The Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018-2019.

The international response to the evolving Ebola epidemic in eastern Democratic Republic of Congo (DRC) has had interim successes while facing ongoing difficulties. The outbreak has occurred in an area of intractable conflict among multiple armed groups at a time of contentious national elections. Despite porous international borders and considerable population movement, however, transmission has been confined to North Kivu and Ituri provinces. Factors potentially contributing to this containment include conduct of about 55 million screenings, surveillance of contacts (12,591 under surveillance currently), testing of 280 samples per day, provision of safe and dignified burials for most deaths, vaccination of high-risk people (112,485 vaccinated as of May 7, 2019), and medical treatment including four investigational therapies. Major challenges remain. Since late February 2019, a sharp rise in cases and increased transmission have been observed. These coincide with organized attacks by armed groups targeting response teams, deteriorating security, and the population's increasing distrust of the response effort. The risk of local and regional spread remains high given the high proportion of deaths occurring outside treatment facilities, relatively low proportions of new patients who were known contacts, ongoing nosocomial transmission, and persistent delays in detection and reporting. Stopping this epidemic will require the alignment of the principal political and armed groups in eastern DRC in support of the response.

Unenhanced computed tomography (CT) utility for triage at the emergency department during COVID-19 pandemic.

BACKGROUND: Unenhanced chest computed tomography (CT) can assist in the diagnosis and classification of coronavirus disease 2019 (COVID-19), complementing to the reverse-transcription polymerase chain reaction (RT-PCR) tests; the performance of which has yet to be validated in emergency department (ED) setting. The study sought to evaluate the diagnostic performance of chest CT in the diagnosis and management of COVID-19 in ED. METHODS: This retrospective single-center study included 155 patients in ED who underwent both RT-PCR and chest CT for suspected COVID-19 from March 1st to April 1st, 2020. The clinical information, CT images and laboratory reports were reviewed and the performance of CT was assessed, using the RT-PCR as standard reference. Moreover, an adjudication committee retrospectively rated the probability of COVID-19 before and after the CT calculating the net reclassification improvement (NRI). Their final diagnosis was considered as reference. The proportion of patients with negative RT-PCR test that was directed to the referent hospital based on positive CT findings was also assessed. RESULTS: Among 155 patients, 42% had positive RT-PCR results, and 46% had positive CT findings. Chest CT showed a sensitivity of 84.6%, a specificity of 80.0% and a diagnostic accuracy of 81.9% in suggesting COVID-19 with RT-PCR as reference. Concurrently, corresponding values of 89.4%, 84.3% and 86.5% were retrieved with the adjudication committee diagnosis as reference. For the subgroup of patients with age > 65, specificity and sensitivity were 50% and 80.8%, respectively. In patients with negative RT-PCR results, 20% (18/90) had positive chest CT finding and 22% (4/18) of those were eventually considered as COVID-19 positive according to the adjudication committee. After CT, the estimated probability of COVID-19 changed in 10/104 (11%) patients with available data: 4 (4%) were downgraded, 6 (6%) upgraded. The NRI was 1.92% (NRI event -2.08% + NRI non-event 5.36%). No patient with negative RT-PCR but positive CT was eventually directed to hospital. CONCLUSION: Chest CT showed promising sensitivity for diagnosing COVID-19 across all patients' subgroups. However, CT did not modify the estimated probability of COVID-19 infection in a substantial proportion of patients and its utility as an emergency department triage tool warrants further analyses.

Period prevalence and identification challenges of viral haemorrhagic fever suspect cases in a tertiary referral hospital in Guinea: a cross-sectional, retrospective study of triage and emergency room patient profiles.

BACKGROUND: A functioning Viral Haemorrhagic Fever (VHF) surveillance system in countries at risk for outbreaks can reduce early transmission in case of an outbreak. Surveillance performance depends on the application of suspect case definitions in daily clinical practice. Recommended suspect case criteria during outbreaks are designed for high sensitivity and include general symptoms, pyrexia, haemorrhage, epidemiological link and unexplained death in patients. Non-outbreak criteria are narrower, relying on the persistence of fever and the presence of haemorrhagic signs. METHODS: This study ascertains VHF suspect case prevalence based on outbreak and non-outbreak criteria in a Guinean regional hospital for a period of three months. The study further describes clinical trajectories of patients who meet non-outbreak VHF suspect case criteria in order to discuss challenges in their identification. We used cross-sectional data collection at triage and emergency room to record demographic and clinical data of all admitted patients during the study period. For the follow-up study with description of diagnostic trajectories of VHF suspect cases, we used retrospective chart review. RESULTS: The most common symptoms of all patients upon admission were fever, tiredness/weakness and abdominal pain. 686 patients met EVD outbreak criteria, ten adult patients and two paediatric patients met study-specific non-outbreak VHF suspect case criteria. None of the suspect cases was treated as VHF suspect case and none tested positive for malaria upon admission. Their most frequent discharge diagnosis was unspecific gastrointestinal infection. The most common diagnostic measures were haemoglobin level and glycaemia for both adults and for children; of the requested examinations for hospitalized suspect cases, 36% were not executed or obtained. Half of those patients self-discharged against medical advice. CONCLUSIONS: Our study shows that the number of VHF suspect cases may vary greatly depending on which suspect case criteria are applied. Identification of VHF suspect cases seems challenging in clinical practice. We suggest that this may be due to the low use of laboratory diagnostics to support certain diagnoses and the non-application of VHF suspect case definitions in clinical practice. Future VHF suspect case management should aim to tackle such challenges in comparable hospital settings.

Solving the jigsaw of conflict-related environmental damage: Utilizing open-source analysis to improve research into environmental health risks.

Investigation of the environmental impacts of armed conflict has been made easier in recent years with the development of new and improved methods for documenting and monitoring environmental damage and pollution. For decades, research into conflict-linked environmental damage and its links to human health have been overlooked and research underfunded, hindering a complete humanitarian response and effective post-conflict reconstruction. Recent developments in the field of open-source investigation have shown promising results due to the increased use of mobile phones, access to the internet and freely available methods for remote observation by satellite. Utilizing and analysing these sources of data can help us to understand how conflicts are associated with environmental damage, pollution and their negative impacts upon public health. Further research and development in this field will help to inform more effective humanitarian responses, mitigate risks to health and identify priorities for post-conflict reconstruction programs. Data-driven open-source research can also strengthen international discussions on state accountability for military activities and build a case for the responsibility of warring parties to protect the environment as well as the people who depend on it.

Science, technology, power and sex: PrEP and HIV-positive gay men in Paris.

The pre-exposure prophylaxis (PrEP) drug Truvada is a new HIV prevention technology that is predominantly promoted as relevant to HIV-negative gay men. This paper explores what PrEP represents for HIV-positive gay men living in Paris, based upon data collected through interviews and ethnographic research. While HIV-positive gay men do not directly consume Truvada through PrEP, they nonetheless hold opinions and understandings of this drug, specifically as it relates to their own sexuality. This paper expands the representations and meanings of this new technology in a different light through the voices of gay men living with HIV in Paris. The main argument of this article is that PrEP as an additional HIV prevention tool blurs the lines between science, technologies and human sexuality.

Changing therapeutic geographies of the Iraqi and Syrian wars.

The health consequences of the ongoing US-led war on terror and civil armed conflicts in the Arab world are much more than the collateral damage inflicted on civilians, infrastructure, environment, and health systems. Protracted war and armed conflicts have displaced populations and led to lasting transformations in health and health care. In this report, we analyse the effects of conflicts in Iraq and Syria to show how wars and conflicts have resulted in both the militarisation and regionalisation of health care, conditions that complicate the rebuilding of previously robust national health-care systems. Moreover, we show how historical and transnational frameworks can be used to show the long-term consequences of war and conflict on health and health care. We introduce the concept of therapeutic geographies--defined as the geographic reorganisation of health care within and across borders under conditions of war.

Counselling against HIV in Africa: a genealogy of confessional technologies.

This paper contextualises counselling within a broader historical formation that links disclosure to healing and deploys confessional technologies to incite disclosure and awareness of the mysterious substance of the self. Foucault's argument that sexuality was the privileged arena for using confessional technologies to 'produce' the truth of the self is particularly relevant in light of the diffusion of counselling practices in Africa in the wake of the HIV epidemic, particularly with their emphasis on inciting appropriate sexual behaviour. Examination of the historical assemblage of counselling practices shows how they articulate what the self is, the nature of truth and a politics of language. This paper focuses on the genealogy of four key assumptions that express this confessional reason. These are that: (1) people can be 'empowered' to have control on their own lives by working on themselves, (2) secrets untold become pathogens, (3) the ability to heal requires that one first overcome personal illness, (4) the experience of sharing secrets is cathartic and healing. The genealogy intertwines four strands: that of the Unconscious as revealed by Freud and his followers, attempts to treat shell-shocked veterans of World War I, group psychotherapy and participatory research after World War II.

Abacavir/lamivudine fixed-dose combination with ritonavir-boosted darunavir: a safe and efficacious regimen for HIV therapy.

BACKGROUND: Current treatment guidelines recommend the use of tenofovir (TDF) and emtricitabine (FTC) along with a third agent to treat HIV-positive adults. However, other treatment options, including the use of abacavir (ABC) and lamivudine (3TC) when used with ritonavir-boosted darunavir (DRV/r), have rarely been studied. OBJECTIVE: We evaluated the safety and efficacy of the coformulation of ABC/3TC administered with DRV/r in treatment-naïve and treatment-experienced patients. METHODS: HIV-infected adults who received an open-label combination of ABC/3TC/ DRV/r were followed in a community clinic in Montréal. Patients had no resistance to any of the compounds in their regimen. Viral load (VL), CD4 cell count, AST, ALT, and creatinine levels were examined throughout the 48 weeks of follow-up. RESULTS: Sixty-seven patients with a mean age of 45 years were enrolled. Two did not return for follow-up and were excluded. Thirty-five (52%) were treatment- experienced and the remaining were treatment-naïve. HLA-B*5701 test results were available for 56 patients and none were positive. At baseline, mean VL was 4.8 log for treatment-naïve and 2.3 log for experienced patients. Twelve patients discontinued the study regimen prior to reaching the endpoint. At week 48, 79% had a VL <50. Median CD4 cell gain was higher among treatment-naïve patients (273 cells) than among treatment-experienced patients (102 cells) (P = .002). No patient experienced any grade 2 or higher liver enzyme elevation throughout the study. CONCLUSIONS: The new combination of ABC/3TC/DRV/r demonstrates a high rate of antiviral activity with no major toxicity. The drug combination appears to be generally safe and well tolerated.

A call for citizen science in pandemic preparedness and response: beyond data collection.

The COVID-19 pandemic has underlined the need to partner with the community in pandemic preparedness and response in order to enable trust-building among stakeholders, which is key in pandemic management. Citizen science, defined here as a practice of public participation and collaboration in all aspects of scientific research to increase knowledge and build trust with governments and researchers, is a crucial approach to promoting community engagement. By harnessing the potential of digitally enabled citizen science, one could translate data into accessible, comprehensible and actionable outputs at the population level. The application of citizen science in health has grown over the years, but most of these approaches remain at the level of participatory data collection. This narrative review examines citizen science approaches in participatory data generation, modelling and visualisation, and calls for truly participatory and co-creation approaches across all domains of pandemic preparedness and response. Further research is needed to identify approaches that optimally generate short-term and long-term value for communities participating in population health. Feasible, sustainable and contextualised citizen science approaches that meaningfully engage affected communities for the long-term will need to be inclusive of all populations and their cultures, comprehensive of all domains, digitally enabled and viewed as a key component to allow trust-building among the stakeholders. The impact of COVID-19 on people's lives has created an opportune time to advance people's agency in science, particularly in pandemic preparedness and response.

Reliability of anthropometric measures in a longitudinal cohort of patients initiating ART in West Africa.

BACKGROUND: Anthropometric measurements are a non invasive, inexpensive, and suitable method for evaluating the nutritional status in population studies with relatively large sample sizes. However, anthropometric techniques are prone to errors that could arise, for example, from the inadequate training of personnel. Despite these concerns, anthropometrical measurement error is seldom assessed in cohort studies. We describe the reliability and challenges associated with measurement of longitudinal anthropometric data in a cohort of West African HIV+ adults . METHODS: In a cohort of patients initiating antiretroviral treatment in Mali, we evaluated nutritional status using anthropometric measurements(weight, height, mid-upper arm circumference, waist circumference and triceps skinfold). Observers with no prior experience in the field of anthropometry were trained to perform anthropometrical measurements. To assess the intra- and inter-observer variability of the measurements taken in the course of the study, two sub-studies were carried out: one at the beginning and one at the end of the prospective study. Twelve patients were measured twice on two consecutive days by the same observer on both study occasions. The technical error of measurement (TEM) (absolute and relative value), and the coefficient of reliability (R) were calculated and compared across reliability studies. RESULTS: According to the R and relative TEM, inter-observer reliabilities were only acceptable for height and weight. In terms of intra-observer precision, while the first and second anthropometrists demonstrated better reliability than the third, only height and weight measurements were reliable. Looking at total TEM, we observed that while measurements remained stable between studies for height and weight, circumferences and skinfolds lost precision from one occasion to the next. CONCLUSIONS: Height and weight were the most reliable measurements under the study's conditions. Circumferences and skinfolds demonstrated less reliability and lost precision over time, probably as a result of insufficient supervision over the entire length of the study. Our results underline the importance of a careful observer's selection, good initial preparation, as well as the necessity of ongoing training and supervision over the entire course of a longitudinal nutritional study. Failure to do so could have major repercussions on data reliability and jeopardize its utilization.

Biological validation of self-reported condom use among sex workers in Guinea.

Self-reported condom use may be prone to social desirability bias. Our aim was to assess the validity of self-reported condom use in a population of female sex workers using prostate specific antigen (PSA) as a gold standard biomarker of recent unprotected vaginal intercourse. We collected data on 223 sex-workers in Conakry, Guinea in order to assess the sensitivity and specificity of self-reported condom use as well as to examine the predictors of discordance between self-report and PSA presence. PSA was detected in 38.4% of samples. Sensitivity of self-reported condom use was 14.6% and its specificity was 94.7%. Self-perceived high risk of HIV infection was the only significant independent predictor of misreported condom use. PSA could be useful to validate self-reported condom use in surveys and to allow a better understanding of factors associated with social desirability in sexual behaviour reporting.

Heavy Metal Toxicity in Armed Conflicts Potentiates AMR in A. baumannii by Selecting for Antibiotic and Heavy Metal Co-resistance Mechanisms.

Acinetobacter baumannii has become increasingly resistant to leading antimicrobial agents since the 1970s. Increased resistance appears linked to armed conflicts, notably since widespread media stories amplified clinical reports in the wake of the American invasion of Iraq in 2003. Antimicrobial resistance is usually assumed to arise through selection pressure exerted by antimicrobial treatment, particularly where treatment is inadequate, as in the case of low dosing, substandard antimicrobial agents, or shortened treatment course. Recently attention has focused on an emerging pathogen, multi-drug resistant A. baumannii (MDRAb). MDRAb gained media attention after being identified in American soldiers returning from Iraq and treated in US military facilities, where it was termed "Iraqibacter." However, MDRAb is strongly associated in the literature with war injuries that are heavily contaminated by both environmental debris and shrapnel from weapons. Both may harbor substantial amounts of toxic heavy metals. Interestingly, heavy metals are known to also select for antimicrobial resistance. In this review we highlight the potential causes of antimicrobial resistance by heavy metals, with a focus on its emergence in A. baumanni in war zones.

Precarity, clinical labour and graduation from Ebola clinical research in West Africa.

The provision of gifts and payments for healthy volunteer subjects remains an important topic in global health research ethics. This paper provides empirical insights into theoretical debates by documenting participants' perspectives on an Ebola vaccine trial in West Africa. This trial provided hundreds of Africans with regular payments, food packages and certificates for participation. The researchers conducting the trials considered these socioeconomic provisions to be gifts in accordance with contemporary ethical standards and principles. Trial participants viewed them differently, however, approaching trial participation as a means for training and employment in what was from their perspective a new job market: the post-Ebola expansion of research and health care systems. This paper analyses participation in contemporary research by viewing the context-specific histories of trial participants through the lens of prior interventions, specifically participatory reintegration programmes conducted in Anglophone West Africa to overcome civil war crises. In particular, we argue that participation in the Ebola vaccine trial was inadvertently shaped by the design and outcomes of past reintegration programmes. Our results highlight the need to investigate existing socioeconomic landscapes which surround and indeed permeate clinical research as a prerequisite for understanding the participatory motives of vulnerable participants in West Africa and elsewhere.

Cohort profile: l'Actuel Pre-Exposure Prophylaxis (PrEP) Cohort study in Montreal, Canada.

PURPOSE: The l'Actuel PrEP Cohort was established to monitor the uptake, effectiveness, safety and changes in sexual risk behaviours among individuals receiving pre-exposure prophylaxis (PrEP) for the prevention of HIV. This prospective dynamic cohort is based at Clinique médicale l'Actuel, a large sexual health clinic located in Montreal, Canada. PARTICIPANTS: Since the cohort inception in January of 2013 through June 2018, 2156 individuals consulted for PrEP as participants in the l'Actuel PrEP Cohort. Median age was 35 years (IQR: 29-44 years) and the majority (96%) were men who have sex with men. Among 1551 individuals who initiated PrEP care, the median duration of follow-up was 9.2 months (IQR: 3.7-19.6), with substantial variation based on year of cohort entry. The l'Actuel PrEP Cohort contains both daily and intermittent 'on-demand' PrEP users and has the largest reported population of intermittent PrEP users (n=406) in North America. FINDINGS TO DATE: No incident HIV infections have occurred among individuals using PrEP over 1637 person-years of follow-up. However, retention in PrEP care is essential as three individuals who discontinued PrEP subsequently acquired HIV, translating to an HIV incidence of 3.9 cases per 100 person-years (95% CI: 1.3 to 12.1). Among a sample of participants with 1 year of follow-up before and after PrEP initiation (n=109), a moderate increase in sexually transmitted infections was observed following PrEP start. FUTURE PLANS: The l'Actuel PrEP Cohort continues to grow with new participants starting PrEP monthly and extended follow-up for existing users. The cohort data will be used for ongoing monitoring of PrEP and for population-level modelling of the impact of PrEP on HIV incidence in Montreal.

Characterization of drug resistance in antiretroviral-treated patients infected with HIV-1 CRF02_AG and AGK subtypes in Mali and Burkina Faso.

BACKGROUND: In a multicentred cohort of patients on antiretroviral therapy (ART) in Burkina Faso and Mali, we analysed the prevalence of HIV drug resistance mutations in patients failing a modified directly observed therapy (mDOT) protocol. METHODS: Patients on ART >6 months and with viral load (VL) >500 copies/ml were enrolled in a mDOT protocol. Genotypic resistance testing was performed on pre- and post-mDOT plasma samples of patients who still had VL >500 copies/ml after mDOT. RESULTS: Eight hundred and one patients from seven sites participated in the study. One hundred and thirteen patients (14.1%) had VL >500 copies/ml. Most patients were treated with lamivudine along with zidovudine or stavudine and efavirenz or nevirapine. Genotypes were available for 46 patients. The predominant HIV-1 subtypes were CRFO2_AG in 26 (56.5%) and AGK/K/AK in 12 (26.1%) patients. The prevalence of drug resistance mutations by class were as follows for nucleoside reverse transcriptase inhibitors: 1841/V (82.6%), 215Y/F (32.6%), 219E/Q (19.6%), 70R (19.6%), 67N (21.7%), 41L (15.2%) and 151M(2.2%). For non-nucleoside reverse transcriptase inhibitors the prevalence was: 103N (50%) and 181C/I (19.6%). Phylogenetic analysis showed that, although the genetic distances were small among isolates, there was no clustering of a particular subtype in a specific region and that the high prevalence of AGK subtype in our drug-resistant population was not due to a circulating resistant strain. CONCLUSION: Although CRFO2_AG is the dominant clade in the Burkina Faso/Mali region, isolates with subtype K reverse transcriptase were frequent in our cohort. Drug resistance mutation pathways in subtype K reverse transcriptase need to be further evaluated in a larger cohort of non-B HIV-infected individuals.

Gender dynamics and sexual norms among youth in Mali in the context of HIV/AIDS prevention.

Socially constructed ideas of gender norms and values attached to sexuality need to be considered when aiming to build the young people's capacity to adopt HIV preventive behaviours. We conducted ten focus groups and sixteen individual interviews to explore sexual norms among youth in Bamako. Premarital sex, multiple partnering, condom use and transactional sex were discussed. The findings suggest that young people's sexual norms are shaped by kin or authoritative elders as well as by external influences coming from Western culture. Sexual norms are differentially constructed by men and women and are in contradiction with those of older generations. Views on premarital sex, condom use and transactional sex generated controversy among men and women, as well as among more sexually conservative or progressive youth. However, there was general rejection of multiple partnerships. Empowering youth to pursue open debates on sexuality may be an avenue for HIV/AIDS prevention in Mali.