Global mid-upper arm circumference cut-offs for adults: a call to action.

Since 2009, mid-upper arm circumference (MUAC) has become an accepted measure for screening children for acute malnutrition and determining eligibility for services to manage acute malnutrition. Use of MUAC has increased the reach and enhanced the quality of community-based management of acute malnutrition services. Increasingly, MUAC is also used to assess nutritional status and eligibility for nutrition support among adolescents and adults, including pregnant and lactating women and HIV and TB clients. However, globally recognised cut-offs have not been established to classify malnutrition among adults using MUAC. Therefore, different countries and programmes use different MUAC cut-offs to determine eligibility for programme services. Patient monitoring guidelines provided by WHO for country adaptation to support the integrated management of adult illness do not include MUAC, in part because guidance does not exist about what MUAC cut-off should trigger further action.

Determining a global mid-upper arm circumference cut-off to assess underweight in adults (men and non-pregnant women).

OBJECTIVE: To determine if a global mid-upper arm circumference (MUAC) cut-off can be established to classify underweight in adults (men and non-pregnant women). DESIGN: We conducted an individual participant data meta-analysis (IPDMA) to explore the sensitivity (SENS) and specificity (SPEC) of various MUAC cut-offs for identifying underweight among adults (defined as BMI < 18·5 kg/m2). Measures of diagnostic accuracy were determined every 0·5 cm across MUAC values from 19·0 to 26·5 cm. A bivariate random effects model was used to jointly estimate SENS and SPEC while accounting for heterogeneity between studies. Various subgroup analyses were performed. SETTING: Twenty datasets from Africa, South Asia, Southeast Asia, North America and South America were included. PARTICIPANTS: All eligible participants from the original datasets were included. RESULTS: The total sample size was 13 835. Mean age was 32·6 years and 65 % of participants were female. Mean MUAC was 25·7 cm, and 28 % of all participants had low BMI (<18·5 kg/m2). The area under the receiver operating characteristic curve for the pooled dataset was 0·91 (range across studies 0·61-0·98). Results showed that MUAC cut-offs in the range of ≤23·5 to ≤25·0 cm could serve as an appropriate screening indicator for underweight. CONCLUSIONS: MUAC is highly discriminatory in its ability to distinguish adults with BMI above and below 18·5 kg/m2. This IPDMA is the first step towards determining a global MUAC cut-off for adults. Validation studies are needed to determine whether the proposed MUAC cut-off of 24 cm is associated with poor functional outcomes.

Content guidance for mobile phones short message service (SMS)-based antiretroviral therapy adherence and appointment reminders: a review of the literature.

Mobile phones are increasingly being used to support health activities, including the care and management of people living with HIV/AIDS. Short message service (SMS) has been explored as a means to optimize and support behaviour change. However, there is minimal guidance on messaging content development. The purpose of this review was to inform the content of SMS messages for mobile health (mHealth) initiatives designed to support anti-retroviral therapy adherence and clinic appointment keeping in resource-limited settings. PubMed, OvidMedline, Google Scholar, K4Health's mHealth Evidence database, the mHealth Working Group project resource, and Health COMpass were searched. A request to online communities for recommendations on message content was also made. 1010 unique sources were identified, of which 51 were included. The information was organized into three categories: pre-message development, message development, and security and privacy. Fifteen of the publications explicitly provided their message content. Important lessons when developing the content of SMS were: (1) conducting formative research; (2) grounding content in behaviour change theory; and (3) reviewing proposed content with experts. Best practices exist for developing message content for behaviour change. Efforts should be continued to apply lessons learned from the existing literature to inform mHealth initiatives supporting HIV/AIDS care and treatment.

Food Insecurity, Morbidities, and Substance Use in Adults on Probation in Rhode Island.

When individuals are on probation, they face challenges with securing employment and safe housing due to their criminal records, which may make food access problematic. Food insecurity is a construct used as a marker for food access that considers financial constraints and has been associated with poorer health and substance use. There is limited research on the extent of food insecurity and associated morbidities and substance use among adults on probation. We conducted a cross-sectional study in 2016, surveying 304 probationers in Rhode Island to determine whether food insecurity is associated with obesity, high blood pressure, depression, and substance use. Separate logistic regression models were used to determine the associations between food insecurity and obesity, high blood pressure, depression, and substance use. Food insecurity was experienced by 70% of our study population. The estimated prevalence of high blood pressure was significantly higher in our study sample compared to the general US population. Food insecurity was not associated with obesity, high blood pressure, or current drug use in this study sample. Food insecurity was independently associated with more than three times greater odds of being depressed (AOR 3.33, 95%CI 1.89, 5.86) and a nearly twofold greater odds of self-reporting a lower health status (AOR 1.91, 95%CI 1.18, 3.10) after adjusting for gender, race/ethnicity, age, income categories, and being homeless. Probationers were found to have a higher estimated prevalence of high blood pressure and food insecurity compared to the general population, which highlights the health disparities faced by this population. Our findings have important implications for future research and interventions to decrease the health burden not only on the individuals but their families and communities.

Competing priorities that rival health in adults on probation in Rhode Island: substance use recovery, employment, housing, and food intake.

BACKGROUND: Individuals on probation experience economic disadvantage because their criminal records often prohibit gainful employment, which compromises their ability to access the basic components of wellbeing. Unemployment and underemployment have been studied as distinct phenomenon but no research has examined multiple determinants of health in aggregate or explored how these individuals prioritize each of these factors. This study identified and ranked competing priorities in adults on probation and qualitatively explored how these priorities impact health. METHODS: We conducted in-depth interviews in 2016 with 22 adults on probation in Rhode Island to determine priority rankings of basic needs. We used Maslow's hierarchy of needs theory and the literature to guide the priorities we pre-selected for probationers to rank. Within a thematic analysis framework, we used a modified ranking approach to identify the priorities chosen by participants and explored themes related to the top four ranked priorities. RESULTS: We found that probationers ranked substance use recovery, employment, housing, and food intake as the top four priorities. Probationers in recovery reported sobriety as the most important issue, a necessary basis to be able to address other aspects of life. Participants also articulated the interrelatedness of difficulties in securing employment, food, and housing; these represent stressors for themselves and their families, which negatively impact health. Participants ranked healthcare last and many reported underinsurance as an issue to accessing care. CONCLUSIONS: Adults on probation are often faced with limited economic potential and support systems that consistently place them in high-risk environments with increased risk for recidivism. These findings emphasize the need for policies that address the barriers to securing gainful employment and safe housing. Interventions that reflect probationer priorities are necessary to begin to mitigate the health disparities in this population.

Calcium Intake and Cardiovascular Disease Risk: An Updated Systematic Review and Meta-analysis.

BACKGROUND: Conflicting evidence exists regarding potential cardiovascular risks associated with high levels of calcium intake. PURPOSE: To update and reanalyze 2 systematic reviews to examine the effects of calcium intake on cardiovascular disease (CVD) among generally healthy adults. DATA SOURCES: MEDLINE; Cochrane Central Register of Controlled Trials; Scopus, including EMBASE; and previous evidence reports from English-language publications from 1966 to July 2016. STUDY SELECTION: Randomized trials and prospective cohort and nested case-control studies with data on dietary or supplemental intake of calcium, with or without vitamin D, and cardiovascular outcomes. DATA EXTRACTION: Study characteristics and results extracted by 1 reviewer were confirmed by a second reviewer. Two raters independently assessed risk of bias. DATA SYNTHESIS: Overall risk of bias was low for the 4 randomized trials (in 10 publications) and moderate for the 27 observational studies included. The trials did not find statistically significant differences in risk for CVD events or mortality between groups receiving supplements of calcium or calcium plus vitamin D and those receiving placebo. Cohort studies showed no consistent dose-response relationships between total, dietary, or supplemental calcium intake levels and cardiovascular mortality and highly inconsistent dose-response relationships between calcium intake and risks for total stroke or stroke mortality. LIMITATIONS: CVD disease outcomes were secondary end points in all trials. Dose-response metaregression analysis of cohort studies was limited by potential confounding, ecological bias, and imprecise measures of calcium exposures. Data were scarce regarding very high calcium intake-that is, beyond recommended tolerable upper intake levels. CONCLUSION: Calcium intake within tolerable upper intake levels (2000 to 2500 mg/d) is not associated with CVD risk in generally healthy adults. PRIMARY FUNDING SOURCE: National Osteoporosis Foundation.

Concurrent Anemia and Elevated C-Reactive Protein Predicts HIV Clinical Treatment Failure, Including Tuberculosis, After Antiretroviral Therapy Initiation.

BACKGROUND: Anemia is a known risk factor for clinical failure following antiretroviral therapy (ART). Notably, anemia and inflammation are interrelated, and recent studies have associated elevated C-reactive protein (CRP), an inflammation marker, with adverse human immunodeficiency virus (HIV) treatment outcomes, yet their joint effect is not known. The objective of this study was to assess prevalence and risk factors of anemia in HIV infection and to determine whether anemia and elevated CRP jointly predict clinical failure post-ART. METHODS: A case-cohort study (N = 470 [236 cases, 234 controls]) was nested within a multinational randomized trial of ART efficacy (Prospective Evaluation of Antiretrovirals in Resource Limited Settings [PEARLS]). Cases were incident World Health Organization stage 3, 4, or death by 96 weeks of ART treatment (clinical failure). Multivariable logistic regression was used to determine risk factors for pre-ART (baseline) anemia (females: hemoglobin <12.0 g/dL; males: hemoglobin <13.0 g/dL). Association of anemia as well as concurrent baseline anemia and inflammation (CRP ≥ 10 mg/L) with clinical failure were assessed using multivariable Cox models. RESULTS: Baseline anemia prevalence was 51% with 15% prevalence of concurrent anemia and inflammation. In analysis of clinical failure, multivariate-adjusted hazard ratios were 6.41 (95% confidence interval [CI], 2.82-14.57) for concurrent anemia and inflammation, 0.77 (95% CI, .37-1.58) for anemia without inflammation, and 0.45 (95% CI, .11-1.80) for inflammation without anemia compared to those without anemia and inflammation. CONCLUSIONS: ART-naive, HIV-infected individuals with concurrent anemia and inflammation are at particularly high risk of failing treatment, and understanding the pathogenesis could lead to new interventions. Reducing inflammation and anemia will likely improve HIV disease outcomes. Alternatively, concurrent anemia and inflammation could represent individuals with occult opportunistic infections in need of additional screening.

National Institutes of Health Funding for Tuberculosis Comorbidities Is Disproportionate to Their Epidemiologic Impact.

Tuberculosis (TB) is a leading infectious killer worldwide. We systematically searched the National Institutes of Health Research, Portfolio Online Reporting Tools Expenditures and Results (RePORTER) website to compare research funding for key TB comorbidities-undernutrition, alcohol use, human immunodeficiency virus, tobacco use, and diabetes-and found a large mismatch between the population attributable fraction of these risk factors and the funding allocated to them.

Lower nutritional status and higher food insufficiency in frail older US adults.

Frailty is a state of decreased physical functioning and a significant complication of ageing. We examined frailty, energy and macronutrient intake, biomarkers of nutritional status and food insufficiency in US older adult (age ≥ 60 years) participants of the Third National Health and Nutrition Examination Survey (n 4731). Frailty was defined as meeting ≥ 2 and pre-frailty as meeting one of the following four-item criteria: (1) slow walking; (2) muscular weakness; (3) exhaustion and (4) low physical activity. Intake was assessed by 24 h dietary recall. Food insufficiency was self-reported as 'sometimes' or 'often' not having enough food to eat. Analyses were adjusted for sex, race, age, smoking, education, income, BMI, other co-morbid conditions and complex survey design. Prevalence of frailty was highest among people who were obese (20·8 %), followed by overweight (18·4 %), normal weight (16·1 %) and lowest among people who were underweight (13·8 %). Independent of BMI, daily energy intake was lowest in people who were frail, followed by pre-frail and highest in people who were not frail (6648 (se 130), 6966 (se 79) and 7280 (se 84) kJ, respectively, P< 0·01). Energy-adjusted macronutrient intakes were similar in people with and without frailty. Frail (adjusted OR (AOR) 4·7; 95 % CI 1·7, 12·7) and pre-frail (AOR 2·1; 95 % CI 0·8, 5·8) people were more likely to report being food insufficient than not frail people. Serum albumin, carotenoids and Se levels were lower in frail adults than not frail adults. Research is needed on targeted interventions to improve nutritional status and food insufficiency among frail older adults, while not necessarily increasing BMI.

HEAR US: a qualitative study of racial discrimination in Boston's Chinatown and empowering change from within the community.

Objective: To qualitatively explore the impact of anti-Asian racism in a Chinese community in the greater Boston area. Methods: Individual semi-structured interviews (n = 27) were conducted between June and September 2021. Eligible participants were ethnic Chinese immigrants living in the Boston area, who were recruited through a community-based organization and by word-of-mouth. Interviews were conducted in Mandarin and Cantonese and translated into English. Data were coded and analyzed using a directed approach to content analysis. Results: The majority of participants reported personal experiences of anti-Asian racism, ranging from microaggressions to violent attacks. Although lockdown and isolation during COVID-19 affected all communities, the Chinese community suffered unique and prolonged trauma stemming from the fear of violent attacks against Asians. The older person/people, in particular, were severely isolated due to fear of exposure to anti-Asian hate crimes. Participants reported a variety of emotional, mental, and physical health effects associated with feelings of fear, anxiety, isolation, and powerlessness. Many preferred to engage in self-protective behavior changes rather than relying on external resources. Conclusion: Participants advocated for more education, community, and governmental support, and increased allyship between communities of color. These findings provide cultural context on the trauma this population faces and can inform further actions to address the wide range of reported health effects.

Sources of exposure and risk among employees infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in a large, urban, tertiary-care hospital in the United States.

Objective: Hospital employees are at risk of SARS-CoV-2 infection through transmission in 3 settings: (1) the community, (2) within the hospital from patient care, and (3) within the hospital from other employees. We evaluated probable sources of infection among hospital employees based on reported exposures before infection. Design: A structured survey was distributed to participants to evaluate presumed COVID-19 exposures (ie, close contacts with people with known or probable COVID-19) and mask usage. Participants were stratified into high, medium, low, and unknown risk categories based on exposure characteristics and personal protective equipment. Setting: Tertiary-care hospital in Boston, Massachusetts. Participants: Hospital employees with a positive SARS-CoV-2 PCR test result between March 2020 and January 2021. During this period, 573 employees tested positive, of whom 187 (31.5%) participated. Results: We did not detect a statistically significant difference in the proportion of employees who reported any exposure (ie, close contacts at any risk level) in the community compared with any exposure in the hospital, from either patients or employees. In total, 131 participants (70.0%) reported no known high-risk exposure (ie, unmasked close contacts) in any setting. Among those who could identify a high-risk exposure, employees were more likely to have had a high-risk exposure in the community than in both hospital settings combined (odds ratio, 1.89; P = .03). Conclusions: Hospital employees experienced exposure risks in both community and hospital settings. Most employees were unable to identify high-risk exposures prior to infection. When respondents identified high-risk exposures, they were more likely to have occurred in the community.

High rates of serum selenium deficiency among HIV- and HCV-infected and uninfected drug users in Buenos Aires, Argentina.

OBJECTIVE: To describe the prevalence of low serum Se and determine whether HIV, hepatitis C virus (HCV) and/or the types of drugs used are associated with serum Se in a cohort of infected and uninfected drug users. DESIGN: Independent correlates of low serum Se levels based on data collected from food recalls, physical examinations and clinical questionnaires were identified using multivariate regression analysis. SETTING: Buenos Aires, Argentina SUBJECTS: A total of 205 (twenty-five female and 180 male) former and current drug users. RESULTS: Drug users had an average serum Se level of 69·8 (sd 32·8) µg/d, [corrected] and 82 % were considered deficient (<85 µg/l). [corrected] Multivariate analyses found that HIV- and/or HCV-infected individuals had lower mean Se compared with healthy, uninfected drug users (HIV/HCV co-infection: -25·3 µg/l (se 7·6), P = 0·001; HIV alone: -28·9 µg/l (se 6·9), P < 0·001; HCV alone: -19·4 µg/l (se 7·1), P = 0·006). Current and previous drug use was associated with higher serum Se. Cigarette smoking and heavy alcohol consumption were not found to be associated with Se status. CONCLUSIONS: Low serum Se levels are highly prevalent among drug users in Buenos Aires, Argentina. Se supplementation and/or dietary interventions may be warranted in drug users who are at high risk for HIV and/or HCV infection.

Food Access, Dietary Intake, and Nutrition Knowledge of Adults on Probation.

OBJECTIVE: To examine food access, dietary intake, and perceptions about diet and associations with health among adults on probation. DESIGN: Using a mixed-methods approach, interviews were used to understand food access, dietary intake, and diet and associations with health. A survey measured self-assessed diet quality and diet and associations with health. SETTING: One probation office in Rhode Island. PARTICIPANTS: English-speaking adults on probation in 2016 (n = 22 interviews, n = 304 surveys). MAIN OUTCOME MEASURE(S): Food access, dietary intake, knowledge about diet and health, and perceptions about healthy food. ANALYSIS: We used a thematic analytic approach to analyze the interviews. Descriptive statistics were performed for the survey. RESULTS: Many interviewees had inadequate food access, although most participated in the Supplemental Nutrition Assistance Program, and some received food from food banks. Interviewees primarily shopped at grocery stores and prepared food at home, and dietary intakes did not meet the 2020-2025 Dietary Guidelines for Americans. Almost two-thirds (64.2%) of survey participants reported good or fair diet quality. Based on the survey results, the majority of participants strongly agreed and agreed with the statements, "The types of foods I eat affect my health" and "The types of food I eat affect my weight." CONCLUSIONS AND IMPLICATIONS: This study identified low-quality dietary intake and food acquisition strategies, such as shopping sales, buying bulk, and going to multiple stores, by US adults on probation to access food with limited resources. Participants reported interest in eating healthier foods and knew there was a connection between dietary intake and health. These data support addressing ways to improve food access and dietary quality, focusing on future programs and policies for this population.

Predictors of loss to follow-up from HIV antiretroviral therapy in Namibia.

Despite progress on population-level HIV viral suppression, unknown outcomes amongst people who have initiated antiretroviral therapy (ART) in low- and middle-income countries, commonly referred to as loss to follow-up (LTFU), remains a barrier. The mean global estimate of LTFU is 20%, exceeding the World Health Organization target of <15%. Pervasive predictors associated with LTFU include younger age, low body mass index, low CD4 count, advanced HIV clinical stage and certain ART regimens. In Namibia, ART use by eligible individuals exceeds 85%, surpassing the global average. Nonetheless, LTFU remains a barrier to achieving viral suppression and requires research to elucidate context-specific factors. An observational cohort study was conducted in Namibia in 2012 by administering surveys to individuals who presented for HIV care and initiated ART for the first time. Additional data were collected from routine medical data monitoring systems. Participants classified as LTFU at 12 months were traced to confirm their status. Predictors of LTFU were analyzed using multivariable logistic regression. Of those who presented consecutively to initiate ART, 524 were identified as eligible to enroll in the study, 497 enrolled, and 474 completed the baseline questionnaire. The cohort had mean age 36 years, 39% were male, mean CD4 cell count 222 cells/mm3, 17% were WHO HIV clinical stage III-IV, and 14% started efavirenz-based regimens. Tracing participants classified as LTFU yielded a re-categorization from 27.8% (n = 132) to 14.3% (n = 68) LTFU. In the final multivariable model, factors associated with confirmed LTFU status were: younger age (OR 0.97, 95% CI 1.00-1.06, p = 0.02); male sex (OR 2.34, CI 1.34-4.06, p = 0.003); difficulty leaving work or home to attend clinic (OR 2.55, CI 1.40-4.65, p = 0.002); and baseline efavirenz-based regimen (OR 2.35, CI 1.22-4.51, p = 0.01). Interventions to reduce LTFU should therefore target young men, particularly those who report difficulty leaving work or home to attend clinic and are on an efavirenz-based regimen.

Nutrition issues in the HIV-infected injection drug user: findings from the nutrition for healthy living cohort.

OBJECTIVE: The purpose of this paper is to highlight disparities between injection drug users (IDUs) and those who had never been IDUs from the Nutrition for Healthy Living (NFHL) cohort. Although IDUs were enrolled in the cohort throughout its duration, few analyses have sought to highlight findings specific to them. METHODS: NFHL, a prospective, longitudinal cohort conducted from 1995-2005, included 881 human immunodeficiency virus (HIV) -infected men and women over the age of 18. Subjects were seen every 6 months; body composition and dietary and laboratory data were collected. Individuals were classified as current IDUs, past IDUs, and never-IDUs. The classification of ever-IDU combined current and past users. RESULTS: In NFHL, a higher proportion of ever-IDUs were women, African American, had a high school education or less, smoked, and were housing insecure and food insecure compared to never-IDUs. Ever-IDUs had lower total, soluble, and insoluble fiber and individual micronutrient intakes. A higher proportion of ever-IDUs had hepatitis C and HIV-related symptoms, used highly active antiretroviral therapy (HAART) less, and had a CD4 count <500 cells/mm3, than never-IDUs, at the study endpoint. CONCLUSIONS: The course of HIV infection in past and current IDUs appears to be unique and requires more investigation. Physiologic and sociodemographic characteristics of IDUs contribute to poor disease management and nutritional status. Classic manifestations of HIV persist in IDUs in the HAART era.

Heavy injection drug use is associated with lower percent body fat in a multi-ethnic cohort of HIV-positive and HIV-negative drug users from three U.S. cities.

BACKGROUND: The clinical implications of lower body weight in drug using populations are uncertain given that lower mean weights may still fall within the healthy range. OBJECTIVES: To determine the effect of type, mode and frequency of drug use on underlying body composition after accounting for differences in body shape and size. METHODS: We conducted a cross-sectional analysis of 511 participants from the Tufts Nutrition Collaborative (TNC) Study. Data included measures of body composition, a 24-hour dietary recall, and a detailed health history and lifestyle questionnaire. Multivariate regression analysis was used to determine the independent effect of drug use on percent body fat (BF) after adjusting for BMI and waist circumference. RESULTS: Heavy injection drug users (IDUs) had a 2.6% lower percent BF than non-users after adjusting for BMI, waist circumference, and other confounders. (p = 0.0006). Differences in percent BF were predominantly due to higher lean mass, rather than lower fat mass. Cocaine and heroin had similar effects on body composition. CONCLUSIONS: In the U.S., where the general population is prone to over-nutrition, the average percent BF for heavy injectors does not fall into a range low enough to suggest harmful effects. However, in populations with substantial levels of under-nutrition, small differences in percent BF among drug users will have a greater impact on health status. SCIENTIFIC SIGNIFICANCE: Differences in BMI, weight and body composition are not always straightforward. Accounting for underlying nutritional status and relative differences in fat and FFM is critical when interpreting results. diagnosed patients and prevent them from returning to prison.

Impact of Substance Use Disorder on Midterm Mortality After Valve Surgery for Endocarditis.

BACKGROUND: Fueled by the burgeoning opioid epidemic, valve surgeries for substance use disorder-related infective endocarditis (SUD-IE) are increasing. The impact of substance use disorder on postvalve replacement morbidity needs further investigation. METHODS: We queried The Society of Thoracic Surgeons Adult Cardiac Surgery Database for all valve surgeries for infective endocarditis at Tufts Medical Center (2002-2016) and collected demographic and disease-related data, including timing of mortality subclassified as short-term (<6 months including operative), midterm (6 months to 5 years), and extended-term (>5 years). Patients with documentation of illicit drug use before the operation were considered to have SUD-IE. Deaths were confirmed through review of medical record and matching with the Massachusetts Vital Statistics Database. We performed univariate and multivariate proportional hazard regressions examining the impact of substance use disorder mortality in people who received a valve replacement. RESULTS: In the cohort of 228 patients, 80 (35%) had SUD-IE. Eight-six people (38%) died, and overall mortality was higher in people with SUD-IE compared with non-SUD-IE (48% vs 32%, P = .025). SUD-IE was associated with a higher risk of overall mortality (adjusted hazard ratio, 2.41; 95% confidence interval, 1.38-4.20; P = .002). Although the difference between short-term or extended-term mortality was not significant, SUD-IE was associated with increased frequency of midterm mortality (53% vs 31%, P = .003). CONCLUSIONS: Our data reflect high rates of postvalve surgery morbidity and mortality in people with SUD-IE at a tertiary care center. The midterm postoperative period is a vulnerable period for people with SUD-IE worthy of further investigation.

Enteric parasitic infections in children and dogs in resource-poor communities in northeastern Brazil: Identifying priority prevention and control areas.

The aim of this study was to determine the prevalence and risk factors of the main enteric parasitic infections that affect children and dogs in the municipality of Ilhéus, Bahia, Brazil; and to identify the geopolitical areas that should receive priority interventions to combat them. Between March and November 2016, fecal samples of 143 dogs and 193 children aged 1 month to 5 years were collected in 40 rural and semirural communities using a systematic sampling approach, stratified by district. Samples were collected by legal guardians of the children and / or dog owners. Eggs, larvae, cysts and oocysts of parasites were concentrated by centrifugal-flotation and centrifugal-sedimentation, and acid-resistant staining was used to visualize parasites. One hundred and thirty-two children (68.4%), 111 dogs (77.6%) and 199 (73.7%) dog fecal samples collected from streets were parasitized. Giardiasis, cryptosporidiosis, amoeba infections and hookworm were the most frequent infections in all studied populations, in addition to trichuriasis in dogs and ascaridiasis in children. A predominance of Giardia and hookworms was observed in children and dogs, respectively. The coastal districts of Aritaguá, Olivença and the main district had a higher parasitic diversity and overlapping of important potential zoonotic infections. Age over one year (p<0.001), adjusted OR = 3.65; 95% CI = 1.86-7.16) and income below the minimum monthly salary (p = 0.02, adjusted OR = 2.78, 95% CI = 1.17-6.59) were the main factors associated with intestinal parasitic infections in children and dogs, respectively. The coastal districts of Aritaguá and Olivença and the main district should be prioritized through enteric disease control programs, and the factors associated with infections must be considered in the design of health interventions in these districts. The integration between affirmative income actions and investments to improve the health infrastructure of these communities may work more effectively than current preventive measures to combat enteric parasites.

High levels of HIV drug resistance among adults failing second-line antiretroviral therapy in Namibia.

To support optimal third-line antiretroviral therapy (ART) selection in Namibia, we investigated the prevalence of HIV drug resistance (HIVDR) at time of failure of second-line ART. A cross-sectional study was conducted between August 2016 and February 2017. HIV-infected people ≥15 years of age with confirmed virological failure while receiving ritonavir-boosted protease inhibitor (PI/r)-based second-line ART were identified at 15 high-volume ART clinics representing over >70% of the total population receiving second-line ART. HIVDR genotyping of dried blood spots obtained from these individuals was performed using standard population sequencing methods. The Stanford HIVDR algorithm was used to identify sequences with predicted resistance; genotypic susceptibility scores for potential third-line regimens were calculated. Two hundred thirty-eight individuals were enrolled; 57.6% were female. The median age and duration on PI/r-based ART at time of enrolment were 37 years and 3.46 years, respectively. 97.5% received lopinavir/ritonavir-based regimens. The prevalence of nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI), and PI/r resistance was 50.6%, 63.1%, and 13.1%, respectively. No significant association was observed between HIVDR prevalence and age or sex. This study demonstrates high levels of NRTI and NNRTI resistance and moderate levels of PI resistance in people receiving PI/r-based second-line ART in Namibia. Findings underscore the need for objective and inexpensive measures of adherence to identify those in need of intensive adherence counselling, routine viral load monitoring to promptly detect virological failure, and HIVDR genotyping to optimize selection of third-line drugs in Namibia.