Economic vulnerability and non-initiation of antiretroviral therapy in India: a qualitative study.

In India, many people living with HIV (PLHIV) do not successfully initiate antiretroviral therapy (ART) after diagnosis. We conducted a clinic-based qualitative study at the Y.R. Gaitonde Centre for AIDS Research in Chennai, Tamil Nadu to explore factors that influence ART non-initiation. We interviewed 22 men and 15 women; median age was 42 (IQR, 36-48) and median CD4+ was 395 (IQR, 227-601). Participants were distrustful of HIV care freely available at nearby government facilities. Faced with the perceived need to access the private sector and therefore pay for medications and transportation costs, non-initiators with high CD4+ counts often decided to postpone ART until they experienced symptoms whereas non-initiators with low CD4+ counts often started ART but defaulted quickly after experiencing financial stressors or side effects. Improving perceptions of quality of care in the public sector, encouraging safe serostatus disclosure to facilitate stronger social support, and alleviating economic hardship may be important in encouraging ART initiation in India.

An Advanced Cardiac Life Support Application Improves Performance during Simulated Cardiac Arrest.

OBJECTIVES: Variability in cardiopulmonary arrest training and management leads to inconsistent outcomes during in-hospital cardiac arrest. Existing clinical decision aids, such as American Heart Association (AHA) advanced cardiovascular life support (ACLS) pocket cards and third-party mobile apps, often lack comprehensive management guidance. We developed a novel, guided ACLS mobile app and evaluated user performance during simulated cardiac arrest according to the 2020 AHA ACLS guidelines via randomized controlled trial. METHODS: Forty-six resident physicians were randomized to lead a simulated code team using the AHA pockets cards (N = 22) or the guided app (N = 24). The primary outcome was successful return of spontaneous circulation (ROSC). Secondary outcomes included code leader stress and confidence, AHA ACLS guideline adherence, and errors. A focus group of 22 residents provided feedback. Statistical analysis included two-sided t-tests and Fisher's exact tests. RESULTS: App users showed significantly higher ROSC rate (50 vs. 18%; p = 0.024), correct thrombolytic administration (54 vs. 23%; p = 0.029), backboard use (96 vs. 27%; p < 0.001), end-tidal CO2 monitoring (58 vs. 27%; p = 0.033), and confidence compared with baseline (1.0 vs 0.3; p = 0.005) compared with controls. A focus group of 22 residents indicated unanimous willingness to use the app, with 82% preferring it over AHA pocket cards. CONCLUSION: Our guided ACLS app shows potential to improve user confidence and adherence to the AHA ACLS guidelines and may help to standardize in-hospital cardiac arrest management. Further validation studies are essential to confirm its efficacy in clinical practice.

Mapping metabolic activity at single cell resolution in intact volcanic fumarole sediment.

Interactions among microorganisms and their mineralogical substrates govern the structure, function and emergent properties of microbial communities. These interactions are predicated on spatial relationships, which dictate metabolite exchange and access to key substrates. To quantitatively assess links between spatial relationships and metabolic activity, this study presents a novel approach to map all organisms, the metabolically active subset and associated mineral grains, all while maintaining spatial integrity of an environmental microbiome. We applied this method at an outgassing fumarole of Vanuatu's Marum Crater, one of the largest point sources of several environmentally relevant gaseous compounds, including H2O, CO2 and SO2. With increasing distance from the sediment-air surface and from mineral grain outer boundaries, organism abundance decreased but the proportion of metabolically active organisms often increased. These protected niches may provide more stable conditions that promote consistent metabolic activity of a streamlined community. Conversely, exterior surfaces accumulate more organisms that may cover a wider range of preferred conditions, implying that only a subset of the community will be active under any particular environmental regime. More broadly, the approach presented here allows investigators to see microbial communities 'as they really are' and explore determinants of metabolic activity across a range of microbiomes.

The Convergence of Disclosure Concerns and Poverty Contributes to Loss to HIV Care in India: A Qualitative Study.

In India, there is little evidence on reasons for high rates of loss to HIV care. We conducted a clinic-based qualitative study at the YR Gaitonde Centre for AIDS Research and Education to explore factors that influence loss to care. In all, 17 men and 14 women were interviewed; median age was 42 (interquartile range [IQR], 36-48) and median CD4 count was 448 (IQR, 163-609). A majority reported avoiding treatment freely available at nearby government facilities because of disclosure concerns and perceptions of poor quality. As a result, participants sought care in the private sector where they were subjected to medication and transport costs. Life circumstances causing lost wages or unexpected expenditures therefore prevented participants from attending clinic, resulting in loss to care. Improving perceptions of quality of care in the public sector, addressing disclosure concerns, and reducing economic hardships among people living with HIV may be important in reducing loss to HIV care in India.