Implementing HbA1c monitoring in sub-Saharan Africa: Lessons learnt from a pilot project in Mozambique.

Aims: We aimed to evaluate lesson learnt from a pilot project in Mozambique focused on point-of-care (POC) HbA1c testing for diabetes management in primary health care facilities. Methods: Over a three-year period, several health centers were equipped with POC HbA1c testing machines. The evaluation involved 12 months of data collection, interviews with patients and staff, and regular supervision visits. Results: The project screened over 22,000 individuals and provided HbA1c testing to 2362 diabetes patients. Among the analyzed results, 65.7 % had HbA1c levels below 7 %, 10.9 % between 7 % and 8.5 %, and 23.4 % above 8.5 %. POC testing showed advantages such as reduced costs and improved workload management. Conclusions: Limited access to HbA1c testing remains a challenge in African countries. The pilot project demonstrated the feasibility of POC HbA1c testing and highlighted the need for increased efforts to make it more widely available, leading to improved diabetes management and patient outcomes.

COVID-19 infection rate and mortality in a local health authority in Italy: Differences between home-dwelling and residential older adults.

Objectives: The health emergency following the COVID-19 pandemic has seen hospital structures collapse and put in crisis nursing homes and other long-term care facilities worldwide. Our study aims to analyze and comparing the data relating to the infection rate and mortality for COVID-19 in the elderly over 75 living in the long-term care facilities and in the home-dwelling population. Study design: The study adopts a retrospective cohort design and was conducted in Italy, in the Lazio region, in the area of the Local Health Authority (LHA) named "Azienda Sanitaria Locale Roma 6". Methods: Data were extracted from the COVID-19 surveillance system of the Lazio region. The primary outcome is the SARS-CoV-2 incidence rate in the period between 1st September 2020 and 31st May 2021. The secondary outcome is the mortality rate. Results: Living in a residential versus a home-dwelling setting was associated with a higher infection rate (OR 5.03, CI 4.67-5.43; p < 0.001). The mortality rate was higher for individuals living in a residential setting (19.3 %, CI 17.1%-21.7 %) than those living at home (13.0 %, CI 11.7%-14.5 %). Conclusions: These findings confirm the high mortality in Long-Term Care Facilities and provide new information on the infection rate. The containment measures adopted in the Long-Term Care Facilities during the COVID-19 pandemic, show limited correlation with reduced risk of contagion, but could have created unintended harm for the residents by increasing the social isolation and all other causes of mortality.

Insufficient measles antibody protection in 6-month-old Malawian infants: Reconsider vaccination schedule?

Measles vaccination is currently recommended at 9 months, since maternal antibodies are supposed to protect infants until that age. In this study of 6-month-old Malawian infants 98.3% (58/59) had non-protective IgG levels against measles, irrespective of HIV exposure. Anticipating the first dose at 6 months could be considered.

Micronutrient and Nutritional Status of HIV-Exposed and HIV-Unexposed Malawian Infants in the First Year of Life: Assessment of Ferritin, Vitamin A, and D Status and Its Association with Growth.

Breastfed Malawian infants from Human Immunodeficiency Virus (HIV)-uninfected and HIV-infected women who received antiretroviral therapy were followed until 12 months of age, allowing us to evaluate plasma levels of ferritin, vitamin A (as retinol-binding protein, RBP), and vitamin D (25(OH)D) at six months, as well as nutritional status and growth between six and 12 months. Ferritin and RBP levels were adjusted for inflammation. The study included 88 infants, 63 of whom were part of a recent cohort (2019-2021) that included 49 HIV-exposed but uninfected (HEU) and 14 HIV-unexposed and uninfected (HUU) infants, as well as 25 infants (all HEU) from an earlier cohort (2008-2011). No differences were observed between HEU and HUU infants regarding micronutrient levels, anthropometric indexes, growth, and rates of stunting, being underweight, or wasting. HEU infants from the earlier cohort, when compared to more recent HEU infants, had significantly worse anthropometric measures at six months and inferior growth between six and twelve months. Overall, ferritin deficiency involved 68.6% of infants, while vitamin A and vitamin D deficiency involved 8% and 1.2% of infants, respectively. Micronutrient deficiencies were not associated with HIV exposure, cohort, stunting, being underweight, or wasting. At six months, stunting, being underweight, and wasting involved 25.0%, 2.7% and 2.8% of infants, respectively, with no differences related to HIV exposure. Ferritin deficiency at six months was associated with inferior subsequent growth. In this small observational study conducted in Malawian infants, no major nutritional gap was observed between HIV-exposed and HIV-unexposed infants, though the study highlighted specific nutritional deficiencies that deserve attention. High rates of stunting and ferritin deficiency were observed in the first year of life in Malawian infants, irrespective of maternal HIV status; a significant association between ferritin deficiency and worse subsequent growth was found. Vitamin A and vitamin D deficiencies were much less frequent. Based on the data observed, nutritional interventions should give priority to the correction of ferritin deficiency and chronic undernutrition.

Rates of Seroprotection against Vaccine-Preventable Infectious Diseases in HIV-Exposed and -Unexposed Malawian Infants.

BACKGROUND: The evaluation of seroprotection rates against vaccine-preventable infectious diseases allows for the identification of risk populations. HIV-exposed infants, even if not infected with HIV, have higher morbidity and mortality in comparison to unexposed counterparts. The aim of this study was to compare the specific IgG levels against Haemophilus influenzae type-B (HiB), Hepatitis-B (HBV), and Streptococcus pneumoniae (Spn) in two groups of infants (HIV-exposed and HIV-unexposed) living in Malawi. METHODS: Blood samples from 62 infants, 49 HIV-exposed, uninfected (HEU), and born to women living with HIV and 13 HIV-unexposed and uninfected (HUU), were collected at 6 months, and specific IgG levels were determined using ELISA tests. RESULTS: The antibody levels against HiB, HBV, and Spn were similar in the two groups. At six months, all HUU infants and 81.6% of HEU infants showed seroprotective levels against HiB, while a percentage of protection varying from 80.6 to 84.6% was observed for HBV and Spn regardless of HIV exposure. Only 59.2% of HEU and 69.2% of HUU infants showed antibody protection against all three pathogens. CONCLUSIONS: These results indicate similar rates of seroprotection among HEU and HUU infants but also suggest that a consistent fraction of infants received incomplete vaccinations. Strategies to enforce participation in immunization programs in Malawi should be a health priority.

Cytomegalovirus viremia in HIV-exposed and HIV-unexposed infants in Malawi.

In sub-Saharan Africa the great majority of infants acquire Cytomegalovirus (CMV) infection within the first year of life. Maternal long-term antiretroviral therapy (ART) has been suggested to reduce the rate of CMV acquisition in HIV-exposed infants. In the present study serum samples collected at 6 months of age from HIV-exposed and HIV-unexposed infants were analyzed for the presence of CMV DNA (with CMV positivity defined by levels of CMV DNA > 1000 UI/ml). Twenty out of 58 (34.5%) infants had CMV DNA > 1000 UI/ml. There was no difference in the prevalence of CMV viremia between HIV-exposed and -unexposed infants [33.3% (15/45) vs 38.5% (5/13), respectively, P = 0.488]. In the HIV-exposed group, mothers of CMV-negative infants had received a longer antiretroviral treatment before delivery in comparison to mothers of CMV-positive infants (28 vs 3 months, P = 0.187). No differences in weights and lengths at birth, and at 1, 6 and 12 months were observed between CMV-positive and CMV-negative infants. In this study, the prevalence of CMV viremia at six months of age was high in infants born to HIV-positive mothers receiving long-term ART, similar to that of HIV-unexposed infants. Considering the possible relevant impact of CMV on infant health, strategies for containment of the infection should be explored.

On-Field Test of Tuberculosis Diagnosis through Exhaled Breath Analysis with a Gas Sensor Array.

Tuberculosis (TB) is among the more frequent causes of death in many countries. For pulmonary TB, early diagnosis greatly increases the efficiency of therapies. Although highly sensitive tests based on nucleic acid amplification tests (NAATs) and loop-mediated isothermal amplification (TB-LAMP) are available, smear microscopy is still the most widespread diagnostics method in most low-middle-income countries, and the true positive rate of smear microscopy is lower than 65%. Thus, there is a need to increase the performance of low-cost diagnosis. For many years, the use of sensors to analyze the exhaled volatile organic compounds (VOCs) has been proposed as a promising alternative for the diagnosis of several diseases, including tuberculosis. In this paper, the diagnostic properties of an electronic nose (EN) based on sensor technology previously used to identify tuberculosis have been tested on-field in a Cameroon hospital. The EN analyzed the breath of a cohort of subjects including pulmonary TB patients (46), healthy controls (38), and TB suspects (16). Machine learning analysis of the sensor array data allows for the identification of the pulmonary TB group with respect to healthy controls with 88% accuracy, 90.8% sensitivity, 85.7% specificity, and 0.88 AUC. The model trained with TB and healthy controls maintains its performance when it is applied to symptomatic TB suspects with a negative TB-LAMP. These results encourage the investigation of electronic noses as an effective diagnostic method for future inclusion in clinical practice.

Diagnostic yield of urine lipoarabinomannan and sputum tuberculosis tests in people living with HIV: a systematic review and meta-analysis of individual participant data.

BACKGROUND: Sputum is the most widely used sample to diagnose active tuberculosis, but many people living with HIV are unable to produce sputum. Urine, in contrast, is readily available. We hypothesised that sample availability influences the diagnostic yield of various tuberculosis tests. METHODS: In this systematic review and meta-analysis of individual participant data, we compared the diagnostic yield of point-of-care urine-based lipoarabinomannan tests with that of sputum-based nucleic acid amplification tests (NAATs) and sputum smear microscopy (SSM). We used microbiologically confirmed tuberculosis based on positive culture or NAAT from any body site as the denominator and accounted for sample provision. We searched PubMed, Web of Science, Embase, African Journals Online, and clinicaltrials.gov from database inception to Feb 24, 2022 for randomised controlled trials, cross-sectional studies, and cohort studies that assessed urine lipoarabinomannan point-of-care tests and sputum NAATs for active tuberculosis detection in participants irrespective of tuberculosis symptoms, HIV status, CD4 cell count, or study setting. We excluded studies in which recruitment was not consecutive, systematic, or random; provision of sputum or urine was an inclusion criterion; less than 30 participants were diagnosed with tuberculosis; early research assays without clearly defined cutoffs were tested; and humans were not studied. We extracted study-level data, and authors of eligible studies were invited to contribute deidentified individual participant data. The main outcomes were the tuberculosis diagnostic yields of urine lipoarabinomannan tests, sputum NAATs, and SSM. Diagnostic yields were predicted using Bayesian random-effects and mixed-effects meta-analyses. This study is registered with PROSPERO, CRD42021230337. FINDINGS: We identified 844 records, from which 20 datasets and 10 202 participants (4561 [45%] male participants and 5641 [55%] female participants) were included in the meta-analysis. All studies assessed sputum Xpert (MTB/RIF or Ultra, Cepheid, Sunnyvale, CA, USA) and urine Alere Determine TB LAM (AlereLAM, Abbott, Chicago, IL, USA) in people living with HIV aged 15 years or older. Nearly all (9957 [98%] of 10 202) participants provided urine, and 82% (8360 of 10 202) provided sputum within 2 days. In studies that enrolled unselected inpatients irrespective of tuberculosis symptoms, only 54% (1084 of 1993) of participants provided sputum, whereas 99% (1966 of 1993) provided urine. Diagnostic yield was 41% (95% credible interval [CrI] 15-66) for AlereLAM, 61% (95% Crl 25-88) for Xpert, and 32% (95% Crl 10-55) for SSM. Heterogeneity existed across studies in the diagnostic yield, influenced by CD4 cell count, tuberculosis symptoms, and clinical setting. In predefined subgroup analyses, all tests had higher yields in symptomatic participants, and AlereLAM yield was higher in those with low CD4 counts and inpatients. AlereLAM and Xpert yields were similar among inpatients in studies enrolling unselected participants who were not assessed for tuberculosis symptoms (51% vs 47%). AlereLAM and Xpert together had a yield of 71% in unselected inpatients, supporting the implementation of combined testing strategies. INTERPRETATION: AlereLAM, with its rapid turnaround time and simplicity, should be prioritised to inform tuberculosis therapy among inpatients who are HIV-positive, regardless of symptoms or CD4 cell count. The yield of sputum-based tuberculosis tests is undermined by people living with HIV who cannot produce sputum, whereas nearly all participants are able to provide urine. The strengths of this meta-analysis are its large size, the carefully harmonised denominator, and the use of Bayesian random-effects and mixed-effects models to predict yields; however, data were geographically restricted, clinically diagnosed tuberculosis was not considered in the denominator, and little information exists on strategies for obtaining sputum samples. FUNDING: FIND, the Global Alliance for Diagnostics.

Screening approaches for cervical cancer in Mozambique in HIV positive and negative women.

OBJECTIVE: Cervical cancer (CC) is a global health issue, in Mozambique, 5300 new cases and 3800 deaths are reported each year. The WHO recommends the introduction of HPV molecular testing for CC screening, but Mozambique uses an approach based on visual inspection with acetic acid (VIA). This study aims to evaluate the feasibility of high-risk HPV (hrHPV) testing compared to actual approaches in Mozambique. METHODS: An observational study was carried out in the DREAM center in Zimpeto, Mozambique. Women aged 30-55 were included. HPV testing was performed with the Cobas HPV test. They were then screened with the current national recommendations based on VIA. Cryotherapy was performed on-site or referred for colposcopy if necessary. RESULTS: In the period, 1207 women were enrolled, 47.8% HIV+; 124 (10.3%) VIA+, and HPV DNA test was positive in 325 (26.9%) women. HPV positivity rates were higher in HIV-infected women. In the sample, 52.8% of the 124 VIA+ women were HPV uninfected and underwent unnecessary cryotherapy or colposcopy. Meanwhile, 24.7% of the 1083 VIA- women were actually HPV infected. In comparison, a screen, triage and treat approach based on hrHPV testing would only test and treat the 325 HPV-infected women. CONCLUSION: The study found high rates of hrHPV infection, particularly in HIV-positive women, with many concurrent or multiple infections. The current screening method misses important hrHPV infections and results in many unnecessary treatments. These results support the use of HPV molecular testing as the initial screening test for CC.

A novel, integrated approach for understanding and investigating Healthcare Associated Infections: A risk factors constellation analysis.

INTRODUCTION: Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) are major public health threats in upper- and lower-middle-income countries. Electronic health records (EHRs) are an invaluable source of data for achieving different goals, including the early detection of HAIs and AMR clusters within healthcare settings; evaluation of attributable incidence, mortality, and disability-adjusted life years (DALYs); and implementation of governance policies. In Italy, the burden of HAIs is estimated to be 702.53 DALYs per 100,000 population, which has the same magnitude as the burden of ischemic heart disease. However, data in EHRs are usually not homogeneous, not properly linked and engineered, or not easily compared with other data. Moreover, without a proper epidemiological approach, the relevant information may not be detected. In this retrospective observational study, we established and engineered a new management system on the basis of the integration of microbiology laboratory data from the university hospital "Policlinico Tor Vergata" (PTV) in Italy with hospital discharge forms (HDFs) and clinical record data. All data are currently available in separate EHRs. We propose an original approach for monitoring alert microorganisms and for consequently estimating HAIs for the entire period of 2018. METHODS: Data extraction was performed by analyzing HDFs in the databases of the Hospital Information System. Data were compiled using the AREAS-ADT information system and ICD-9-CM codes. Quantitative and qualitative variables and diagnostic-related groups were produced by processing the resulting integrated databases. The results of research requests for HAI microorganisms and AMR profiles sent by the departments of PTV from 01/01/2018 to 31/12/2018 and the date of collection were extracted from the database of the Complex Operational Unit of Microbiology and then integrated. RESULTS: We were able to provide a complete and richly detailed profile of the estimated HAIs and to correlate them with the information contained in the HDFs and those available from the microbiology laboratory. We also identified the infection profile of the investigated hospital and estimated the distribution of coinfections by two or more microorganisms of concern. Our data were consistent with those in the literature, particularly the increase in mortality, length of stay, and risk of death associated with infections with Staphylococcus spp, Pseudomonas aeruginosa, Klebsiella pneumoniae, Clostridioides difficile, Candida spp., and Acinetobacter baumannii. Even though less than 10% of the detected HAIs showed at least one infection caused by an antimicrobial resistant bacterium, the contribution of AMR to the overall risk of increased mortality was extremely high. CONCLUSIONS: The increasing availability of health data stored in EHRs represents a unique opportunity for the accurate identification of any factor that contributes to the diffusion of HAIs and AMR and for the prompt implementation of effective corrective measures. That said, artificial intelligence might be the future of health data analysis because it may allow for the early identification of patients who are more exposed to the risk of HAIs and for a more efficient monitoring of HAI sources and outbreaks. However, challenges concerning codification, integration, and standardization of health data recording and analysis still need to be addressed.

Enhancing retention in care in HIV-infected adolescents during COVID-19 in Mozambique: results from the DREAM program.

INTRODUCTION: Around 1,7 million adolescents aged 10-19 years worldwide are infected with HIV, 84% of them living in Sub-Saharan Africa. Mozambique is one of the countries with the highest prevalence of HIV in the world. According to UNAIDS, HIV services for adolescents should be tailored and specifically designed for them. METHODS: We aimed to evaluate a package of activities to enhance the retention of HIV-infected adolescent in Mozambique. We retrospectively reviewed routine data from 7 health centers involved in 26 months, from March 2020 to May 2022. A package of tailored interventions was implemented in all the sites. We reviewed activity data from the included centers. RESULTS: The median number of patients per center was 343 (IQR: 289-466) at the beginning of the period and 395 (IQR: 322-453) at the end. The median overall retention in care and rate of lost to follow-up at the beginning and the end of the period were respectively: 94.2% (IQR 91.9-97.3%) to 99.0% (IQR 96.8-99.5%), 1.5% (IQR 1-3.2%) to 0% (IQR 0.0-0.3%). The total number of deaths increased reaching a plateau after September 2021. All the indicators improved after the beginning of the intervention, also during COVID-19 pandemic. CONCLUSIONS: Our data support the idea that enhancing retention in care for HIV positive adolescents need tailored interventions, based on deep rooting in the specific social context. Tailored intervention can resist external shock such as COVID-19.

A 12-month Prospective Study of HIV-infected and HIV-uninfected Women and Their Infants in Malawi: Comparative Analysis of Clinical Events and Infant Growth.

Few studies have compared clinical outcomes in HIV-exposed uninfected (HEU) and HIV-unexposed uninfected (HUU) infants in the current scenario of universal and lifelong maternal antiretroviral therapy (ART). HIV-uninfected and HIV-infected Malawian women receiving ART and their breastfed infants were followed for 12 months postpartum, analyzing the rates of infectious and noninfectious events and assessing infant growth at 6 weeks, 6 months, and 12 months. The cohorts included 227 mothers (70 HIV-negative, 157 HIV-positive) and 235 infants (72 HUU, 163 HEU). No maternal or infant deaths occurred during follow-up. HIV-negative women were less likely to complete follow-up (48.6% versus 91.1%). Mothers with and without HIV had similar rates of both infectious and noninfectious events per person-month. Infants who were HEU, compared with HUU, had higher rates of events of any type, lower respiratory tract infections (LRTI), and noninfectious events. HEU had lower body mass index (BMI) at 6 weeks but did not differ from HUU in all anthropometric measures at 6 and 12 months; in growth between 6 weeks and 12 months; and in occurrence of stunting, underweight, and wasting at 6 weeks, 6 months, and 12 months. During the first year of life, infants who were HEU, compared with HUU, showed a transiently lower BMI and an increased risk of LRTI.

Maternal retention and early infant HIV diagnosis in a prospective cohort study of HIV-positive women and their children in Malawi.

BACKGROUND: Post-partum loss to follow-up and lack of early HIV infant diagnosis (EID) can significantly affect the efficiency of programs for the prevention of mother-to-child transmission. METHODS: In a prospective observational study 167 women were enrolled at week 36 of gestation and followed with their infants up to one year after delivery. Retention was defined as the proportion of women who attended the 12 months visit and EID as an HIV PCR test performed within 2 months. Determinants for retention and EID were assessed in univariate analyses and in multivariable logistic regression models. RESULTS: Women lost to follow-up (24/167 or 14.4%) had a shorter duration of antiretroviral therapy (ART) at enrolment in comparison to women retained in care (p = 0.025). Lack of EID (occurring in 18.9% of the cases) was directly correlated, although not significantly, with a history of child death (p = 0.071), a higher educational level (p = 0.083), and female infant gender (p = 0.064). CONCLUSIONS: Longer duration of ART at enrolment significantly predicted a better post-partum retention, suggesting that specific counselling interventions should be targeted to recent ART initiators. A low proportion of infants did not receive an EID, but predictive factors were difficult to identify.

Improving Male Partner Involvement in HIV-Positive Women's Care Through Behavioral Change Interventions in Malawi (WeMen Study): A Prospective, Controlled Before-and-After Study.

Several strategies and interventions have been implemented to improve male partner involvement (MI) in Sub-Saharan Africa, but evidence on successful interventions is scarce. This controlled before-and-after intervention study aims to evaluate the impact of three interventions on male partners' involvement in HIV+ women's care in Malawi. We piloted these three interventions: the organization of a special day for men, the deployment of male champions in communities to increase awareness on MI, and the delivery of an incentive (food package) for couples attending the facility. We observed a significant increase in the number of women accompanied by their partners (from 48.5 to 81.4%) and the number of women feeling safe at home (from 63.5 to 95.2%) after the special day intervention. This outcome increased after the deployment of male champions in communities (from 44.0 to 75.0%). No significant improvement was observed in the site where we delivered the incentive to couples. Our findings showed that the special day for men and the use of male champions might effectively increase the male involvement in the health of their female partners.

Characteristics of nursing homes and early preventive measures associated with risk of infection from COVID-19 in Lazio region, Italy: a retrospective case-control study.

OBJECTIVES: To understand which organisational-structural characteristics of nursing homes-also referred to as long-term care facilities (LTCFs)-and the preventative measures adopted in response to the pandemic are associated with the risk of a COVID-19 outbreak. SETTING: LTCFs in Lazio region in Italy. DESIGN: The study adopts a case-control design. PARTICIPANTS: We included 141 facilities and 100 provided information for the study. Cases were defined as facilities reporting a COVID-19 outbreak (two or more cases) in March-December 2020; controls were defined as LTCFs reporting one case or zero. The exposures include the structural-organisational characteristics of the LTCFs as reported by the facilities, preventative measures employed and relevant external factors. RESULTS: Twenty facilities reported an outbreak of COVID-19. In binary logistic regression models, facilities with more than 15 beds were five times more likely to experience an outbreak than facilities with less than 15 beds OR=5.60 (CI 1.61 to 25.12; p value 0.002); admitting new residents to facilities was associated with a substantially higher risk of an outbreak: 6.46 (CI 1.58 to 27.58, p value 0.004). In a multivariable analysis, facility size was the only variable that was significantly associated with a COVID-19 outbreak OR= 5.37 (CI 1.58 to 22.8; p value 0.012) for larger facilities (>15 beds) versus smaller (<15 beds). Other characteristics and measures were not associated with an outbreak. CONCLUSION: There was evidence of a higher risk of COVID-19 in larger facilities and when new patients were admitted during the pandemic. All other structural-organisational characteristics and preventative measures were not associated with an outbreak. This finding calls into question existing policies, especially where there is a risk of harm to residents. One such example is the restriction of visitor access to facilities, resulting in the social isolation of residents.

Premenopausal Syndrome and NAFLD: A New Approach Based on Gender Medicine.

Non-alcoholic fatty liver disease (NAFLD) is a multifactorial condition that affects 25% of the world's population. There is a clear difference in both geographical distribution and sex in childbearing age. These differences are reduced when women become older and senescence begins. The factors that affect the likelihood of developing NAFLD in a premenopausal woman are an imbalance of sex hormones (especially in estradiol and androgen), microbiome dysregulation, insulin resistance, early menarche, the length of time that the woman breastfeeds for and polycystic ovarian syndrome (PCOS). The aim of this review is to identify various physical ailments that may not appear to be serious to young women but that then affect the onset of NAFLD in perimenopause and can degenerate into NASH. These conditions should also be considered in future clinical management, as well as in research opportunities, in order to customize the monitoring and treatment of NAFLD, considering gender medicine for those women who had early metabolic symptoms that were not considered to be significant at the time.

Understanding the meanings of male partner support in the adherence to therapy among HIV-positive women: a gender analysis.

BACKGROUND: Previous literature reports that low male partner support is a barrier to women's adherence and retention in HIV care programs. OBJECTIVE: This qualitative study explored the relationships between partners to understand what is meant by male partner support in adherence of HIV-positive women in four healthcare facilities in Southern Malawi. METHODS: We conducted 8 semi-structured focus group discussions (FGDs) with 73 participants (40 men and 33 women) and 10 in-depth interviews (IDIs) between August 2018 to December 2019. Participants were HIV-positive patients, healthcare workers (HCWs), expert patients (EPs), and couples attending the clinic. All data were digitally recorded, transcribed verbatim, and analysed using a gender-responsive grounded theory approach. RESULTS: This study confirms previous literature, which suggests male partner support is expressed by providing access to transport to the clinic and accompaniment to appointments. However, we found that men can also control access to resources and decision-making. Support is more complex than previous literature reported and, in some cases, gender norms significantly limit women's capacity to engage in care independently of male support since women need male partner permission to access the resources to attend clinics. CONCLUSIONS: This paper suggests that restrictive male-partner gender norms limit women's power to engage in care. Most importantly, the gender analysis reveals that what previous literature describes as male partner support can sometimes hide male partner control in permitting access to resources to attend health facilities. For this reason, policies enhancing male support should consider the gender power relationship between partners to avoid reinforcing gender inequality.

Immunoglobulin G passive transfer from mothers to infants: total IgG, IgG subclasses and specific antipneumococcal IgG in 6-week Malawian infants exposed or unexposed to HIV.

BACKGROUND: The impaired transplacental passage of IgG from mothers living with HIV to their infants could be one of the causes of the high vulnerability to infections of HIV-exposed uninfected (HEU) infants, but controversial results have been obtained in different settings. The aim of this study was to assess in 6-week old HEU and HIV-unexposed, uninfected (HUU) Malawian infants the total IgG levels, the subclasses profile and the concentrations of global anti-pneumococcal capsular polysaccharide (anti-PCP) IgG and IgG2. METHODS: Dried blood spots were collected from 80 infants (40 HEU, 40 HUU) and antibodies concentrations determined by nephelometric method (total IgG and subclasses), or using ELISA (anti-PCP total IgG and IgG2). Results are expressed as median levels with IQR, while the proportions of each subclass out of the total IgG are used to describe the subclasses profile. RESULTS: At 6 weeks HEU infants had higher median levels of total IgG and IgG1 and a significantly lower level of IgG2 [0.376 (0.344-0.523) g/l vs 0.485 (0.374-0.781) g/l, p = 0.037] compared to the HUU counterparts. The IgG subclasses distribution confirmed the underrepresentation of IgG2 (IgG2 represented 5.82% of total IgG in HEU and 8.87% in HUU). The anti-PCP IgG and IgG2 levels were significantly lower in HEU infants [8.9 (5.4-15.1) mg/l vs 16.2 (9.61-25.8) mg/l in HUU, p < 0.001, and 2.69 (1.90-4.29) mg/l vs 4.47 (2.96-5.71) mg/l in HUU, p = 0.001, respectively]. CONCLUSION: Compared to HUU infants, HEU infants have IgG abnormalities mainly represented by low IgG2 levels, suggesting that despite maternal antiretroviral therapy, the mechanisms of IgG transplacental passage continue to be impaired in women living with HIV. HEU infants also showed a significantly lower level of specific anti-PCP IgG, possibly favouring a high vulnerability to S. pneumoniae infection at an age when protection is mostly depending on maternal IgG.

Early detection of poor glycemic control in patients with diabetes mellitus in sub-Saharan Africa: a cohort study in Mozambique.

Introduction: WHO estimates 422 million cases of diabetes mellitus worldwide. Mozambique has the second-highest mortality related to DM in the African region.Objectives of the present study are to provide data about a DM care service in Mozambique and to evaluate early outcomes of treatment. Methods: The new patients diagnosed with DM in a two-years period in a health centre in Maputo (Mozambique) were included in a retrospective cohort study. Fasting blood glucose (FBG), waist circumference (WC) and BMI were collected at baseline and after three months. Results: 188 patients were enrolled. Median BMI, WC and FBG at baseline were respectively 28 kg/m2(Inter Quartile Range [IQR]23.4-31.8), 98cm (IQR 87-105) and 209mg/dL (IQR 143-295). A non-pharmacological intervention was prescribed for six patients, while 182 patients received metformin 500 mg b.i.d. FBG was significantly reduced at control (226[±103.7]mg/dL vs 186[±93.2]mg/dL, p<0.000); however, glycemic control was reached in 74 patients (39.4%); not controlled patients changed regimen. Elderly patients had a higher glycemic control (adjusted Odds Ratio 2.50, 95% CI 1.11-5.06, p=0.002). Conclusion: Strategies for early detection of scarce glycemic control are feasible in Mozambique and could lead to prompt regimen switch; an invasive therapeutic approach could be preferable in selected cases to achieve control.

The Effectiveness of Intervening on Social Isolation to Reduce Mortality during Heat Waves in Aged Population: A Retrospective Ecological Study.

BACKGROUND: Heat waves are correlated with increased mortality in the aged population. Social isolation is known as a vulnerability factor. This study aims at evaluating the correlation between an intervention to reduce social isolation and the increase in mortality in the population over 80 during heat waves. METHODS: This study adopted a retrospective ecologic design. We compared the excess mortality rate (EMR) in the over-80 population during heat waves in urban areas of Rome (Italy) where a program to reduce social isolation was implemented, to others where it was not implemented. We measured the mortality of the summer periods from 2015 to 2019 compared with 2014 (a year without heat waves). Winter mortality, cadastral income, and the proportion of people over 90 were included in the multivariate Poisson regression. RESULTS: The EMR in the intervention and controls was 2.70% and 3.81%, respectively. The rate ratio was 0.70 (c.i. 0.54-0.92, p-value 0.01). The incidence rate ratio (IRR) of the interventions, with respect to the controls, was 0.76 (c.i. 0.59-0.98). After adjusting for other variables, the IRR was 0.44 (c.i. 0.32-0.60). CONCLUSIONS: Reducing social isolation could limit the impact of heat waves on the mortality of the elderly population.