"I hope I die. That is what I hope for": Qualitative study of lived experiences of mental health of Indian women living with HIV experiencing intersectional stigma.

Poor mental health due to stigma and discrimination has been well documented among women living with HIV. Although they often have other marginalized and stigmatized identities, little is known about their mental health as a result of experiencing multiple stigmas. Current narratives of mental health as a result of HIV-related stigma center on common mental health disorders such as anxiety and depression. However, biomedical diagnostic categories may not be as well known in all cultural and social contexts, and people may choose to express their distress in their own language. It is therefore important to listen to how women express their mental health concerns in their own language-their lived experiences-in order to best support them. To fill this research gap, semi-structured interviews were conducted in Kolkata, India, with 31 women living with HIV and 16 key informants. Data were coded and analyzed using thematic network analysis. The results showed that women suffered from poor mental health, which in turn affected their physical health. This happened through reduced adherence to medication, lowered CD4 counts, and the physical effects of stress, which could be perceived as prolonged. Participants described women's mental health concerns as worry, sadness, hopelessness, and fear, but biomedical diagnostic labels were rarely used. This allowed women to avoid additional stigmatization due to mental illness, which can attract some risk in this social context. As many women living with HIV experience poor mental health, they should be supported with a combination of psychosocial and psychological interventions. These include screening all women for mental illness and offering them mental health first aid. Those requiring additional support should be offered specialist psychotherapeutic and pharmacological care. This must be accompanied by stigma reduction interventions if they are to be successful in addressing the mental health needs of women living with HIV.

How does domestic violence stigma manifest in women's lives in Afghanistan? A study of survivors' lived experiences of help-seeking across three provinces.

Afghanistan has one of the highest rates of domestic violence in the world, with an estimated 46% women reporting lifetime violence. Survivors of domestic violence experience significant stigma from their families and communities, often in the form of blame, shame, gossip, and dismissal. While the manifestations of stigma are often the same across cultural settings, the drivers may be different. We conducted sixty semi-structured interviews with survivors of domestic violence in three provinces of Afghanistan. Data were analysed using thematic network analysis. Our analysis highlights stigma as a structural phenomenon in Afghanistan underpinned by mutually reinforcing structural elements (including community, government authorities, marital and natal families, other survivors and the self). In a country with a deeply patriarchal social structure, the main manifestation of stigma was the silencing of survivors of violence, as domestic violence was considered a private affair. Notions of honour were paramount in fuelling stigma against survivors of violence, as any action to report or leave violent relationships was considered dishonourable. Our findings have implications for the design of services to help survivors of violence seek help for the violence they experience, especially at a time when such services are increasingly constricted for women in Afghanistan.

Mixed studies review of domestic violence in the lives of women affected by HIV stigma.

We conducted a mixed studies review to examine domestic violence and stigma against women affected by HIV. We searched Medline, Web of Science, PsycINFO and EMBASE databases with no starting date limit. Studies that reported on experiences of stigma, discrimination, or domestic violence against women affected by HIV in any country were included. Because the review focused on HIV stigma-related violence, we only included studies that reported violence following an HIV diagnosis or at the time of HIV testing. A total 1056 records were screened; 89 articles were assessed for full text eligibility and 49 studies were selected for evidence synthesis. A convergent approach was used and study findings were analysed thematically. Four broad themes emerged: (1) being affected by HIV increases domestic violence, (2) supportive reactions from partners, (3) HIV stigma is associated with domestic violence, and (4) domestic violence associated with HIV-stigma is gendered. Research gaps identified included the burden of intersectional stigma of domestic violence and HIV, and the mediating role of HIV stigma in domestic violence for women with HIV, highlighting the need for further research in this area to reduce violence against women living with HIV.

Risk factors for violence against women in high-prevalence settings: a mixed-methods systematic review and meta-synthesis.

INTRODUCTION: Violence against women (VAW) affects one in three women globally. In some countries, women are at much higher risk. We examined risk factors for VAW in countries with the highest 12-month prevalence estimates of intimate partner violence (IPV) to develop understanding of this increased risk. METHODS: For this systematic review, we searched PUBMED, CINAHL, PROQUEST (Middle East and North Africa; Latin America and Iberia; East and South Asia), Web of Science, EMBASE and PsycINFO (Ovid) for records published between 1 January 2000 and 1 January 2021 in English, French and Spanish. Included records used quantitative, qualitative, or mixed-methods, reported original data, had VAW as the main outcome, and focused on at least one of 23 countries in the highest quintile of prevalence figures for women's self-reported experiences of physical and/or sexual violence in the past 12 months. We used critical interpretive synthesis to develop a conceptual model for associations between identified risk factors and VAW. RESULTS: Our search identified 12 044 records, of which 241 were included for analysis (2 80 360 women, 40 276 men, 274 key informants). Most studies were from Bangladesh (74), Uganda (72) and Tanzania (43). Several quantitative studies explored community-level/region-level socioeconomic status and education as risk factors, but associations with VAW were mixed. Although fewer in number and representing just one country, studies reported more consistent effects for community-level childhood exposure to violence and urban residence. Theoretical explanations for a country's high prevalence point to the importance of exposure to other forms of violence (armed conflict, witnessing parental violence, child abuse) and patriarchal social norms. CONCLUSION: Available evidence suggests that heightened prevalence of VAW is not attributable to a single risk factor. Multilayered and area-level risk analyses are needed to ensure funding is appropriately targeted for countries where VAW is most pervasive. PROSPERO REGISTRATION NUMBER: The review is registered with PROSPERO (CRD42020190147).

A nanogel-based trivalent PspA nasal vaccine protects macaques from intratracheal challenge with pneumococci.

Current polysaccharide-based pneumococcal vaccines are effective but not compatible with all serotypes of Streptococcus pneumoniae. We previously developed an adjuvant-free cationic nanogel nasal vaccine containing pneumococcal surface protein A (PspA), which is expressed on the surfaces of all pneumococcal serotypes. Here, to address the sequence diversity of PspA proteins, we formulated a cationic nanogel-based trivalent pneumococcal nasal vaccine and demonstrated the vaccine's immunogenicity and protective efficacy in macaques by using a newly developed nasal spray device applicable to humans. Nasal vaccination of macaques with cationic cholesteryl pullulan nanogel (cCHP)-trivalent PspA vaccine effectively induced PspA-specific IgGs that bound to pneumococcal surfaces and triggered complement C3 deposition. The immunized macaques were protected from pneumococcal intratracheal challenge through both inhibition of lung inflammation and a dramatic reduction in the numbers of bacteria in the lungs. These results demonstrated that the cCHP-trivalent PspA vaccine is an effective candidate vaccine against pneumococcal infections.

Characterization and Specification of a Trivalent Protein-Based Pneumococcal Vaccine Formulation Using an Adjuvant-Free Nanogel Nasal Delivery System.

We previously developed a safe and effective nasal vaccine delivery system using a self-assembled nanosized hydrogel (nanogel) made from a cationic cholesteryl pullulan. Here, we generated three pneumococcal surface protein A (PspA) fusion antigens as a universal pneumococcal nasal vaccine and then encapsulated each PspA into a nanogel and mixed the three resulting monovalent formulations into a trivalent nanogel-PspA formulation. First, to characterize the nanogel-PspA formulations, we used native polyacrylamide gel electrophoresis (PAGE) to determine the average number of PspA molecules encapsulated per nanogel molecule. Second, we adopted two methods-a densitometric method based on lithium dodecyl sulfate (LDS)-PAGE and a biologic method involving sandwich enzyme-linked immunosorbent assay (ELISA)-to determine the PspA content in the nanogel formulations. Third, treatment of nanogel-PspA formulations by adding methyl-ß-cyclodextrin released each PspA in its native form, as confirmed through circular dichroism (CD) spectroscopy. However, when nanogel-PspA formulations were heat-treated at 80 °C for 16 h, CD spectroscopy showed that each PspA was released in a denatured form. Fourth, we confirmed that the nanogel-PspA formulations were internalized into nasal mucosa effectively and that each PspA was gradually released from the nanogel in epithelial cells in mice. Fifth, LDS-PAGE densitometry and ELISA both indicated that the amount of trivalent PspA was dramatically decreased in the heat-treated nanogel compared with that before heating. When mice were immunized nasally using the heat-treated formulation, the immunologic activity of each PspA was dramatically reduced compared with that of the untreated formulation; in both cases, the immunologic activity correlated well with the content of each PspA as determined by LDS-PAGE densitometry and ELISA. Finally, we confirmed that the trivalent nanogel-PspA formulation induced equivalent titers of PspA-specific serum IgG and mucosal IgA Abs in immunized mice. These results show that the specification methods we developed effectively characterized our nanogel-based trivalent PspA nasal vaccine formulation.

Challenges in accessing and utilising health services for women accessing DOTS TB services in Kolkata, India.

Challenges in accessing and utilising TB treatment are a major reason for the existing gaps in tuberculosis (TB) control in India. Twenty qualitative interviews were conducted with women who were attending or had attended a directly observed treatment short course (DOTS) clinic in Kolkata, India. The resulting data were analysed using a thematic approach. Our results indicated that women experienced several challenges categorised as (1) DOTS specific challenges, (2) lack of client friendly services, and (3) resource constraints. DOTS specific challenges included having to come to the clinic for medicines, lack of privacy, providers minimising contact with patients, length of treatment, drug side effects and pill burden. Lack of client friendly services led to mistrust in government services and a preference for private providers, which was compounded by corruption in the medical system. Inability to complete household duties due to inflexible clinic hours, long lines and overcrowded spaces, and mistreatment from providers were further challenges faced by women. Lastly, resource constraints meant women faced financial difficulties with additional treatment costs and suffered from lack of adequate food and nutrition. Our findings lead to several recommendations for addressing these challenges that should help improve women's experiences with DOTS TB treatment.

New Strategy Is Needed to Prevent Pneumococcal Meningitis.

BACKGROUND: Polysaccharide conjugate vaccines (PCVs) target the pneumococcal capsular types that most commonly cause fatal pneumonia and sepsis. Because these types were eliminated by the vaccines, it became apparent that in immunized populations, most invasive pneumococcal diseases, including bacteremia, sepsis and complicated pneumonia, were greatly reduced. However, the protective effects of PCVs against another invasive disease, meningitis, has shown much less or no decrease in disease incidence. METHODS: References were identified through searches of PubMed for articles published from January 1930 to the present by use of specific search terms. Relevant articles were also identified through searches in Google and Google Scholar. Relevant references cited in those articles were also reviewed. RESULTS: Even in the presence of the PCVs, meningitis rates in children have been reported globally to be as high as 13 per 100,000 annually. Widespread use of vaccines resulted in the emergence of a broad diversity of replacement non-PCV type strains. These strains generally failed to cause sepsis, but caused meningitis of comparable severity and levels similar to, or in excess of, prior pneumococcal meningitis rates. This is probably because these non-PCV type strains do not survive well in the blood, therefore possibly entering the brain through nonhematogenous routes. CONCLUSIONS: Because virtually all cases of pneumococcal meningitis lead to either permanent neurologic sequelae or death, it would be well worth the effort to develop a new vaccine capable of preventing pneumococcal meningitis regardless of capsular type. Such a vaccine would need to protect against colonization with most, if not all, pneumococci.

Patient Perspectives on Factors Influencing Medication Adherence Among People with Coronary Heart Disease (CHD) and CHD Risk Factors.

BACKGROUND: Few qualitative studies have explored factors influencing medication adherence among people with coronary heart disease (CHD) or CHD risk factors. We explored how factors related to the patient (e.g. self-efficacy), social/economic conditions (e.g. social support and cost of medications), therapy (e.g. side effects), health condition (e.g. comorbidities), and the healthcare system/healthcare team (e.g. support from healthcare providers and pharmacy access) influence medication adherence, based on the World Health Organization Multidimensional Adherence Model (WHO-MAM). METHODS: We conducted 18 in-depth qualitative interviews from April to July 2018 with ambulatory care patients aged ≥45 years (8 black men, 5 black women, 2 white men, and 3 white women) who were using medications for diabetes, hypertension, dyslipidemia and/or CHD. We used thematic analysis to analyze the data, and sub-themes emerged within each WHO-MAM dimension. FINDINGS: Patient-related factors included beliefs about medications as important for self and faith; the desire to follow the advice of family, friends, and influential others; and self-efficacy. Social/economic factors included observations of social network members and information received from them; social support for medication adherence and pharmacy utilization; and economic influences. Therapy-related barriers included side effects and medicine schedules. Only a few participants mentioned condition-related factors. Healthcare system/healthcare team-related factors included support from doctors and pharmacists; and ease of pharmacy access and utilization. CONCLUSION: These results underscore the need for multidimensional interventions aimed at improving medication adherence and overall health of patients with CHD and CHD risk factors.

The diversity of the proline-rich domain of pneumococcal surface protein A (PspA): Potential relevance to a broad-spectrum vaccine.

Pneumococcal surface protein A (PspA) is a surface exposed, highly immunogenic protein of Streptococcus pneumoniae. Its N-terminal α-helical domain (αHD) elicits protective antibody in humans and animals that can protect mice from fatal infections with pneumococci and can be detected in vitro with opsonophagocytosis assays. The proline-rich domain (PRD) in the center of the PspA sequence can also elicit protection. This study revealed that although the sequence of PRD was diverse, PRD from different pneumococcal isolates contained many shared elements. The inferred amino acid sequences of 123 such PRDs, which were analyzed by assembly and alignment-free (AAF) approaches, formed three PRD groups. Of these sequences, 45 were classified as Group 1, 19 were classified as Group 2, and 59 were classified as Group 3. All Group 3 sequences contained a highly conserved 22-amino acid non-proline block (NPB). A significant polymorphism was observed, however, at a single amino acid position within NPB. Each of the three PRD groups had characteristic patterns of short amino acid repeats, with most of the repeats being found in more than one PRD group. One of these repeats, PKPEQP as well as the NPB were previously shown to elicit protective antibodies in mice. In this study, we found that sera from 12 healthy human adult volunteers contained antibodies to all three PRD groups. This suggested that a PspA-containing vaccine containing carefully selected PRDs and αHDs could redundantly cover the known diversity of PspA. Such an approach might reduce the chances of PspA variants escaping a PspA vaccine's immunity.

Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India.

BACKGROUND: Stigma associated with tuberculosis (TB) is still common in many societies, contributing to delays in treatment seeking and treatment non-compliance. India has the highest burden of TB in the world with female TB patients bearing a considerable burden of TB-related stigma. Objectives: This study aimed to explore the manifestations and consequences of stigma experienced by female TB patients in an urban setting in India and their strategies to cope with the social stigma of TB. METHODS: Twenty qualitative interviews were conducted with female TB patients who were either currently on treatment or had undergone treatment at a TB clinic in Kolkata, India. Data were coded and analyzed with the NVivo qualitative software using a thematic approach. RESULTS: Our results indicated that TB stigma mainly manifested through social isolation and avoidance due to fear of contagion, gossip and verbal abuse, failed marriage prospects, and neglect from family. Consequences of stigma described by the women included non-disclosure, feelings of guilt, and mental health issues including suicidal ideation. Positive coping strategies used by women to cope with the experiences of stigma included positive reframing, prayer, talking to other patients, focusing on school work, and relaxation activities. Negative coping activities included self-imposed social isolation and anger. In some cases, non-disclosure due to stigma had an impact on TB transmission and control behaviors. Conclusions: Stigma-reduction strategies, such as community awareness programs and formation of social support groups to dispel the myths and misconceptions associated with TB, may improve TB treatment seeking and adherence.Acknowledgement: Our deepest thanks to the Reverend, St. James' Church, Dr. Ali Akbar Chowdhury (Medical Officer), staff and participants at the Calcutta Diocesan Tuberculosis Relief Trust, without whom this study would not be possible. We also thank Sushmita Mukherjee for help with translations. Lastly, we thank the Sparkman Center for Global Health at the University of Alabama at Birmingham for providing travel funds for this study.

Pneumococcal surface protein A inhibits complement deposition on the pneumococcal surface by competing with the binding of C-reactive protein to cell-surface phosphocholine.

In the presence of normal serum, complement component C3 is deposited on pneumococci primarily via the classical pathway. Pneumococcal surface protein A (PspA), a major virulence factor of pneumococci, effectively inhibits C3 deposition. PspA's C terminus has a choline-binding domain that anchors PspA to the phosphocholine (PC) moieties on the pneumococcal surface. C-reactive protein (CRP), another important host defense molecule, also binds to PC, and CRP binding to pneumococci enhances complement C3 deposition through the classical pathway. Using flow cytometry of PspA(+) and PspA(-) strains, we observed that the absence of PspA led to exposure of PC, enhanced the surface binding of CRP, and increased the deposition of C3. Moreover, when the PspA(-) mutant was incubated with a pneumococcal eluate containing native PspA, there was decreased deposition of CRP and C3 on the pneumococcal surface compared with incubation with an eluate from a PspA(-) strain. This inhibition was not observed when a recombinant PspA fragment, which lacks the choline-binding region of PspA, was added to the PspA(-) mutant. Also, there was much greater C3 deposition onto the PspA(-) pneumococcus when exposed to normal mouse serum from wild-type mice as compared with that from CRP knockout mice. Furthermore, when CRP knockout mouse serum was replenished with CRP, there was a dose-dependent increase in C3 deposition. The combined data reveal a novel mechanism of complement inhibition by a bacterial protein: inhibition of CRP surface binding and, thus, diminution of CRP-mediated complement deposition.

Diagnosis and management of atypical mycobacterial infection after laparoscopic surgery.

Atypical mycobacterial infections at the laparoscopic port site are a frequent problem encountered in patients undergoing laparoscopic surgery. In this study we concentrate on the clinical diagnosis, management and prevention of this problem. In this series we assess 19 patients presenting with port hole infections after laparoscopic surgery and were treated with a combination of oral clarithromycin and ciprofloxacin. Seven patients who had persistent nodules were given injections of amikacin directly into the infection foci along with standard oral therapy. Most of the patients treated with standard oral therapy for 28 days showed recovery. The patients with persistent nodules 4 weeks after completion of therapy were treated with injections of amikacin directly into the nodule which lead to resolution of symptoms. For prevention of infection, proper sterilization and storage of instruments is recommended. Laparoscopic port hole infections is a preventable problem and can also be treated by nonsurgical method.