Changes in Stigma and Social Support among Participants in a Randomized Trial of a Novel Expanded Social Network-based HIV Testing Intervention in KwaZulu-Natal, South Africa.

HIV-related stigma is a well-documented barrier to HIV testing in South Africa, and may be particularly likely to create reluctance to test among South African men, who have reported feeling blamed for HIV by their partners and communities. The present study presents a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention explicitly designed to reduce stigma as a barrier to testing by asking people to recruit anyone they know to testing, thus allowing them to avoid the potential for increased stigma and/or blame associated with direct risk partner recruitment, and helping to normalize openly discussing HIV among social networks. We examined baseline and 6-10-week follow-up data from a 2022-2023 randomized trial in KwaZulu-Natal, South Africa that recruited 110 individuals who had been newly diagnosed with HIV and randomly assigned them to recruit people to HIV testing either via the E-SNRHT intervention or via risk network recruitment. Participants in the E-SNRHT intervention reported significant decreases in anticipated and enacted HIV-related stigma between baseline and follow-up; and the E-SNRHT intervention was more effective at decreasing enacted HIV-related stigma than was risk network recruitment. Individuals newly diagnosed with HIV by the E-SNRHT intervention reported significant increases in social support between intervention enrollment and follow-up, and all of these individuals reported participating in positive conversations about HIV services with peers in the 6-10 weeks after intervention enrollment. These findings suggest that E-SNRHT is a potentially important strategy to reduce HIV-related stigma as a barrier to HIV testing among peer networks in KwaZulu-Natal.

Factors associated with age-disparate sexual partnerships among males and females in South Africa: a multinomial analysis of the 2012 national population-based household survey data.

BACKGROUND: In South Africa, age-disparate to sexual relationships where the age difference between partners is 5 years or greater is an important contributor to the spread of HIV. However, little is known about the predictors of age-disparate sexual relationships. This study investigates factors associated with age-disparate sexual relationships among males and females in South Africa. METHODS: This analysis used the 2012 nationally representative population-based household survey conducted using multi-stage stratified cluster sampling design. Multivariate multinomial stepwise logistic regression models were used to determine factors associated with age-disparate sexual relationships. RESULTS: Of 15,717 participants, who responded to the question on age-disparate sexual relationships, 62% males versus 58.5% females had partners within 5 years older or younger, 34.7% of males versus 2.7% of females had partners at least 5 years younger and 3.3% of males versus 38.8% of females had partners at least 5 years older. Among both males and females predictors of age-disparate sexual relationships were education, employment, socioeconomic status, locality type, age at sexual debut, condom use at last sexual act and HIV status while race was also an additional predictor for among females. Including unprotected sex and risk of HIV infection among adolescent girls and young women with sexual partners 5 years older their age. CONCLUSIONS: This study suggest that there is a need for reprioritizing the combination of behavioural and structural interventions to address risky sexual behaviours, unprotected sex, poverty, limited education and gender inequitable norms related to age-disparate sexual relationships and HIV.

Determinants of HIV infection among adolescent girls and young women aged 15-24 years in South Africa: a 2012 population-based national household survey.

BACKGROUND: South Africa is making tremendous progress in the fight against HIV, however, adolescent girls and young women aged 15-24 years (AGYW) remain at higher risk of new HIV infections. This paper investigates socio-demographic and behavioural determinants of HIV infection among AGYW in South Africa. METHODS: A secondary data analysis was undertaken based on the 2012 population-based nationally representative multi-stage stratified cluster random household sample. Multivariate stepwise backward and forward regression modelling was used to determine factors independently associated with HIV prevalence. RESULTS: Out of 3092 interviewed and tested AGYW 11.4% were HIV positive. Overall HIV prevalence was significantly higher among young women (17.4%) compared to adolescent girls (5.6%). In the AGYW model increased risk of HIV infection was associated with being young women aged 20-24 years (OR = 2.30, p = 0.006), and condom use at last sex (OR = 1.91, p = 0.010), and decreased likelihood was associated with other race groups (OR = 0.06, p < 0.001), sexual partner within 5 years of age (OR = 0.53, p = 0.012), tertiary level education (OR = 0.11, p = 0.002), low risk alcohol use (OR = 0.19, p = 0.022) and having one sexual partner (OR = 0.43, p = 0.028). In the adolescent girls model decreased risk of HIV infection was associated with other race groups (OR = 0.01, p < 0.001), being married (OR = 0.07), p = 0.016], and living in less poor household (OR = 0.08, p = 0.002). In the young women's models increased risk of HIV infection was associated with condom use at last sex (OR = 2.09, p = 0.013), and decreased likelihood was associated with other race groups (OR = 0.17, p < 0.001), one sexual partner (OR = 0.6, p = 0.014), low risk alcohol use (OR = 0.17, p < 0.001), having a sexual partner within 5 years of age (OR = 0.29, p = 0.022), and having tertiary education (OR = 0.29, p = 0.022). CONCLUSION: These findings support the need to design combination prevention interventions which simultaneously address socio-economic drivers of the HIV epidemic, promote education, equity and access to schooling, and target age-disparate partnerships, inconsistent condom use and risky alcohol consumption.

Comparison of a novel expanded social network recruitment intervention with risk network recruitment to HIV testing: locating undiagnosed cases in South Africa.

OBJECTIVE: To ascertain whether a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention recruits men and individuals with previously undiagnosed HIV at higher rates than risk network recruitment. DESIGN: Initial "seed" participants were prospectively randomly assigned to the E-SNRHT intervention or to risk network recruitment. Their network members were included in the study arm of their recruiter. SETTING: Three Department of Health clinics and two drug treatment centers (DTCs) in the Msunduzi municipality of KwaZulu-Natal, South Africa. PARTICIPANTS: Clinics and DTCs referred 110 newly HIV-diagnosed adult "seeds" to the study from June 2022 to February 2023. E-SNRHT seeds were asked to recruit network members as described below; risk network recruitment arm seeds were asked to recruit recent sex and/or injection partners. Presenting a recruitment coupon (from clinic/DTC staff or another participant) was required for eligibility. INTERVENTION: E-SNRHT seeds were shown educational material about HIV transmission risks and then asked to recruit anyone they know (e.g., friends, family) whom they thought could benefit from HIV testing. MAIN OUTCOME MEASURES: Rates of recruiting men to HIV testing and locating individuals with previously undiagnosed HIV. RESULTS: E-SNRHT recruited significantly higher proportions of men to HIV testing (70.3 vs. 40.4%; χ2  = 16.33; P  < 0.0005) and located significantly more previously undiagnosed cases of HIV per seed than risk network recruitment (rate ratio = 9.40; P  < 0.0001). E-SNRHT also recruited significantly higher proportions of women with previously undiagnosed HIV (29.0 vs. 10.7%; χ2  = 3.87; P  = 0.049). CONCLUSION: E-SNRHT is an important strategy to expand the reach of HIV testing among men and undiagnosed cases of HIV in KwaZulu-Natal.

Couples motivational interviewing with mobile breathalysers to reduce alcohol use in South Africa: a pilot randomised controlled trial of Masibambisane.

INTRODUCTION: Heavy alcohol use among people living with HIV in sub-Saharan Africa can hinder the success of HIV treatment programmes, impacting progress towards United Nations Programme on HIV/AIDS goals. Primary partners can provide critical forms of social support to reduce heavy drinking and could be included in motivational interviewing (MI) interventions to address heavy drinking; however, few studies have evaluated MI interventions for couples living with HIV in sub-Saharan Africa. We aim to evaluate the feasibility and acceptability of a couple-based MI intervention with mobile breathalyser technology to reduce heavy alcohol use and improve HIV treatment outcomes among HIV-affected couples in South Africa. METHODS AND ANALYSIS: We will employ a three-arm randomised controlled trial to assess the efficacy of couple-based MI (MI-only arm) and in conjunction with mobile breathalysers (MI-plus arm) to address alcohol use and HIV outcomes, as compared with enhanced usual care (control arm). We will enrol heterosexual couples aged 18-49 in a primary relationship for at least 6 months who have at least one partner reporting hazardous alcohol use and on antiretroviral therapy for 6 months. Participants in both MI arms will attend three manualised counselling sessions and those in the MI-plus arm will receive real-time feedback on blood alcohol concentration levels using a mobile breathalyser. Couples randomised in the control arm will receive enhanced usual care based on the South African ART Clinical Guidelines. Feasibility and acceptability indicators will be analysed descriptively, and exploratory hypotheses will be examined through regression models considering time points and treatment arms. ETHICS AND DISSEMINATION: The study was approved by the University of California, San Francisco (HRPP; protocol number 21-35034) and Human Sciences Research Council Research Ethics Committee (REC: protocol number 1/27/20/21). We will disseminate the results at local community meetings, community-level health gatherings and conferences focused on HIV and alcohol use. TRIAL REGISTRATION NUMBER: NCT05756790.

Melasma in people with darker skin types: a scoping review protocol on prevalence, treatment options for melasma and impact on quality of life.

BACKGROUND: Melasma is one of the most encountered dermatoses in dermatology and skin care clinics. It is a challenging chronic, recurrent condition associated with hyperpigmentation. Its aetiology is poorly understood. Melasma affects all races and gender but is more prevalent in women with darker skin types. Being a facial lesion, melasma has a severe impact on quality of life due to its disfigurement. While many modalities of treatment for melasma exists, unfortunately, effectiveness and safety remain a huge concern. Treatment modalities are variable and often unsatisfactory. The objective of this scoping review is to systemically map available evidence from literature regarding melasma on people with darker skin types, garner insight as to how melasma affects the quality of life and begin to investigate and gain understanding on effectiveness of different treatments used for melasma. METHODS: A scoping review guided by Arksey and O'Malley's framework, the enhancements and recommendations of Levac, Colquhoun and O'Brien, Daudt and associates and the 2015 Johanna Briggs Institute's guidelines will be conducted. Systematic electronic searches of databases and search engines will include Scopus, PubMed, CINAHL Complete, Cochrane, Science Direct, and Web of Science which will be conducted to attain published peer-reviewed articles of all study designs excluding reviews and grey literature. All literature that meets the inclusion criteria, research question and sub-question will be included in this review. All the retrieved literature will be exported to an Endnote X20 library. Quality appraisal of the included articles will be conducted using the mixed methods appraisal tool (MMAT) 2018 version. DISCUSSION: We anticipate mapping relevant literature on the melasma, investigating the effectiveness of treatment options of melasma as well as evaluating its association with quality of life in people with darker skin types. This study is likely to reveal research gaps, which could guide future implementation research on melasma treatment interventions. SYSTEMATIC REVIEW REGISTRATION: This protocol has been registered a priori with OSF and is accessible on this link: https://osf.io/ru3jc/ .

Factors influencing poor medication adherence amongst patients with chronic disease in low-and-middle-income countries: A systematic scoping review.

Background: Poor medication adherence among patients with Chronic Diseases is one of the significant health problems globally. Despite this, evidence on chronic medication adherence in low and middle-income countries is unclear. Objective: This scoping review aimed to identify factors influencing poor medication adherence amongst patients with chronic diseases in low and middle-income countries. Methods: We searched studies exploring factors influencing poor medication adherence amongst patients in low and middle-income countries across the following databases published between 2008 to 2018: Public or publisher Medline, Google scholar, Cumulated Index to Nursing and Allied Health Literature, Health Source, and Medline with full text via Elton B. Stephen's Company host. Methodological quality assessment of the primary studies was done as recommended by Levac, Colquhoun, and O'Brien (2010) review using a Mixed-Method Appraisal Tool 2018. We reported the results following the Preferred Reporting Item for Systematic reviews and Meta-Analyses extension for Scoping Review guidelines. Results: From the initial 154 records screened, we identified six (6) eligible studies that presented evidence on factors influencing poor medication adherence amongst patients in low and middle-income countries. Studies included were from the following countries: Jordan, South Africa, Guatemala, Ethiopia, Indonesia, India, and Palestine. Kappa agreement of the full article screening shows that there was 76.92% agreement versus 58.12% expected by chance which constitutes a considerably good agreement between screeners (Kappa statistic = 0.45 and p-value <0.05). Of the six included studies that underwent methodological quality, five scored 100%, which is regarded as the highest score the remaining one scored between 50-75%, indicating a moderate to low risk bias overall. All included studies presented evidence on medication adherence as being in either knowledge of the diseases, attitudes towards medication taking, beliefs that a patient holds about the treatment or disease, and quality control amongst chronic diseases patients. Conclusions: Our scoping review provides evidence that poor medication adherence in LMICs is influenced by a lack of knowledge, negative attitudes, and negative beliefs, leading to poor quality of life. There is limited research evidence on the effect of patients' beliefs and perceptions on medication adherence in low and middle-income countries. We call upon further research on beliefs, perceptions, and effectiveness of interventions towards chronic medication adherence in low and middle-income countries.

The HIV Epidemic in South Africa: Key Findings from 2017 National Population-Based Survey.

South Africa has the largest number of people living with HIV worldwide. South Africa has implemented five population-based HIV prevalence surveys since 2002 aimed at understanding the dynamics and the trends of the epidemic. This paper presents key findings from the fifth HIV prevalence, incidence, and behaviour survey conducted in 2017 following policy, programme, and epidemic change since the prior survey was conducted in 2012. A cross-sectional population-based household survey collected behavioural and biomedical data on all members of the eligible households. A total of 39,132 respondents from 11,776 households were eligible to participate, of whom 93.6% agreed to be interviewed, and 61.1% provided blood specimens. The provided blood specimens were used to determine HIV status, HIV incidence, viral load, exposure to antiretroviral treatment, and HIV drug resistance. Overall HIV incidence among persons aged 2 years and above was 0.48% which translates to an estimated 231,000 new infections in 2017. HIV prevalence was 14.0% translating to 7.9 million people living with HIV. Antiretroviral (ARV) exposure was 62.3%, with the lowest exposure among those aged 15 to 24 years (39.9%) with 10% lower ARV coverage among males compared to females. Viral suppression among those on treatment was high (87.3%), whilst HIV population viral load suppression was much lower (62.3%). In terms of risk behaviours, 13.6% of youth reported having had an early sexual debut (first sex before the age of 15 years), with more males reporting having done so (19.5%) than females (7.6%). Age-disparate relationships, defined as having a sexual partner 5+ years different from oneself,) among adolescents were more common among females (35.8%) than males (1.5%). Self-reported multiple sexual partnerships (MSPs), defined as having more than one sexual partner in the previous 12 months, were more commonly reported by males (25.5%) than females (9.0%). Condom use at last sexual encounter was highest among males than females. Three quarters (75.2%) of people reported they had ever been tested for HIV, with more females (79.3%) having had done so than males (70.9%). Two-thirds of respondents (66.8%) self-reported having tested for HIV in the past 12 months. Finally, 61.6% of males in the survey self-reported as having been circumcised, with circumcision being more common among youth aged 15-24 years (70.2%), Black Africans (68.9%), and those living in both rural informal (tribal) areas (65%) and urban areas (61.9%). Slightly more (51.2%) male circumcisions were reported to have occurred in a medical setting than in traditional settings (44.8%), with more young males aged 15-24 (62.6%) and men aged 25-49 (51.5%) reporting to have done so compared to most men aged 50 and older (57.1%) who reported that they had undergone circumcision in a traditional setting. The results of this survey show that strides have been made in controlling the HIV epidemic, especially in the reduction of HIV incidence, HIV testing, and treatment. Although condom use at last sex act remains unchanged, there continue to be some challenges with the lack of significant behaviour change as people, especially youth, continue to engage in risky behaviour and delay treatment initiation. Therefore, there is a need to develop or scale up targeted intervention programmes to increase HIV testing further and put more people living with HIV on treatment as well as prevent risky behaviours that put young people at risk of HIV infection.

The use of non-prescribed antibiotics; prevalence estimates in low-and-middle-income countries. A systematic review and meta-analysis.

BACKGROUND: The global increase in the utilization of non - prescribed antibiotics (NPA), is concerning, with high persistence within the low and middle-income countries (LMICs). With a negative impact on the health of individuals and communities the use of NPA paves the way to the  propagation of superbugs that potentially predisposes to changes in bacterial resistance patterns, antibiotic resistance (AR) and antimicrobial resistance (AMR). This study aimed at estimating through a systematic review and meta-analysis, the prevalence of NPA utilisation and describe its primary sources in LMICs. METHODS: The study is a systematic review and meta-analysis which study protocol was registered in PROSPERO (CRD42017072954). The review used The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.  The studies searched in databases were deemed eligible if reported evidence of practices of self-medication with antibiotics (SMA) and the prevalence of NPA utilisation within adult participants from LMICs, published between 2007 to 2017. The pooled analyses were carried out using Meta XL statistical software. The pooled prevalence was calculated with a 95% confidence interval (CI). The risk of bias of the included studies was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS: The review included a total of 11 cross-sectional studies, involving 5080 participants and conducted in LMICs from Asia (India, Laos, Nepal, Pakistan, Sri Lanka and Yemen), Latin America (Guatemala), Africa (Nigeria). All studies reported existing  practices of SMA, with reported prevalence ranging from 50% to 93,8%. The pooled prevalence of SMA was 78% (95% CI: 65-89%). The main sources of NPA were; pharmacies, family and friends, old prescriptions, home cabinet and leftover antibiotics. CONCLUSION: This study revealed a high prevalence of utilisation of NPA in the studied LMICs, these were found to be twice as high in women than men and those participants aged between 18 and 40 years old. The review suggests f considering broader qualitative and comprehensive contextuallized research to better understand the nuances of NPA use. These would be benefitial to uncover uncover gray areas, inform decisions, support the (re) design and implementation of multifaceted interventions towards antibiotic stewardship and conservancy in LMICs.

Prevalence and correlates of prescription drug diversion and misuse among people living with HIV in the eThekwini district, KwaZulu-Natal, South Africa.

BACKGROUND: Prescription drug diversion, and misuse has increased over the past decade and is notably in high-income-countries and significantly contributes to the opioid epidemic. People living with HIV (PLWH) are particularly vulnerable to prescription drug diversion, and misuse as most experience chronic pain, mental health problems and HIV-related illnesses. The researchers investigated the prevalence and correlates of prescription drug diversion, and misuse among PLWH in the eThekwini district, KwaZulu-Natal. METHODS: A cross-sectional study was conducted among 392 PLWH, conveniently recruited from the public healthcare facilities located in rural, semi-urban and urban areas of the eThekwini district. Participants answered questions about their background, prescription medications, substance use, and prescription drug diversion, and misuse. Descriptive analysis was performed to estimate the prevalence of prescription drug diversion, and misuse. Multivariable logistic regression was used to identify predictors of prescription drug diversion, and misuse. FINDINGS: Overall, 13% of the participants reported lifetime prescription drug diversion. The most common type of diversion was using prescription medication not prescribed by a healthcare provider (11%), followed by sharing of prescription medication (9%) and buying prescription medication without a medical script (5%). Twenty-three per cent of the participants reported prescription drug misuse in the past 90 days, with using prescription medication without a healthcare providers' guidance (9%) and not following the scheduled time periods (8%) being the most common reported types of misuse. Self-medicating was identified as a risk factor for prescription drug misuse. There was no association between ART adherence and prescription drug diversion, and misuse. CONCLUSION: The study findings contribute to improving the limited data available on prescription drug diversion, and misuse among PLWH in South Africa. The prevalence underscores a need for urgent interventions when prescribing medications with potential risks. Addressing the risk of self-medicating is imperative for HIV care outcomes and to avert death.

Prescription drug diversion, misuse, and abuse among people living with HIV: a scoping review protocol.

BACKGROUND: Prescription drugs are controlled medicines due to their potential risks of being diverted, misused, and abused. Since the introduction of antiretroviral (ARVs) drugs, HIV is currently regarded as a chronic condition. However, prescription drug diversion, misuse, and abuse might serve as one of the critical barriers for achieving optimal medication adherence among people living with HIV, thereby negatively impacting the HIV care mandate. The primary aim of this scoping review is to gather evidence on the prevalence, practices, risk factors, and motives associated with prescription drug diversion, misuse, and abuse, as well as the evidence on the association between prescription drug diversion, misuse, and abuse with antiretroviral treatment (ART) adherence. METHODS: This review will be guided by Arksey and O'Malley's framework as well as recommendations by Levac et al. (Implement Sci 5:69, 2010). We will search the following databases for relevant literature meeting our eligibility criteria: PubMed, Google Scholar, EBSCOhost (Academic Search Complete, MEDLINE, and Newspaper Source), World Health Organization, Science Direct, and Open Access Theses and Dissertations. Studies published within the period of January 1996 to June 2019 are eligible. The included studies should report evidence on the prevalence, practices, risk factors, motives, or association between ART adherence and prescription drug diversion, misuse, and abuse. Thematic analysis will be applied to summarize the review findings. DISCUSSION: We anticipate finding a considerable number of research studies on prescription drug diversion, misuse, and abuse among people living with HIV. Our synthesis of this evidence base is intended to serve as guidance for future research studies. The study findings will be disseminated through the traditional academic platforms, such as peer-reviewed publications and presentations at relevant local and international conferences, symposiums, and seminars. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017074076.

Risk factors for prescription drug diversion among people living with HIV: a systematic scoping review.

BACKGROUND: In addition to numerous infections and frequent pain constantly affecting people living with HIV (PLWH), various risk factors might contribute to prescription drug diversion. The purpose of the study is to map existing evidence on risk factors contributing to prescription drug diversion among PLWH. METHODS: Arksey and O'Malley's framework and the recommendation by Levac et al. (2010) guided this study. We searched for relevant literature from the following databases: PubMed; Google Scholar; EBSCOhost (Academic Search Complete, MEDLINE and Newspaper Source), Cochrane, WHO, HIV, ScienceDirect and Open Access Theses and Dissertations. Studies reporting evidence on risk factors contributing to prescription drug diversion and published in the period January 1996 to July 2017 were included. Thematic content analysis was performed to summarize the findings. RESULTS: The search identified 734 studies. After full-text screening of the eligible studies, risk factors contributing to prescription drug diversion among PLWH were reported in 20 included studies. It was found that there is limited research on prescription drug diversion among PLWH in low-middle-income countries (LMICs). Risk factors contributing to prescription drug diversion were being a substance user or substance dependent; being male; young in age; being stigmatized; not disclosed HIV status; diagnosed with mental health problems; being HIV infected; poor health and well being; being White; being homeless or not owing a home; having low educational level; having history of diversion, misuse or abuse; in possession of addictive prescriptions; being unemployed and living in high neighbourhood disorder. CONCLUSION: Evidence shows that there is limited research on prescription drug diversion among PLWH in LMICs. The study findings show that the risk factors contributing to prescription drug diversion are related with risk factors for HIV transmission and infection. PROSPERO REGISTRATION NUMBER: CRD42017074076.

Evidence of factors influencing self-medication with antibiotics in LMICs: a systematic scoping review protocol.

BACKGROUND: The Sustainable Development Goals (SDGs) emphasize the need for strengthening the capacity of all developing countries in the early warning, risk reduction and management of national as well as global health risks. Despite there being a considerable amount of effort in controlling and promoting the rational use of antibiotics, studies show that the practice of self-medication with antibiotics (SMA) systematically exposes individuals to the risk of antibiotic resistance and other antibiotic side effects. The proposed scoping review aims to map literature on the factors influencing self-medication with antibiotics in low- and middle-income countries (LMICs). METHODS AND ANALYSIS: The adopted search strategy for this scoping review study will involve electronic databases including PubMed, Web of Knowledge, Science Direct, EBSCOhost (PubMed, CINAHL, MEDLINE), Google Scholar, BioMed Central and World Health Organization library. A two-stage mapping strategy will be conducted. Stage 1 will screen studies through examining their titles and screening abstracts descriptively by focus and method as stipulated by the inclusion and exclusion criteria. In stage 2, the researchers will extract data from the included studies. A parallel screening and data extraction will be undertaken by two reviewers. In accessing the quality of the included studies, the researchers will utilize the mixed methods appraisal tool (MMAT, version 11). The NVivo computer software (version 11) shall be used to classify, sort, arrange and examine relationships in the data, and to extract the relevant outcomes and for the thematic analysis of the studies. DISCUSSION: The study anticipates finding relevant studies reporting evidence on the factors influencing self-medication with antibiotics in LMICs. The evidence obtained from the included studies will help guide future research. The study findings will be disseminated electronically and in print with presentations being done at relevant platforms, i.e. conferences related to antibiotic use, antimicrobial resistance, health seeking behaviour and the use of medicines. SYSTEMATIC REVIEW REGISTRATION: Prospero Registration Number: CRD42017072954.