reproductive health (SRH) and exercising their rights. We assessed the effectiveness of interventions to improve self-efficacy and empowerment of women living with HIV to make SRH decisions through a systematic review. METHODS AND FINDINGS: We included peer-reviewed articles indexed in PubMed, PsycINFO, CINAHL, Embase, and Scopus published through January 3, 2017, presenting multi-arm or pre-post intervention evaluations measuring one of the following outcomes: (1) self-efficacy, empowerment, or measures of SRH decision-making ability, (2) SRH behaviors (e.g., condom use, contraceptive use), or (3) SRH outcomes (e.g., sexually transmitted infections [STIs]). Twenty-one studies evaluating 11 intervention approaches met the inclusion criteria. All were conducted in the United States or sub-Saharan Africa. Two high-quality randomized controlled trials (RCTs) showed significant decreases in incident gonorrhea and chlamydia. Sixteen studies measuring condom use generally found moderate increases associated with the intervention, including in higher-quality RCTs. Findings on contraceptive use, condom self-efficacy, and other empowerment measures (e.g., sexual communication, equitable relationship power) were mixed. Studies were limited by small sample sizes, high loss to follow-up, and high reported baseline condom use. CONCLUSIONS: While more research is needed, the limited existing evidence suggests that these interventions may help support the SRH and rights of women living with HIV. This review particularly highlights the importance of these interventions for preventing STIs, which present a significant health burden for women living with HIV that is rarely addressed holistically. Empowerment-based interventions should be considered as part of a comprehensive package of STI and other SRH services for women living with HIV.

Integration of sexually transmitted infection (STI) services into HIV care and treatment services for women living with HIV: a systematic review.

OBJECTIVE: To review and critically appraise the existing evidence on integration of sexually transmitted infection (STI) services into HIV care and treatment services for women living with HIV. DESIGN: Systematic review. DATA SOURCES: Four electronic databases were searched through 16February 2017 using keywords for HIV, STIs and integration. Reference lists of included articles and other reviews were also screened. REVIEW METHODS: We included studies that compared women living with HIV who received STI services integrated into HIV care and treatment services with those who received HIV care and treatment services without integrated STI services or standard of care. RESULTS: Of 170 articles identified, 3 studies reported in 4 articles were included. Two studies evaluated comprehensive care for people living with HIV in the UK; in both cases, quality and uptake of STI services seemed to improve following integration. The third study conducted a comparative case study across different models of care in Swaziland: two clinics integrated with sexual and reproductive health services (including STI services), and two stand-alone HIV clinics (without STI services). Coverage for Pap smears among women living with HIV was higher at the fully integrated site, but there was no significant difference in the prevalence of sexual health screening or advice on sexual health. Reported client satisfaction was generally higher at the stand-alone HIV clinic, and a diverse range of factors related to implementation of different care models challenged the notion that integrated services are always superior or desired. CONCLUSION: While there is a limited evidence base for integrating STI services into HIV care and treatment services, existing studies indicate that integration is feasible and has the potential for positive outcomes. However, diverse population needs and health system factors must be considered when designing models of care to provide STI services to women living with HIV.

Identifying the Sociocultural Barriers and Facilitating Factors to Nutrition-related Behavior Change: Formative Research for a Stunting Prevention Program in Ntchisi, Malawi.

BACKGROUND: As the Scaling Up Nutrition (SUN) movement gains momentum globally, more attention and resources are being given to integrated nutrition interventions. In 2013, the Government of Malawi, with support from the World Food Programme and partners, initiated such an intervention in Ntchisi District. Aimed to reduce the prevalence of stunting, the intervention has several components, including the provision of a small-quantity, lipid-based nutrient supplement (SQ-LNS) for children aged 6 to 23 months. OBJECTIVE: This paper describes formative research findings derived from a Rapid Assessment Procedures (RAP) approach to inform the integrated nutrition intervention. METHODS: With a three-phase, emergent research design, this study utilized ethnographic methods including in-depth interviews, direct meal observations, and full-day child observations. Free lists and pile sorts were conducted to define food and illness domains through cultural domain analysis. Participants included community leaders, caregivers, health surveillance assistants, and children aged 6 to 23 months. RESULTS: Community members felt that nutrition-related illnesses were less salient and threatening than other illnesses, and food quality was less important than food quantity. Household food allocation occurred in predictable patterns and varied by type of household member and season. Considered an energy-giving food, the SQ-LNS was accepted, but health education and communications tailored to local understanding of nutrition and health are necessary to ensure its appropriate utilization. CONCLUSIONS: Tailoring a communications strategy to Ntchisi, Malawi could only be done through formative research to understand the sociocultural factors influencing nutrition-related behaviors. A RAP approach allowed for a comprehensive understanding of this local environment.

Multi-level factors affecting entry into and engagement in the HIV continuum of care in Iringa, Tanzania.

Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.

Barriers and facilitators of retention in HIV care and treatment services in Iringa, Tanzania: the importance of socioeconomic and sociocultural factors.

Although an increasing number of people living with HIV (PLHIV) in sub-Saharan Africa are benefiting from the rapid scale-up of antiretroviral therapy (ART), retention in HIV care and treatment services remains a major concern. We examined socioeconomic and sociocultural barriers and potential facilitators of retention in ART in Iringa, Tanzania, a region with the second highest prevalence of HIV in the country. In 2012, 116 in-depth interviews were conducted to assess community members' perceptions, barriers and facilitators of HIV treatment in Iringa, including key informants, persons at heightened risk for infection, and HIV service-delivery users. Data were transcribed, translated, entered into Atlas.ti, coded, and analyzed for key themes. In order to provide the full range of perspectives across the community on issues that may affect retention, we report findings from all 116 participants, but draw on verbatim quotes to highlight the experiences of the 14 PLHIV who reported that they were receiving HIV care and treatment services. Despite the growing availability of HIV care and treatment services in Iringa, participants reported significant barriers to retention, including lack of knowledge and misperceptions of treatment, access problems that included difficulties in reaching distant clinics and pervasive poverty that left PLHIV unable to cope with out-of-pocket costs associated with their care, persistent stigmatization of PLHIV and frequent reliance on alternative healing systems instead of biomedical treatment. Positive perceptions of the efficacy of ART, improved ART availability in the region, improved access to care through supplemental aid, and social support were perceived to enhance treatment continuation. Our findings suggest that numerous socioeconomic and sociocultural barriers inhibit retention in HIV care and treatment services in this setting. Intervention strategies that improve ART accessibility, incorporate supplemental aid, enhance social support, reduce stigma, and develop partnerships with alternative healers are needed to improve HIV-related outcomes.

"Everything that looks good ain't good!": perspectives on urban redevelopment among persons with a history of injection drug use in Baltimore, Maryland.

BACKGROUND: While urban redevelopment is intended to ameliorate urban decay, some studies demonstrate that it can negatively impact some residents. Few studies have considered its impact on persons with a history of drug use. METHODS: A convenience sample of 25 current or former injection drug users from Baltimore, Maryland, enrolled in the AIDS Linked to the Intravenous Experience study, and reporting residence in or bordering a redeveloping neighborhood participated in 1-2 semi-structured in-depth interviews from July, 2011 to February, 2012. Interviews explored personal experiences with redevelopment and perceptions of community-wide impact. Data were analyzed using the constant comparison method. RESULTS: Respondents rarely described urban redevelopment as solely negative or positive. Revitalization and increased security in the redeveloping area were reported as positive consequences. Negative consequences included the lack of redevelopment-related employment opportunities, disruption of social ties, and housing instability among relocated residents. Respondents also said that urban redevelopment led to the displacement of drug markets to adjacent neighborhoods and outlying counties. Residential relocation and displacement of drug markets were reported as beneficial for persons in contemplative and later stages of recovery. CONCLUSION: These findings support a holistic approach to urban redevelopment that increases access to employment opportunities and affordable housing, and ensures equitable coverage of public services such as law enforcement.

Understanding the partial protection of male circumcision for HIV prevention among women in Iringa Region, Tanzania: an ethnomedical model.

Communicating the partial efficacy of male circumcision for HIV prevention is challenging. Understanding how people conceptualize risk can help programs communicate messages in a way that is understandable to local communities. This article explores women's ethnomedical model of disease transmission related to male circumcision in Iringa Region, Tanzania. We conducted in-depth interviews (IDIs) with 32 female partners of male circumcision clients and focus group discussions (FGDs) with married (n=3) and unmarried (n=3) women from November 2011 to February 2012. Interviews were digitally recorded, transcribed, and translated into English, and codes were developed based on emerging themes. While women understand that circumcised men are still at risk of HIV, risk is perceived to be low as long as both partners avoid abrasions during sexual intercourse and the man's penis is kept clean. Women said that HIV transmission only occurs when both partners have abrasions on their genitalia and mixing of blood occurs. Abrasions are thought to be the result of friction from fast or dry sex and are more likely to occur with uncircumcised men; thus, HIV can be prevented if a man is circumcised and couples have gentle, lubricated sex. In addition, women reported that the foreskin traps particles of sexually transmitted infections (STIs) including HIV, which can easily be passed on to female partners. In contrast, circumcised men are viewed as being able to clean themselves of disease particles and, therefore, do not easily acquire diseases or transmit them to female partners. These findings align with the scientific understanding of increased HIV risk associated with abrasions or microflora in the foreskin; however, the ethnomedical model differs from scientific understanding in that disease transmission can in fact occur without either of these conditions. Programs can build upon these findings to better convey risks along with the benefits of male circumcision.

Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition, and family planning services.

BACKGROUND: The integration of HIV/AIDS and maternal, neonatal, child health and nutrition services (MNCHN), including family planning (FP) is recognized as a key strategy to reduce maternal and child mortality and control the HIV/AIDS epidemic. However, limited evidence exists on the effectiveness of service integration. OBJECTIVES: To evaluate the impact of integrating MNCHN-FP and HIV/AIDS services on health, behavioral, and economic outcomes and to identify research gaps. SEARCH METHODS: Using the Cochrane Collaboration's validated search strategies for identifying reports of HIV interventions, along with appropriate keywords and MeSH terms, we searched a range of electronic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE (via PubMed), and Web of Science / Web of Social Science. The date range was from 01 January 1990 to 15 October 2010. There were no limits to language. SELECTION CRITERIA: Included studies were published in peer-reviewed journals, and provided intervention evaluation data (pre-post or multi-arm study design).The interventions described were organizational strategies or change, process modifications or introductions of technologies aimed at integrating MNCHN-FP and HIV/AIDS service delivery. DATA COLLECTION AND ANALYSIS: We identified 10,619 citations from the electronic database searches and 101 citations from hand searching, cross-reference searching and interpersonal communication. After initial screenings for relevance by pairs of authors working independently, a total of 121 full-text articles were obtained for closer examination. MAIN RESULTS: Twenty peer-reviewed articles representing 19 interventions met inclusion criteria. There were no randomized controlled trials. One study utilized a stepped wedge design, while the rest were non-randomized trials, cohort studies, time series studies, cross-sectional studies, serial cross-sectional studies, and before-after studies. It was not possible to perform meta-analysis. Risk of bias was generally high. We found high between-study heterogeneity in terms of intervention types, study objectives, settings and designs, and reported outcomes. Most studies integrated FP with HIV testing (n=7) or HIV care and treatment (n=4). Overall, HIV and MNCHN-FP service integration was found to be feasible across a variety of integration models, settings and target populations. Nearly all studies reported positive post-integration effects on key outcomes including contraceptive use, antiretroviral therapy initiation in pregnancy, HIV testing, and quality of services. AUTHORS' CONCLUSIONS: This systematic review's findings show that integrated HIV/AIDS and MNCHN-FP services are feasible to implement and show promise towards improving a variety of health and behavioral outcomes. However, significant evidence gaps remain. Rigorous research comparing outcomes of integrated with non-integrated services, including cost, cost-effectiveness, and health outcomes such as HIV and STI incidence, morbidity and mortality are greatly needed to inform programs and policy.