Community Insights in Phylogenetic HIV Research: The CIPHR Project Protocol.

Inferring HIV transmission networks from HIV sequences is gaining popularity in the field of HIV molecular epidemiology. However, HIV sequences are often analyzed at distance from those affected by HIV epidemics, namely without the involvement of communities most affected by HIV. These remote analyses often mean that knowledge is generated in absence of lived experiences and socio-economic realities that could inform the ethical application of network-derived information in 'real world' programmes. Procedures to engage communities are noticeably absent from the HIV molecular epidemiology literature. Here we present our team's protocol for engaging community activists living in Nairobi, Kenya in a knowledge exchange process - The CIPHR Project (Community Insights in Phylogenetic HIV Research). Drawing upon a community-based participatory approach, our team will (1) explore the possibilities and limitations of HIV molecular epidemiology for key population programmes, (2) pilot a community-based HIV molecular study, and (3) co-develop policy guidelines on conducting ethically safe HIV molecular epidemiology. Critical dialogue with activist communities will offer insight into the potential uses and abuses of using such information to sharpen HIV prevention programmes. The outcome of this process holds importance to the development of policy frameworks that will guide the next generation of the global response.

Risk factors of HIV and variation in access to clean needles among people who inject drugs in Pakistan.

We identified key risk factors for HIV among people who inject drugs (PWID) in Pakistan and explored access to free clean needles. Multivariable logistic regression was used to investigate associations between HIV prevalence and demographic, behavioral, and socio-economic characteristics of PWID. Data came from the Government of Pakistan's Integrated Biological and Behavioral Surveillance (IBBS) Round 5 (2016-17; 14 cities). A secondary analysis investigated associations with reported access to clean needles. Unweighted HIV prevalence among 4,062 PWID (99% male) was 21.0%. Longer injecting duration (Odds ratio [OR] 1.06 [95% confidence interval: 1.02-1.10]; per year), higher injecting frequency (OR 1.67 [1.30-2.13]; per unit increase), and injecting heroin (OR 1.90 [1.11-3.25]) were positively associated with HIV prevalence. There was no association between using a used syringe at last injection and HIV. Having>10 years of education had lower odds of HIV than being illiterate (OR 0.58 [0.35-0.95]). Having a regular sexual partner (OR 0.74 [0.57-0.97]) or paying for sex with the opposite sex (OR = 0.62 [0.45-0.85]) had lower odds of HIV than not. Conversely, PWID paying a man/hijra for sex had higher odds of HIV (OR 1.20 [1.00-1.43]). Receipt of clean needles varied by city of residence (0-97% coverage), whilst PWID with knowledge of HIV service delivery programs had higher odds of receiving clean needles (OR 4.58 [3.50-5.99]). Injecting behaviors were associated with HIV prevalence among PWID, though risks related to paying for sex remain complicated. Geographical variation in access to clean needles suggests potential benefits of more widely spread public health services.

Key MessagesWhat is already known on this topicThe HIV epidemic in Pakistan is concentrated among key populations including people who inject drugs.What this study addsInjecting practices, sexual behaviors, and socio-economic factors are associated with HIV prevalence among people who inject drugs. Access to harm reduction services is varied in Pakistan.How this study might affect research, practice, or policyAccess to clean free needles, as well as service delivery programs, with a broad geographical reach remain important to curb the HIV epidemic among people who inject drugs in Pakistan.

Examination of Impact of After-Hours Admissions on Hospital Resource Use, Patient Outcomes, and Costs.

Background: Nighttime and weekends in hospital and intensive care unit (ICU) contexts are thought to present a greater risk for adverse events than daytime admissions. Although some studies exist comparing admission time with patient outcomes, the results are contradictory. No studies currently exist comparing costs with the time of admission. We investigated the differences in-hospital mortality, ICU length of stay, ICU mortality, and cost between daytime and nighttime admissions. Methods: All adult patients (≥18 years of age) admitted to a large academic medical-surgical ICU between 2011 and 2015 were included. Admission cohorts were defined as daytime (8:00-16:59) or nighttime (17:00-07:59). Student's t-tests and chi-squared tests were used to test for associations between days spent in the ICU, days on mechanical ventilation, comorbidities, diagnoses, and cohort membership. Regression analysis was used to test for associations between patient and hospitalization characteristics and in-hospital mortality and total ICU costs. Results: The majority of admissions occurred during nighttime hours (69.5%) with no difference in the overall Elixhauser comorbidity score between groups (p=0.22). Overall ICU length of stay was 7.96 days for daytime admissions compared to 7.07 days (p=0.001) for patients admitted during nighttime hours. Overall mortality was significantly higher in daytime admissions (22.5% vs 20.6, p=0.012); however, ICU mortality was not different. The average MODS was 2.9 with those admitted during the daytime having a significantly higher MODS (3.0, p=0.046). Total ICU cost was significantly higher for daytime admissions (p=0.003). Adjusted ICU mortality was similar in both groups despite an increased rate of adverse events for nighttime admissions. Daytime admissions were associated with increased cost. There was no difference in all hospital total cost or all hospital direct cost between groups. These findings are likely due to the higher severity of illness in daytime admissions. Conclusion: Daytime admissions were associated with a higher severity of illness, mortality rate, and ICU cost. To further account for the effect of staffing differences during off-hours, it may be beneficial to compare weekday and weeknight admission times with associated mortality rates.

Increased Mortality and Costs Associated with Adverse Events in Intensive Care Unit Patients.

Background: Adverse events (AEs) are defined as unintended complications occurring to patients as a result of medical care. AEs are especially prevalent in the intensive care unit (ICU) setting and may lead to negative patient outcomes. Although many studies have examined the impact of AEs on patient outcomes, few have investigated their associated costs. Methods: The study population consisted of 17 173 adult patients (≥18 years of age) who were admitted to the ICU at The Ottawa Hospital (TOH) between 2011 and 2016. AEs were categorized using an established International Classification of Diseases 10th revision (ICD-10) patient safety indicators (PSI) system for AE detection. Logistic regression was performed to determine the association between AEs and in-hospital outcomes, including mortality. In addition, we constructed a generalized linear model to assess the independent association between AEs and total hospital costs. Results: Patients who experienced an AE had longer total hospital and ICU lengths of stay, required more invasive ICU interventions, had more complex discharge plans, and experienced higher rates of in-hospital mortality compared to those who did not experience an AE. Average total hospital costs and ICU-specific costs were higher among patients who experienced an AE ($72 718; $46 715) relative to their counterparts ($20 543; $16 217), but the per day cost was comparable in both groups. After controlling for age, sex, patient comorbidities, and illness severity, AEs were significantly associated with an increased odds of mortality (OR = 1.13, 95% CIs = 1.04, 1.22) and total average costs (Cost Ratio = 1.04, 95% CIs = 1.06, 1.08). The most impactful AE subtypes from a cost- and patient-perspective were hospital-acquired infections (HAI) and cardiac-related AEs. Conclusion: Incidence of AEs among ICU patients is associated with higher patient mortality and elevated costs. Specific causes of these AEs should be investigated, with further protocols and interventions developed to reduce their occurrence.

Characteristics and Outcomes for Low-Risk Hospital Admissions Admitted to the ICU: A Multisite Cohort Study.

IMPORTANCE: Prognostication following ICU admission can often be determined based on known risk factors, including demographics and illness severity; however, little is known about outcomes of patients deemed to be "low-risk" at the time of hospital admission who subsequently are admitted to the ICU. OBJECTIVES: The objectives of this study were to determine the characteristics, outcomes, and costs for patients requiring ICU admission despite having lower predicted mortality when they were admitted to the hospital. DESIGN SETTING AND PARTICIPANTS: In this historical cohort study, we used a prospectively maintained ICU registry that included all ICU admissions to The Ottawa Hospital for patients 18 years or older from January 2011 to December 2016. We classified patients as low-risk using the Hospital-patient 1-year Mortality Risk at admission score, a hospital admission score validated to predict 1-year mortality. MAIN OUTCOMES AND MEASURES: The primary outcome was inhospital mortality. Secondary outcomes included adverse events, resource utilization, and costs. RESULTS: Of the 17,173 total ICU patients, 3,445 (20.1%) were classified as low-risk at hospital admission. Low-risk patients were younger (48.7 vs 67.5 yr; p < 0.001) and had a lower Multiple Organ Dysfunction Score (2.37 vs 4.14; p < 0.001). Mortality for low-risk patients was significantly lower than for non-low-risk patients (4.1% vs 25.4%; p < 0.001). For low-risk patients, multivariable logistic regression showed mortality was independently associated with older age (odds ratio, 1.02 per 1 yr; 95% CI, 1.00-1.03 per 1 yr), Multiple Organ Dysfunction Score (odds ratio, 1.42 per 1 point; 95% CI, 1.31-1.54 per 1 point), fluid management adverse events (odds ratio, 2.84; 95% CI, 1.29-6.25), hospital-acquired infections (odds ratio, 1.60; 95% CI, 1.02-2.51), and mechanical ventilation (odds ratio, 1.98; 95% CI, 1.20-3.26). CONCLUSIONS AND RELEVANCE: Despite their robust premorbid status, low-risk patients admitted to the ICU had significant inhospital mortality. Fluid management adverse events, hospital-associated infections, multiple organ dysfunction, and mechanical ventilation are important prognostic factors for low-risk patients.

Characteristics and resource utilization of high-cost users in the intensive care unit: a population-based cohort study.

BACKGROUND: Healthcare expenditure within the intensive care unit (ICU) is costly. A cost reduction strategy may be to target patients accounting for a disproportionate amount of healthcare spending, or high-cost users. This study aims to describe high-cost users in the ICU, including health outcomes and cost patterns. METHODS: We conducted a population-based retrospective cohort study of patients with ICU admissions in Ontario from 2011 to 2018. Patients with total healthcare costs in the year following ICU admission (including the admission itself) in the upper 10th percentile were defined as high-cost users. We compared characteristics and outcomes including length of stay, mortality, disposition, and costs between groups. RESULTS: Among 370,061 patients included, 37,006 were high-cost users. High-cost users were 64.2 years old, 58.3% male, and had more comorbidities (41.2% had ≥3) when likened to non-high cost users (66.1 years old, 57.2% male, 27.9% had ≥3 comorbidities). ICU length of stay was four times greater for high-cost users compared to non-high cost users (22.4 days, 95% confidence interval [CI] 22.0-22.7 days vs. 5.56 days, 95% CI 5.54-5.57 days). High-cost users had lower in-hospital mortality (10.0% vs.14.2%), but increased dispositioning outside of home (77.4% vs. 42.2%) compared to non-high-cost users. Total healthcare costs were five-fold higher for high-cost users ($238,231, 95% CI $237,020-$239,442) compared to non-high-cost users ($45,155, 95% CI $45,046-$45,264). High-cost users accounted for 37.0% of total healthcare costs. CONCLUSION: High-cost users have increased length of stay, lower in-hospital mortality, and higher total healthcare costs when compared to non-high-cost users. Further studies into cost patterns and predictors of high-cost users are necessary to identify methods of decreasing healthcare expenditure.

Elucidating Drivers for Variations in the Explosive Human Immunodeficiency Virus Epidemic Among People Who Inject Drugs in Pakistan.

BACKGROUND: Pakistan's explosive human immunodeficiency virus (HIV) epidemic among people who inject drugs (PWID) varies widely across cities. We evaluated possible drivers for these variations. METHODS: Multivariable regression analyses were undertaken using data from 5 national surveys among PWID (n = 18 467; 2005-2017) to determine risk factors associated with variations in city-level HIV prevalence. A dynamic HIV model was used to estimate the population-attributable fraction (PAF; proportion of HIV infections prevented over 10 years when that risk factor is removed) of these risk factors to HIV transmission and impact on HIV incidence of reducing their prevalence. RESULTS: Regression analyses suggested that city-level HIV prevalence is strongly associated with the prevalence of using professional injectors at last injection, heroin use in last month, and injecting ≥4 times per day. Through calibrating a model to these associations, we estimate that the 10-year PAFs of using professional injectors, heroin use, and frequent injecting are 45.3% (95% uncertainty interval [UI], 4.3%-79.7%), 45.9% (95% UI, 8.1%-78.4%), and 22.2% (95% UI, 2.0%-58.4%), respectively. Reducing to lowest city-level prevalences of using professional injectors (2.8%; median 89.9% reduction), heroin use (0.9%; median 91.2% reduction), and frequent injecting (0.1%; median 91.8% reduction) in 2020 reduces overall HIV incidence by 52.7% (95% UI, 6.1%-82.0%), 53.0% (95% UI, 11.3%-80.2%), and 28.1% (95% UI, 2.7%-66.6%), respectively, over 10 years. CONCLUSIONS: Interventions should focus on these risk factors to control Pakistan's explosive HIV epidemic among PWID, including a concomitant expansion of high-coverage needle/syringe provision, opioid substitution therapy, and antiretroviral therapy.

An Exploratory Investigation into the Roles of Critical Care Response Teams in End-of-Life Care.

BACKGROUND: Critical Care Response Teams (CCRTs) represent an important interface between end-of-life care (EOLC) and critical care medicine (CCM). The aim of this study was to explore the roles and interactions of CCRTs in the provision of EOLC from the perspective of CCRT members. METHODS: Twelve registered nurses (RNs) and four respiratory therapists (RTs) took part in focus groups, and one-on-one interviews were conducted with six critical care physicians. Thematic coding using a modified constructivist grounded theory approach was used to identify emerging themes through an iterative process involving a four-member coding team. RESULTS: Three main perspectives were identified that spoke to CCRT interactions and perceptions of EOLC encounters. CCRT members felt that they provide a unique skill set of multidisciplinary expertise in treating critically ill patients and evaluating the utility of intensive care treatments. However, despite feeling that they possessed the skills and resources to deliver quality EOLC, CCRT members were ambivalent with respect to whether EOLC was a part of their mandate. Challenges were also identified that impacted the ability of CCRTs to deliver quality EOLC. CONCLUSIONS: This research aids in understanding for the first time CCRT roles in EOLC from the perspectives of individual CCRT members themselves. While CCRTs provide unique multidisciplinary expertise to evaluate the utility of intensive care treatments, opportunities exist to support CCRTs in EOLC, such as dedicated EOLC training, protocols for advance care planning, documentation, and transitions to palliative care.

Cost of Futile ICU Care in One Ontario Hospital.

Critical care is a costly and finite resource that provides the ability to manage patients with life-threatening illnesses in the most advanced forms available. However, not every condition benefits from critical care. There are unrecoverable health states in which it should not be used to perpetuate. Such situations are considered futile. The determination of medical futility remains controversial. In this study we describe the length of stay (LOS), cost, and long-term outcomes of 12 cases considered futile and that have been or were considered for adjudication by Ontario's Consent and Capacity Board (CBB). A chart review was undertaken to identify patients admitted to the Intensive Care Unit (ICU), whose care was deemed futile and cases were considered for, or brought before the CCB. Costs for each of these admissions were determined using the case-costing system of The Ottawa Hospital Data Warehouse. All 12 patients identified had a LOS of greater than 4 months (range: 122-704 days) and a median age 83.5 years. Seven patients died in hospital, while 5 were transferred to long term or acute care facilities. All patients ultimately died without returning to independent living situations. The total cost of care for these 12 patients was $7 897 557.85 (mean: $658 129.82). There is a significant economic cost of providing resource-intensive critical care to patients in which these treatments are considered futile. Clinicians should carefully consider the allocation of finite critical care resources in order to utilize them in a way that most benefits patients.

Suicide and self-harm in adult survivors of critical illness: population based cohort study.

OBJECTIVE: To analyse the association between survival from critical illness and suicide or self-harm after hospital discharge. DESIGN: Population based cohort study using linked and validated provincial databases. SETTING: Ontario, Canada between January 2009 and December 2017 (inclusive). PARTICIPANTS: Consecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period. MAIN OUTCOME MEASURES: The primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models. RESULTS: 423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors (v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56). CONCLUSIONS: Survivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.

Delirium and Associated Length of Stay and Costs in Critically Ill Patients.

PURPOSE: Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) and perform a cost analysis. MATERIALS AND METHODS: Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS. RESULTS: Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p < 0.001); for hospital LOS, this was significant at 6.67 days (p < 0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p < 0.001); for hospital costs, the mean difference was $5,936 (p < 0.001). CONCLUSION: ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.

Costs and Outcomes of Patients Admitted to the Intensive Care Unit With Cancer.

INTRODUCTION: Cancer is associated with significant health-care expenditure, but few studies have examined the cost of patients with cancer in the intensive care unit (ICU). We aimed to describe the costs and outcomes of patients admitted to the ICU with cancer. METHODS: We conducted a retrospective cohort study of patients admitted between 2011 and 2016 to 2 tertiary-care ICUs. We included patients with a cancer-related most responsible diagnosis using International Classification of Disease, 10th Revision, Canada codes. We compared costs and outcomes of patients having cancer with noncancer controls matched for age, sex, and Elixhauser comorbidity score. We used logistic regression to determine predictors of mortality among patients with cancer. RESULTS: There were 1022 patients with cancer during the study period. Mean age was 63.2 years and 577 (56.5%) were male. Inhospital mortality for all patients with cancer was 24.0%. Total cost per patient was higher for patients with cancer compared to noncancer patients (CAD$57 084 vs CAD$40 730; P < .001) but there were no differences in the cost per day (CAD$2868 vs CAD$2887; P = .76) or ICU cost (CAD$30 495 vs CAD$29 382; P = .42). Among patients with cancer, the cost per day was higher for nonsurvivors (CAD$3477 vs CAD$2677; P < .001). Liver disease (odds ratio [OR]: 2.96; 95% confidence interval [CI]: 1.22-7.81), mechanical ventilation (OR: 1.73; 95% CI: 1.25-2.39), hematologic malignancy (OR: 3.88; 95% CI: 2.31-6.54), and unknown primary site (OR: 2.13; 95% CI: 1.36-3.35) were independently associated with mortality in patients with cancer. CONCLUSION: Patients admitted to the ICU with cancer did not differ in cost per day, ICU cost, or mortality compared to matched noncancer controls. Among patients with cancer, nonsurvivors had significantly higher cost per day compared to survivors. Hematologic and unknown primaries, liver disease, and mechanical ventilation were independently associated with mortality in patients with cancer.

Outcomes and Resource Utilization Among Patients Admitted to the Intensive Care Unit Following Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is a common condition, accounting for a significant number of intensive care unit (ICU) admissions. However, little is known about outcomes and costs among ICU patients admitted with acute exacerbations of COPD (AECOPD). We studied predictors of inhospital mortality and costs of ICU admissions for AECOPD. METHODS: Data were obtained from a prospectively maintained registry from 2 ICUs from 2011 to 2016, including adult patients (age ≥ 18) with an ICU discharge diagnosis of AECOPD. The primary outcome was hospital mortality. Secondary outcomes included ICU length of stay, resource utilization, total hospital costs, and cost per survivor. RESULTS: We included 390 patients, of which 27.2% died in hospital. Independent predictors of inhospital mortality included age (odds ratio [OR]: 1.95, CI: 1.58-2.67) and the presence of clinical frailty (OR: 4.12, CI: 2.26-6.95). The mean total hospital costs were Can$35 059, with a cost per survivor of Can$48 191. Factors associated with increased cost included transfer from an inpatient setting, severity of illness, and previous ICU admission. CONCLUSIONS: Approximately a quarter of patients admitted to ICU with AECOPD died during hospitalization, and these patients accrued significant costs. This study identifies important factors associated with poor outcome in this at-risk population, which has value in risk stratification and patient or family discussions addressing goals of care.

Case Discussions in Advanced Care Planning.

BACKGROUND: Advanced care planning (ACP) provides an opportunity for individuals to explore and document their values concerning medical care decisions prior to an acute event. This manuscript explores the value of ACP and compares and contrasts 2 ACP models currently in practice. METHODS: This hypothetical case describes an elderly, frail patient with end-stage chronic obstructive pulmonary disease who is also a high user of health care resources. A new palliative care-led outpatient ACP clinic model is described using this example. RESULTS: Using the ACP clinic model in this case reveals how different a patient's end of life experience may be when proper, proactive planning measures are in place. With proper education and discussion around this patient and family's wishes pertaining to the end of his life, this man was able to change his plan of care from aggressive resuscitation treatment in hospital to a peaceful palliative experience at home. CONCLUSIONS: In this case description, the valuable role of ACP in preserving quality of life for patients, increasing satisfaction with care, and decreasing distress among family members during a medical event is demonstrated.

HIV-1 phylodynamic analysis among people who inject drugs in Pakistan correlates with trends in illicit opioid trade.

Pakistan is considered by the World Health Organization to currently have a "concentrated" HIV-1 epidemic due to a rapid rise in infections among people who inject drugs (PWID). Prevalence among the country's nearly 105,000 PWID is estimated to be 37.8% but has been shown to be higher in several large urban centers. A lack of public health resources, the common use of professional injectors and unsafe injection practices are believed to have fueled the outbreak. Here we evaluate the molecular characteristics of HIV-1 sequences (n = 290) from PWID in several Pakistani cities to examine transmission dynamics and the association between rates of HIV-1 transmission with regards to regional trends in opioid trafficking. Tip-to-tip (patristic) distance based phylogenetic cluster inferences and BEAST2 Bayesian phylodynamic analyses of time-stamped data were performed on HIV-1 pol sequences generated from dried blood spots collected from 1,453 PWID as part of a cross-sectional survey conducted in Pakistan during 2014/2015. Overall, subtype A1 strains were dominant (75.2%) followed by CRF02_AG (14.1%), recombinants/unassigned (7.2%), CRF35_AD (2.1%), G (1.0%) and C (0.3%). Nearly three quarters of the PWID HIV-1 sequences belonged to one of five distinct phylogenetic clusters. Just below half (44.4%) of individuals in the largest cluster (n = 118) did seek help injecting from professional injectors which was previously identified as a strong correlate of HIV-1 infection. Spikes in estimated HIV-1 effective population sizes coincided with increases in opium poppy cultivation in Afghanistan, Pakistan's western neighbor. Structured coalescent analysis was undertaken in order to investigate the spatial relationship of HIV-1 transmission among the various cities under study. In general terms, our analysis placed the city of Larkana at the center of the PWID HIV-1 epidemic in Pakistan which is consistent with previous epidemiological data.

Participatory model building for suicide prevention in Canada.

BACKGROUND: Suicide is a behaviour that results from a complex interplay of factors, including biological, psychological, social, cultural, and environmental factors, among others. A participatory model building workshop was conducted with fifteen employees working in suicide prevention at a federal public health organization to develop a conceptual model illustrating the interconnections between such factors. Through this process, knowledge emerged from participants and consensus building occurred, leading to the development of a conceptual model that is useful to organize and communicate the complex interrelationships between factors related to suicide. METHODS: A model building script was developed for the facilitators to lead the participants through a series of group and individual activities that were designed to elicit participants' implicit models of risk and protective factors for suicide in Canada. Participants were divided into three groups and tasked with drawing the relationships between factors associated with suicide over a simplified suicide process model. Participants were also tasked with listing prevention levers that are in use in Canada and/or described in the scientific literature. RESULTS: Through the workshop, risk and prevention factors and prevention levers were listed and a conceptual model was drafted. Several "lessons learned" which could improve future workshops were generated through reflection on the process. CONCLUSIONS: This workshop yielded a helpful conceptual model contextualising upstream factors that can be used to better understand suicide prevention efforts in Canada.

Violence and Mental Health Among Gender-Diverse Individuals Enrolled in a Human Immunodeficiency Virus Program in Karnataka, South India.

Purpose: Gender-diverse individuals in India face considerable discrimination, stigma, and violence. There is a dearth of published literature describing experiences of violence among this population and potential links to mental health. Methods: A questionnaire was administered to 282 study participants, 18 years of age and older, who self-identified as hijra, kothi, double decker, or bisexual and were actively enrolled in a local HIV prevention program in Bangalore, India in 2012. Responses were used to calculate a composite depression/anxiety score. Associations between sociodemographic characteristics and experiences of physical and sexual violence in the previous six months were tested and differences in depression/anxiety score based on experiences of violence were explored. Results: Recent physical violence was common among study participants and was reported among 46% of nirvan (emasculated) hijras (transgender), 42% of akwa (not emasculated) hijras, and 25% of kothis (feminine acting males). Rape in the previous year was particularly common among akwa hijras (39%). Factors associated with being raped included younger age, less education, and employment in basti (blessings), sex work, chela (disciple of hijra guru), or at a community-based organization. Kothis had the highest depression/anxiety score. No significant difference in depression/anxiety score based on recent history of physical violence or rape was found. Conclusions: Physical violence and poor mental health are common among gender-diverse individuals in Bangalore, Karnataka. There is a need for services that cater to the unique mental health needs of gender-diverse individuals in India, following rights-based approaches that address the underlying roots of oppression they encounter.

Laboratory Detection of First and Repeat Chlamydia Cases Influenced by Testing Patterns: A Population-Based Study.

OBJECTIVES: The purpose of this study was to describe and explore potential driving factors of trends in reported chlamydia infections over time in Manitoba, Canada. METHODS: Surveillance and laboratory testing data from Manitoba Health, Seniors and Active Living were analysed using SAS v9.4. Kaplan-Meier plots of time from the first to second chlamydia infection were constructed, and Cox proportional hazards regression was used to estimate the risk of second repeat chlamydia infections in males and females. RESULTS: Overall, the number of reported infections found mirrored the number of tests conducted. From 2008 to 2014, the number of first infections found among females decreased as the number of first tests conducted among females also decreased. Between 2008 and 2012, the number of repeat tests among females increased and was accompanied by an increase in the number of repeat positive results from 2009 to 2013. From 2008 to 2016, the number of repeat tests and repeat positive results increased steadily among males. CONCLUSIONS: Chlamydia infection rates consistently included a subset composed of repeat infections. The number of cases identified appears to mirror testing volumes, drawing into question incidence calculations that do not include testing volumes. SUMMARY BOX: 1) What is the current understanding of this subject? Chlamydia incidence is high in Manitoba, particularly among young women and in northern Manitoba.2) What does this report add to the literature? This report suggests that incidence calculated using case-based surveillance data alone does not provide an accurate estimate of chlamydia incidence in Manitoba and is heavily influenced by testing patterns.3) What are the implications for public health practice? In general, improving testing rates in clinical practices as well as through the provision of rapid services in non-clinical venues could result in higher screening and treatment rates. In turn, this could lead to a better understanding of true disease occurrence.

The contributions and future direction of Program Science in HIV/STI prevention.

BACKGROUND: Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health. DISCUSSION: To achieve this, Program Science involves the systematic application of theoretical and empirical knowledge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States. CONCLUSION: In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science.

Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India.

PURPOSE: Men and transgender women who have sex with men (MTWSM) continue to be an at-risk population for human immunodeficiency virus (HIV) infection in India. Identification of risk factors and determinants of HIV infection is urgently needed to inform prevention and intervention programming. METHODS: Data were collected from cross-sectional biological and behavioral surveys from four districts in Karnataka, India. Multivariable logistic regression models were constructed to examine factors related to HIV infection. Sociodemographic, sexual history, sex work history, condom practices, and substance use covariates were included in regression models. RESULTS: A total of 456 participants were included; HIV prevalence was 12.4%, with the highest prevalence (26%) among MTWSM from Bellary District. In bivariate analyses, district (P = 0.002), lack of a current regular female partner (P = 0.022), and reported consumption of an alcoholic drink in the last month (P = 0.004) were associated with HIV infection. In multivariable models, only alcohol use remained statistically significant (adjusted odds ratios: 2.6, 95% confidence intervals: 1.2-5.8; P = 0.02). CONCLUSION: The prevalence of HIV continues to be high among MTWSM, with the highest prevalence found in Bellary district.