Brk/PTK6 and Involucrin Expression May Predict Breast Cancer Cell Responses to Vitamin D3.

The process of human embryonic mammary development gives rise to the structures in which mammary cells share a developmental lineage with skin epithelial cells such as keratinocytes. As some breast carcinomas have previously been shown to express high levels of involucrin, a marker of keratinocyte differentiation, we hypothesised that some breast tumours may de-differentiate to a keratinocyte-derived 'evolutionary history'. To confirm our hypothesis, we investigated the frequency of involucrin expression along with that of Brk, a tyrosine kinase expressed in up to 86% of breast carcinomas whose normal expression patterns are restricted to differentiating epithelial cells, most notably those in the skin (keratinocytes) and the gastrointestinal tract. We found that involucrin, a keratinocyte differentiation marker, was expressed in a high proportion (78%) of breast carcinoma samples and cell lines. Interestingly, tumour samples found to express high levels of involucrin were also shown to express Brk. 1,25-dihydroxyvitamin D3, a known differentiation agent and potential anti-cancer agent, decreased proliferation in the breast cancer cell lines that expressed both involucrin and Brk, whereas the Brk/involucrin negative cell lines tested were less susceptible. In addition, responses to 1,25-dihydroxyvitamin D3 were not correlated with vitamin D receptor expression. These data contribute to the growing body of evidence suggesting that cellular responses to 1,25-dihydroxyvitamin D3 are potentially independent of vitamin D receptor status and provide an insight into potential markers, such as Brk and/or involucrin that could predict therapeutic responses to 1,25-dihydroxyvitamin D3.

Changing Flows: Sociotechnical Tinkering for Adaptive Water Management.

The Western United States is experiencing historic drought, increasing pressure on water management systems. Agricultural production that relies on surface water flows is therefore imperiled, requiring new innovations and partnerships in order to adapt and survive. In Arizona, some agriculture continues to rely on historic, low-tech irrigation infrastructure such as hand-dug open ditches that divert river water to flood fields. These ditch systems are managed through both formal ditch companies and informal associations. To address changing water availability and needs, ditch users regularly "tinker" with water infrastructure, experimenting and making changes beyond the original infrastructure plans. Such changes are informed and driven by local social relationships and realities of the physical infrastructure. These dynamics are critical to understanding the adaptive capacity and flexibility of the water system; however, they are challenging to recognize and record. In this paper, we apply the emerging conceptualization of sociotechnical tinkering to examine the adaptive management of irrigation ditches in the Verde Valley of Arizona. We find evidence that water users frequently tinker with their water delivery and monitoring infrastructure to respond to and anticipate changes in water availability. Viewed through the lens of sociotechnical tinkering, these interactions are understood as the material manifestations of situated practice and actor agency within a water management system. This case study contributes to literature on adaptive environmental management and the hydrosocial cycle.

Use of Epidemiology Surge Support to Enhance Robustness and Expand Capacity of SARS-CoV-2 Pandemic Response, South Africa.

As COVID-19 cases increased during the first weeks of the pandemic in South Africa, the National Institute of Communicable Diseases requested assistance with epidemiologic and surveillance expertise from the US Centers for Disease Control and Prevention South Africa. By leveraging its existing relationship with the National Institute of Communicable Diseases for >2 months, the US Centers for Disease Control and Prevention South Africa supported data capture and file organization, data quality reviews, data analytics, laboratory strengthening, and the development and review of COVID-19 guidance This case study provides an account of the resources and the technical, logistical, and organizational capacity leveraged to support a rapid response to the COVID-19 pandemic in South Africa.

An experiential approach to developing radiological content for public health nursing: Lessons from a nuclear disaster.

OBJECTIVE: This study identified the radiological content required for PHNs and public health nursing students based on PHNs' experiences caring for people affected by the 2011 Fukushima Daiichi nuclear power plant accident. DESIGN: We used qualitative research, interviews, and content analysis. SAMPLE: Participants were eight PHNs employed by local governments in Fukushima and neighboring prefectures. RESULTS: Six content themes regarding the nuclear disaster were identified: (a) basic knowledge about radiation, (b) public health nursing activities in emergency exposure situations, (c) management in emergency exposure situations, (d) consultation to support residents affected by the nuclear disaster, (e) activities in the existing exposure situations, and (f) disaster preparedness in the planned exposure situations. Necessary content shifted depending on the phase of the nuclear disaster recovery. CONCLUSIONS: The use of the experiences of PHNs after the nuclear power plant accident to inform PHNs and public health nursing students will enable PHNs to respond appropriately and support people without difficulties. Comprehensive radiation content is needed to address the range of situations caused by nuclear disaster.

Impact of cytogenetic abnormalities in adults with Ph-negative B-cell precursor acute lymphoblastic leukemia.

Multiple cytogenetic subgroups have been described in adult Philadelphia chromosome (Ph)-negative B-cell precursor (BCP) acute lymphoblastic leukemia (ALL), often comprising small numbers of patients. In this study, we aimed to reassess the prognostic value of cytogenetic abnormalities in a large series of 617 adult patients with Ph-negative BCP-ALL (median age, 38 years), treated in the intensified Group for Research on Adult Acute Lymphoblastic Leukemia (GRAALL)-2003/2005 trials. Combined data from karyotype, DNA index, fluorescence in situ hybridization, and polymerase chain reaction screening for relevant abnormalities were centrally reviewed and were informative in 542 cases (88%), allowing classification in 10 exclusive primary cytogenetic subgroups and in secondary subgroups, including complex and monosomal karyotypes. Prognostic analyses focused on cumulative incidence of failure (including primary refractoriness and relapse), event-free survival, and overall survival. Only 2 subgroups, namely t(4;11)/KMT2A-AFF1 and 14q32/IGH translocations, displayed a significantly worse outcome in this context, still observed after adjustment for age and after censoring patients who received allogeneic stem cell transplantation (SCT) in first remission at SCT time. A worse outcome was also observed in patients with low hypodiploidy/near triploidy, but this was likely related to their higher age and worse tolerance to therapy. The other cytogenetic abnormalities, including complex and monosomal karyotypes, had no prognostic value in these intensive protocols designed for adult patients up to the age of 60 years.

Low HIV testing rates among US women who report anal sex and other HIV sexual risk behaviors, 2011-2015.

OBJECTIVE: In 2016, 19% of HIV diagnoses were in women. About 40% of HIV infections in women aged 18-34 years have been attributed to anal sex, suggesting that women who report high risk behaviors such as anal sex might benefit from HIV testing and prevention with preexposure prophylaxis (PrEP). In this analysis, we estimated HIV testing rates among women who reported anal sex. STUDY DESIGN: We analyzed data from the 2011-2015 National Survey of Family Growth to estimate the proportion of sexually active, nonpregnant US women aged 15-44 years who had an HIV test within the past year, stratified by those who reported anal sex and other risk factors, including ≥2 sexual partners, condomless sex with a new partner or multiple partners, gonorrhea in the past year, or any history of syphilis. RESULTS: Overall, 7.9 million of 42.4 million sexually active, nonpregnant US women (18.7%) reported an HIV test within the past year. Among 42.4 million sexually active women, 9.0 million (20.1%) reported they had anal sex in the past year. Among these 9.0 million women, 19.2% reported that their providers asked about their type of intercourse, and 20.1% reported an HIV test within the past year. Overall, HIV testing was higher among women who reported anal sex and reported that their providers asked about type of sex than those whose provider did not ask (37.8% vs 15.9%; P < .001). HIV testing in the past year was higher for women with other risk behaviors compared with anal sex, ranging from 35.8% to 47.2%. CONCLUSION: Overall, HIV testing rates within the past year were low among women with sexual behaviors that increase their risk of acquiring HIV and especially low among those who reported anal sex. Early detection and treatment of HIV, and HIV prevention with PrEP, are effective health services that protect women's health and well-being but that can be offered only based on HIV testing results. Women's health care providers are uniquely poised to assess risk for acquiring HIV, including taking a sexual history that asks about anal sex, and performing HIV testing to identify women who need HIV treatment or might benefit from PrEP.

Detection of early-stage changes in people with chronic diseases: A telehome monitoring-based telenursing feasibility study.

Chronic diseases, such as chronic obstructive pulmonary disease, amyotrophic lateral sclerosis, and diabetes mellitus, require long-term management, which daily telenurse monitoring can provide. The aim of the present feasibility study was to determine if using a telenursing protocol with home monitoring during a 12 week implementation could also identify early signs of deterioration and factors correlated with participants' change in status, while attaining patient acceptance and satisfaction. The purposive sample of 43 participants provided 4533 combined days of monitoring. Outcome feasibility indicators were the range of triggering protocol alerts (70~100%) and diagnoses with exacerbations (20~29.3%). Highly correlated were participants' activity limitation and palpitations with chronic obstructive pulmonary disease, activity limitation and ineffective sputum clearance with amyotrophic lateral sclerosis, and fatigue with diabetes. Acceptance and adherence were high with daily monitoring, including "feelings of safety," and "understanding own condition". Telenursing with home monitoring indicated a trend to accurately detect early-stage changes. Participant acceptance was acceptable. It would be feasible to conduct a randomized, controlled trial using this model with some modifications.

Medical student satisfaction, coping and burnout in direct-entry versus graduate-entry programmes.

CONTEXT: There is ongoing debate regarding the optimal length of medical training, with concern about the cost of prolonged training. Two simultaneous tracks currently exist in Australia: direct entry from high school and graduate entry for students with a bachelor degree. Medical schools are switching to graduate entry based on maturity, academic preparedness and career-choice surety. We tested the assumption that graduate entry is better by exploring student preferences, coping, burnout, empathy and alcohol use. METHODS: From a potential pool of 2188 participants, enrolled at five Australian medical schools, a convenience sample of 688 (31%) first and second year students completed a survey in the middle of the academic year. Participants answered questions about demographics, satisfaction and coping and completed three validated instruments. RESULTS: Over 90% of students preferred their own entry-type, though more graduate-entry students were satisfied with their programme (82.4% versus 65.3%, p < 0.001). There was no difference between graduate-entry and direct-entry students in self-reported coping or in the proportion of students meeting criteria for burnout (50.7% versus 51.2%). Direct-entry students rated significantly higher for empathy (concern, p = 0.022; personal distress, p = 0.031). Graduate-entry students reported significantly more alcohol use and hazardous drinking (30.0% versus 22.8%; p = 0.017). CONCLUSIONS: Our multi-institution data confirm that students are generally satisfied with their choice of entry pathway and do not confirm significant psychosocial benefits of graduate entry. Overall, our data suggest that direct-entry students cope with the workload and psychosocial challenges of medical school, in the first 2 years, as well as graduate-entry students. Burnout and alcohol use should be addressed in both pathways. Despite studies showing similar academic outcomes, and higher total costs, more programmes in Australia are becoming graduate entry. Further research on non-cognitive issues and outcomes is needed so that universities, government funders and the medical profession can decide whether graduate entry, direct entry, or a mix, is ideal.

Prevalence and risk factors of intimate partner violence among pregnant women in Japan.

Intimate partner violence (IPV) during pregnancy can result in adverse outcomes for both mothers and their infants. This cross-sectional study examined the prevalence and risk factors of IPV associated with abuse during pregnancy via a self-administered questionnaire completed by 302 healthy pregnant women. Demographic information was also collected from medical records to analyze risk factors for abuse. Of the 302 women, 48 (15.9%) were identified as experiencing IPV. The identified risk factors were age over 30, multipara, previous abortion experience, and male partner aged under 30.

Association of Client and Provider Race with Approaches Pursued by Social Workers for Reducing Firearm Access.

Social workers assess and intervene to prevent harm among clients at risk of harm to self (HTS) and harm to others (HTO) with a firearm. This study sought to assess the impact of client race on social workers' approaches to reduce firearm access when they weighed voluntary (e.g., store out-of-home) and involuntary (e.g., extreme risk protection order) removal methods. We considered the role of social workers' self-identified race as a moderator of this relationship, comparing white (single race) and Black, Indigenous, and People of Color (BIPOC) social workers. A survey was distributed to Washington state social workers (n = 9073) who were presented with two case vignettes, each randomized to view the client's race as Black or white. Logistic regression was used to assess the association between the client's race and the pursuit of voluntary or involuntary methods, stratified by social workers' race. Among the participants (n = 1306), 26% pursued at least one involuntary care plan option for the HTS client, and 59% for the HTO client. The Black client at risk of HTS had lower odds of an involuntary care plan option compared to the white client (OR = 0.69, 95% CI 0.54-0.88), while the Black client at risk of HTO had higher odds of an involuntary care plan options (OR = 1.13, 95% CI 1.07-1.66). These associations were not statistically significantly different between white (single race selected) and BIPOC social workers. This study contributes to the growing understanding of potential racial disparities in social workers' decision-making regarding firearm access reduction strategies.

Substantial but spatially heterogeneous progress in male circumcision for HIV prevention in South Africa.

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces the risk of male HIV acquisition by 60%. Programmes to provide VMMCs for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Traditional circumcision is also a long-standing male coming-of-age ritual, but practices vary considerably across populations. Accurate estimates of circumcision coverage by age, type, and time at subnational levels are required for planning and delivering VMMCs to meet targets and evaluating their impacts on HIV incidence. METHODS: We developed a Bayesian competing risks time-to-event model to produce region-age-time-type specific probabilities and coverage of male circumcision with probabilistic uncertainty. The model jointly synthesises data from household surveys and health system data on the number of VMMCs conducted. We demonstrated the model using data from five household surveys and VMMC programme data to produce estimates of circumcision coverage for 52 districts in South Africa between 2008 and 2019. RESULTS: Nationally, in 2008, 24.1% (95% CI: 23.4-24.8%) of men aged 15-49 were traditionally circumcised and 19.4% (18.9-20.0%) were medically circumcised. Between 2010 and 2019, 4.25 million VMMCs were conducted. Circumcision coverage among men aged 15-49 increased to 64.0% (63.2-64.9%) and medical circumcision coverage to 42% (41.3-43.0%). Circumcision coverage varied widely across districts, ranging from 13.4 to 86.3%. The average age of traditional circumcision ranged between 13 and 19 years, depending on local cultural practices. CONCLUSION: South Africa has made substantial, but heterogeneous, progress towards increasing medical circumcision coverage. Detailed subnational information on coverage and practices can guide programmes to identify unmet need to achieve national and international targets.

Voluntary medical male circumcision reduces the risk of male HIV acquisition. Programmes to provide circumcisions for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Estimates of circumcision coverage are needed for planning and delivering circumcisions to meet targets and evaluate their impacts on HIV incidence. We developed a model to integrate date from both household surveys and health systems on the number of circumcisions conducted, and applied it to understand how the practices and coverage of circumcision are changing in South Africa. National circumcision coverage increased considerably between 2008 and 2019, however, there remains a substantial subnational variation across districts and age groups. Further progress is needed to reach national and international targets.

Temperature-dependent conformational change affecting Tyr11 and sweetness loops of brazzein.

The sweet protein brazzein, a member of the Csßα fold family, contains four disulfide bonds that lend a high degree of thermal and pH stability to its structure. Nevertheless, a variable temperature study has revealed that the protein undergoes a local, reversible conformational change between 37 and 3°C with a midpoint about 27°C that changes the orientations and side-chain hydrogen bond partners of Tyr8 and Tyr11. To test the functional significance of this effect, we used NMR saturation transfer to investigate the interaction between brazzein and the amino terminal domain of the sweet receptor subunit T1R2; the results showed a stronger interaction at 7°C than at 37°C. Thus the low temperature conformation, which alters the orientations of two loops known to be critical for the sweetness of brazzein, may represent the bound state of brazzein in the complex with the human sweet receptor.

Immigrants' experiences of maternity care in Japan.

Language and cultural differences can negatively impact immigrant women's birth experience. However, little is known about their experiences in Japan's highly homogenous culture. This cross-sectional study used survey data from a purposive sampling of immigrant women from 16 hospitals in several Japanese prefectures. Meeting the criteria and recruited to this study were 804 participants consisting of 236 immigrant women: Chinese (n = 83), Brazilian (n = 62), Filipino (n = 43), South Korean (n = 29) and from variety of English speaking nations (n = 19) and 568 Japanese women. The questionnaire was prepared in six languages: Japanese (kana syllables), Chinese, English, Korean, Portuguese, and Tagalog (Filipino). Associations among quality of maternity care, Japanese literacy level, loneliness and care satisfaction were explored using analysis of variance and multiple linear regression. The valid and reliable instruments used were Quality of Care for Pregnancy, Delivery and Postpartum Questionnaire, Rapid Estimate of Adult Literacy in Medicine Japanese version, the revised UCLA Loneliness Scale-Japanese version and Care satisfaction. Care was evaluated across prenatal, labor and delivery and post-partum periods. Immigrant women scored higher than Japanese women for both positive and negative aspects. When loneliness was strongly felt, care satisfaction was lower. Some competence of Japanese literacy was more likely to obstruct positive communication with healthcare providers, and was associated with loneliness. Immigrant women rated overall care as satisfactory. Japanese literacy decreased communication with healthcare providers, and was associated with loneliness presumably because some literacy unreasonably increased health care providers' expectations of a higher level of communication.

The impact of the development of verbal recoding on children's early writing skills.

BACKGROUND: The spontaneous recoding of visual stimuli into a phonological code to aid short-term retention has been associated with progress in learning to read (Palmer, 2000b). AIM: This study examined whether there was a comparable association with the development of writing skills. SAMPLE: One hundred eight children (64 males) in the second year of the UK educational system (mean age 5:8 years, SD = 4 months) were recruited to the study. METHODS: The children participated in tasks to assess their general cognitive abilities, reading skills, and their predominant short-term memory (STM) strategy for retaining visually presented stimuli. On the basis of their memory profile, children were classified as either engaging in verbal recoding of the stimuli (N = 31) or not (N = 77). Writing performance was indexed as alphabet transcription, spelling, and early text production skills. RESULTS: Children classified as verbal recoders demonstrated better spelling performance and produced more individual letters, words, and T-units in their texts than did children who persisted with a visual memory strategy. In contrast, the alphabet transcription abilities of the groups did not differ. Hierarchical regression analyses revealed that variance in text production skills was associated with STM capacity and that moreover, significant independent variance in the number of words and T-units in the children's texts was predicted by individual differences in verbal recoding abilities. CONCLUSION: The results suggest that the development of verbal recoding skills in STM may play a role in children's early progress in writing, particularly their text generation skills.

Development and applicability of a dignity-centred palliative care programme for people with idiopathic pulmonary fibrosis: A qualitative-driven mixed methods study.

AIMS: This study evaluated the acceptability of a dignity-centred palliative care programme for people with idiopathic pulmonary fibrosis by converging perceptions of living with idiopathic pulmonary fibrosis qualitative data and quantitative data. DESIGN: The qualitative-driven mixed methods research addressed the study aim by using a convergent design. This single arm, non-randomized study used purposive sampling. METHODS: Interviews with 12 stable outpatients with IPF provided qualitative data. Their quantitative data were from six scales: self-esteem, health-related quality of life, anxiety, depression, dyspnoea, cough and programme satisfaction. Intervention was three educational modules: symptom management, enhancing daily activities and life reviews. RESULTS: Semi-structured interviews yielded eight categories. Self-esteem was not statistically significantly changed. Dyspnoea symptoms improved significantly. Participants (n = 9) holding positive attitudes for living with idiopathic pulmonary fibrosis, had improved lifestyle behaviour and improved or maintained self-esteem. The meta-inference regarding idiopathic pulmonary fibrosis perceptions were related to changes in self-esteem.

Training Health Care Professionals in Suicide Assessment, Management, and Treatment.

Washington was the first state to require all licensed general medical and behavioral health care professionals (HCPs) to complete training in suicide assessment, management, and treatment. Results from pretest and posttest surveys of 873 HCPs participating in All Patients Safe, a 6-hour online training course, are presented. Improvements in knowledge and attitudes about suicide and confidence in treating at-risk individuals were observed, demonstrating the effectiveness of delivering large-scale training to HCPs to fulfill state requirements. Future work should examine the impact of training on clinical practices and the role of training in improving patient care.

Antiracism: An Ethical Imperative.

Pediatric ethicists hold a privileged position of influence within health care institutions. Such a position confers a corresponding responsibility to address barriers to the health and flourishing of all children. A major barrier to children's health is racism. Pediatric ethicists can, and should, leverage their position to address racism both in institutional policy and the provision of pediatric care. Health care's historical and continued contributions to fostering and sustaining racist values and systems mean that those within all medical fields- regardless of race, ethnicity, gender, age, or profession-should consider ways they can work to offset and ultimately dismantle those values and systems. Institutional policy is a critical mechanism propagating racism in hospitals and an area where ethicists have a unique perspective to bring antiracism into ethical analysis. Many institutional and organizational policies have unintended consequences, negatively impacting children and families who have been historically marginalized and oppressed. In this paper, we report and discuss existing policies, along with how they are implemented (procedures) and how they are conducted (practices), identified through a workshop during a pediatric subgroup meeting at an annual bioethics conference. We highlight the need to focus on these structural factors and reference scholarship that can be used to correct institutional policies that uphold white supremacy. We conclude with actionable, concrete recommendations for change.

Integration of extreme risk protection orders into the clinical workflow: Qualitative comparison of clinician perspectives.

Extreme risk protection orders (ERPO) seek to temporarily reduce access to firearms for individuals at imminent risk of harming themselves and/or others. Clinicians, including physicians, nurse practitioners, and social workers regularly assess circumstances related to patients' risk of firearm-related harm in the context of providing routine and acute clinical care. While clinicians cannot independently file ERPOs in most states, they can counsel patients or contact law enforcement about filing ERPOs. This study sought to understand clinicians' perspectives about integrating ERPO counseling and contacting law enforcement about ERPOs into their clinical workflow. We analyzed responses to open-ended questions from an online survey distributed May-July of 2021 to all licensed physicians (n = 23,051), nurse practitioners (n = 8,049), and social workers (n = 6,910) in Washington state. Of the 4,242 survey participants, 1,126 (26.5%) responded to at least one of ten open-ended questions. Two coders conducted content analysis. Clinicians identified barriers and facilitators to integrating ERPOs into the clinical workflow; these influenced their preferences on who should counsel or contact law enforcement about ERPOs. Barriers included perceptions of professional scope, knowledge gaps, institutional barriers, perceived ERPO effectiveness and constitutionality, concern for safety (clinician and patient), and potential for damaging provider-patient therapeutic relationship. Facilitators to address these barriers included trainings and resources, dedicated time for counseling and remuneration for time spent counseling, education on voluntary removal options, and ability to refer patients to another clinician. Participants who were hesitant to be the primary clinician to counsel patients or contact law enforcement about ERPOs requested the ability to refer patients to a specialist, such as social workers or a designated ERPO specialist. Results highlight the complex perspectives across clinician types regarding the integration of ERPO counseling into the clinical workflow. We highlight areas to be addressed for clinicians to engage with ERPOs.

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.

Challenges and opportunities for manureshed management across U.S. dairy systems: Case studies from four regions.

The manureshed represents cropland needed to safely assimilate manure nutrients from an animal feeding operation. Dairy manuresheds can be contained on-farm but may need to involve additional farms that can assimilate excess nutrients. We present case studies reviewing challenges and opportunities to manureshed management in four major dairy-producing states using available information on local manuresheds. Additionally, geographic information system software was used with data from regulated Minnesota dairies to assess cropland assimilative capacities and transport needs surrounding large dairies. Manureshed requirements vary across regions, but increased import of feed and soil phosphorus accumulation constrain on-farm manure utilization across the United States. In Minnesota, a growing proportion of Jersey cattle and differences in continuous corn (Zea mays L.) vs. corn-alfafa (Medicago sativa L.) rotations contribute to the amount of land needed to absorb dairy manure nutrients. Farm-gate budgets reveal that N-based manuresheds can be contained within Idaho dairies, but P-based manuresheds extend beyond the farm. In New Mexico, relocation of surplus manure nutrients off the farm is common via informal networks, but incentives to strengthen these networks could ensure sustainable manureshed management. Evaluation of manureshed requirements in Pennsylvania is often complicated by the need for additional nutrient management planning and greater understanding of nutrient balances on the preponderance of small dairies. Nutrient imbalances with highly concentrated dairy production often lead to the need for manure transport off-farm. However, advances in herd and cropland management offer opportunities to improve on-farm nutrient efficiencies, and emerging networks and technologies promise to facilitate manure export when needed.