The five continuum of care criteria that should accompany rectal artesunate interventions: lessons learned from an implementation study in Malawi.

BACKGROUND: Rectal artesunate (RAS) is a World Health Organization (WHO) recommended intervention that can save lives of children 6 years and younger suffering from severe malaria and living in remote areas. Access to RAS and a referral system that ensures continuity of care remains a challenge in low resource countries, raising concerns around the value of this intervention. The objective of this study was to inform RAS programming, using practical tools to enhance severe malaria continuum of care when encountered at community level. METHODS: A single country two-arm-controlled study was conducted in Malawi, where pre-referral interventions are provided by community health workers (CHWs). The study populations consisted of 9 and 14 village health clinics (VHCs) respectively, including all households with children 5 years and younger. CHWs in the intervention arm were trained using a field-tested toolkit and the community had access to information, education, and communication (IEC) mounted throughout the zone. The community in the control arm had access to routine care only. Both study arms were provided with a dedicated referral booklet for danger signs, as a standard of care. RESULTS: The study identified five continuum of care criteria (5 CoC Framework) to reinforce RAS programming: (1) care transitions emerged as to be dependent on a strong cue to action and proximity to an operational VHC with a resident CHWs; (2) consistency of supplies assured the population of the VHC's functionality for severe danger signs management; (3) comprehensiveness care ensured correct assessment and dosing; (4) connectivity of care between all tiers using the referral slip was feasible and perceived positively by caregivers and CHWs and (5) communication between providers from different points of care. Compliance was high throughout but optimized when administered by a sensitized CHW. Over 93% experienced a rapid improvement in the status of their child post RAS. CONCLUSION: RAS cannot operate within a vacuum. The impact of this lifesaving intervention can be easily lost, unless administered as part of a system-based approach. Taken together, the 5CC Framework, identified in this study, provides a structure for future RAS practice guidelines. Trial registration number and date of registration PACTR201906720882512- June 20, 2019.

Sexual and nonsexual violence and mental health among male refugees from the Democratic Republic of Congo residing in Kampala, Uganda: a population-based survey.

We conducted a population-based survey in 2013 in Kampala, Uganda, to examine violence and mental health outcomes among self-settled male refugees from the Eastern Democratic Republic of Congo (DRC). Male DRC refugees aged 18+ years were sampled through respondent-driven sampling. Key interview domains included demographics, experiences of sexual and nonsexual violence, social support, PTSD, depression and suicide ideation. Data analysis was weighted to generate population-level estimates. We sampled 718 men (mean age: 33 years), most of whom had lived in North or South Kivu. Nonsexual violence, such as beatings (79.4%) and torture (63.8%), was frequent. A quarter (26.2%) had been raped; 49.9% of rape victims had been raped on multiple occasions, and 75.7% of rape victims had been gang raped. We estimated 52.8% had post-traumatic stress disorder (PTSD); 44.4% reported suicidal ideation. Numerous traumas were significantly (p < 0.05) associated with PTSD such as rape (adjusted odds ratio [aOR] = 1.82), war-related injuries (aOR = 2.90) or having been exposed to >15 traumas (compared to ≤10; aOR = 6.89). Traumata are frequent experiences in this self-settled male refugee population and are often accompanied by adverse mental health outcomes. Screening for trauma and adverse mental health outcomes and providing targeted services are paramount to improve these refugees' lives.

The SPORTSMART study: a pilot randomised controlled trial of sexually transmitted infection screening interventions targeting men in football club settings.

BACKGROUND: Uptake of chlamydia screening by men in England has been substantially lower than by women. Non-traditional settings such as sports clubs offer opportunities to widen access. Involving people who are not medically trained to promote screening could optimise acceptability. METHODS: We developed two interventions to explore the acceptability and feasibility of urine-based sexually transmitted infection (STI) screening interventions targeting men in football clubs. We tested these interventions in a pilot cluster randomised control trial. Six clubs were randomly allocated, two to each of three trial arms: team captain-led and poster STI screening promotion; sexual health adviser-led and poster STI screening promotion; and poster-only STI screening promotion (control/comparator). Primary outcome was test uptake. RESULTS: Across the three arms, 153 men participated in the trial and 90 accepted the offer of screening (59%, 95% CI 35% to 79%). Acceptance rates were broadly comparable across the arms: captain-led: 28/56 (50%); health professional-led: 31/46 (67%); and control: 31/51 (61%). However, rates varied appreciably by club, precluding formal comparison of arms. No infections were identified. Process evaluation confirmed that interventions were delivered in a standardised way but the control arm was unintentionally 'enhanced' by some team captains actively publicising screening events. CONCLUSIONS: Compared with other UK-based community screening models, uptake was high but gaining access to clubs was not always easy. Use of sexual health advisers and team captains to promote screening did not appear to confer additional benefit over a poster-promoted approach. Although the interventions show potential, the broader implications of this strategy for UK male STI screening policy require further investigation.

Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial.

BACKGROUND: Accelerated partner therapy (APT) is a promising partner notification (PN) intervention in specialist sexual health clinic attenders. To address its applicability in primary care, we undertook a pilot randomised controlled trial (RCT) of two APT models in community settings. METHODS: Three-arm pilot RCT of two adjunct APT interventions: APTHotline (telephone assessment of partner(s) plus standard PN) and APTPharmacy (community pharmacist assessment of partner(s) plus routine PN), versus standard PN alone (patient referral). Index patients were women diagnosed with genital chlamydia in 12 general practices and three community contraception and sexual health (CASH) services in London and south coast of England, randomised between 1 September 2011 and 31 July 2013. RESULTS: 199 women described 339 male partners, of whom 313 were reported by the index as contactable. The proportions of contactable partners considered treated within 6 weeks of index diagnosis were APTHotline 39/111 (35%), APTPharmacy 46/100 (46%), standard patient referral 46/102 (45%). Among treated partners, 8/39 (21%) in APTHotline arm were treated via hotline and 14/46 (30%) in APTPharmacy arm were treated via pharmacy. CONCLUSIONS: The two novel primary care APT models were acceptable, feasible, compliant with regulations and capable of achieving acceptable outcomes within a pilot RCT but intervention uptake was low. Although addition of these interventions to standard PN did not result in a difference between arms, overall PN uptake was higher than previously reported in similar settings, probably as a result of introducing a formal evaluation. Recruitment to an individually randomised trial proved challenging and full evaluation will likely require service-level randomisation. TRIAL REGISTRATION NUMBER: Registered UK Clinical Research Network Study Portfolio id number 10123.

Examining the potential public health benefit of offering STI testing to men in amateur football clubs: evidence from cross-sectional surveys.

BACKGROUND: In Britain, young people continue to bear the burden of sexually transmitted infections (STIs) so efforts are required, especially among men, to encourage STI testing. The SPORTSMART study trialled an intervention that sought to achieve this by offering chlamydia and gonorrhoea test-kits to men attending amateur football clubs between October and December 2012. With football the highest participation team sport among men in England, this paper examines the potential public health benefit of offering STI testing to men in this setting by assessing their sociodemographic characteristics, sexual behaviours, and healthcare behaviour and comparing them to men in the general population. METHODS: Data were collected from 192 (male) members of 6 football clubs in London, United Kingdom, aged 18-44 years via a 20-item pen-and-paper self-completion questionnaire administered 2 weeks after the intervention. These were compared to data collected from 409 men of a similar age who were resident in London when interviewed during 2010-2012 for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a national probability survey that used computer-assisted-personal-interviewing with computer-assisted-self-interview. Age standardisation and multivariable regression were used to account for sociodemographic differences between the surveys. RESULTS: Relative to men in the general population, SPORTSMART men were younger (32.8 % vs. 21.7 % aged under 25 y), and more likely to report (all past year) at least 2 sexual partners (adjusted odds ratio, AOR: 3.25, 95 % CI: 2.15-4.92), concurrent partners (AOR: 2.05, 95 % CI: 1.39-3.02), and non-use of condoms (AOR: 2.17, 95 % CI: 1.39-3.41). No difference was observed in STI/HIV risk perception (AOR for reporting "not at all at risk" of STIs: 1.25, 95 % CI: 0.76-2.04; of HIV: AOR: 1.54, 95 % CI: 0.93-2.55), nor in reporting STI testing in the past year (AOR: 0.83, 95 % CI: 0.44-1.54), which was reported by only one in six men. CONCLUSIONS: Relative to young men in the general population, football club members who completed the SPORTSMART survey reported greater sexual risk behaviour but similar STI/HIV risk perception and STI testing history. Offering STI testing in amateur football clubs may therefore widen access to STI testing and health promotion messages for men at higher STI risk, which, given the minority currently testing and the popularity of football in England, should yield both individual and public health benefit.

Conflict-related violence and mental health among self-settled Democratic Republic of Congo female refugees in Kampala, Uganda - a respondent driven sampling survey.

BACKGROUND: Violence and traumatic events are highly prevalent among refugees, but less is known about the impact of these experiences among self-settled refugees in the country of asylum. We evaluated the association between traumatic experiences and PTSD and depression symptoms among female Democratic Republic of Congo (DRC) refugees living in Kampala, Uganda. METHODS: Participants were recruited using respondent driven sampling in one refugee service center in Kampala, Uganda. Eligibility criteria included: Congolese nationality, age 18+ years, self-settled in Kampala for at least 6 months, refugee status or documentation of application for refugee status. Only data from female participants were included in this analysis. Depression symptoms were screened with the Patient Health Questionnaire-2, and symptom criteria for PTSD and traumatic experiences were evaluated with the Harvard Trauma Questionnaire. Logistic regression models were performed to separately assess associations between mental health outcomes (PTSD and depression), rape and non-sexual violence. RESULTS: Five hundred eighty women with a mean age of 33 years were interviewed. Among participants, 73% (95% CI:67-78%) met symptom criteria for PTSD, 57% (95% CI: 51-63%) for depression, and 65% reported thoughts of ending one's life. 79% of women reported experience of rape, for over half (54%) it occurred more than once, and 82% were gang raped. Crude and adjusted odds ratios (ORs) show that PTSD was most strongly associated with being raped (OR = 2.43, p < 0.01), lacking shelter (OR = 2.86, p < 0.01), lacking food or water (OR = 2.53, p = 0.02), lacking access to health care (OR = 2.84, p < 0.01), forced labor (OR = 2.6, p < 0.01), extortion and/or robbery (OR = 3.08, p < 0.01), experiencing the disappearance/kidnapping of a family member or friend (OR = 2.72, p < 0.01), and witnessing the killing or murder of other people (OR = 3.28, p < 0.01). Depression was significantly associated with several traumatic experiences including rape (OR = 2.3, p = 0.01), and experiencing the disappearance/kidnapping of a child or spouse (OR = 1.99, p = 0.01). CONCLUSIONS: Refugee women self-settled in Kampala reported high lifetime experiences of violence and traumatic events including rape, as well as high rates of PTSD and depression. Future programming addressing self-settled refugees and their settlement in host countries may benefit from including local and national integration strategies.

Task Shifting for Initiation and Monitoring of Antiretroviral Therapy for HIV-Infected Adults in Uganda: The SHARE Trial.

BACKGROUND: With countries moving toward the World Health Organization's "Treat All" recommendation, there is a need to initiate more HIV-infected persons into antiretroviral therapy (ART). In resource-limited settings, task shifting is 1 approach that can address clinician shortages. SETTING: Uganda. METHODS: We conducted a randomized controlled trial to test if nurse-initiated and monitored ART (NIMART) is noninferior to clinician-initiated and monitored ART in HIV-infected adults in Uganda. Study participants were HIV-infected, ART-naive, and clinically stable adults. The primary outcome was a composite end point of any of the following: all-cause mortality, virological failure, toxicity, and loss to follow-up at 12 months post-ART initiation. RESULTS: Over half of the study cohort (1,760) was women (54.9%). The mean age was 35.1 years (SD 9.51). Five hundred thirty-three (31.6%) participants experienced the composite end point. At 12 months post-ART initiation, nurse-initiated and monitored ART was noninferior to clinician-initiated and monitored ART. The intention-to-treat site-adjusted risk differences for the composite end point were -4.1 [97.5% confidence interval (CI): = -9.8 to 0.2] with complete case analysis and -3.4 (97.5% CI: = -9.1 to 2.5) with multiple imputation analysis. Per-protocol site-adjusted risk differences were -3.6 (97.5% CI: = -10.5 to 0.6) for complete case analysis and -3.1 (-8.8 to 2.8) for multiple imputation analysis. This difference was within hypothesized margins (6%) for noninferiority. CONCLUSIONS: Nurses were noninferior to clinicians for initiation and monitoring of ART. Task shifting to trained nurses is a viable means to increase access to ART. Future studies should evaluate NIMART for other groups (e.g., children, adolescents, and unstable patients).