SARS-CoV-2 Seroprevalence and Vaccine Uptake among Pregnant Women at First Antenatal Care Visits in Malawi.

Many SARS-CoV-2 infections are asymptomatic, thus reported cases underestimate actual cases. To improve estimates, we conducted surveillance for SARS-CoV-2 seroprevalence among pregnant women attending their first antenatal care visit (ANC1) from June 2021 through May 2022. We administered a questionnaire to collect demographic, risk factors, and COVID-19 vaccine status information and tested dried blood spots for SARS-CoV-2 antibodies. Although <1% of ANC1 participants reported having had COVID-19, monthly SARS-CoV-2 seroprevalence increased from 15.4% (95% CI: 10.5-21.5) in June 2021 to 65.5% (95% CI: 55.5-73.7) in May 2022. Although COVID-19 vaccination was available in March 2021, uptake remained low, reaching a maximum of 9.5% (95% CI: 5.7-14.8) in May 2022. Results of ANC1 serosurveillance provided prevalence estimates helpful in understanding this population case burden that was available through self-report and national case reports. To improve vaccine uptake, efforts to address fears and misconceptions regarding COVID-19 vaccines are needed.

Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice.

BACKGROUND: The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices. OBJECTIVES: To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice. METHODS: From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project's core activities and outcomes. RESULTS: In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice. CONCLUSIONS: OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects.

Lessons Learned From the Implementation of HIV Biological-Behavioral Surveys of Key Populations in the Caribbean.

In the Caribbean region, HIV prevalence is high among key population (KP) groups, such as sex workers and men who have sex with men. However, there is a lack of high-quality, population-level data estimating HIV prevalence and population sizes of KPs. The President's Emergency Plan for AIDS Relief has funded and completed five bio-behavioral surveillance (BBS) surveys using respondent-driven sampling methodology to target KP in the English-speaking Caribbean region. We describe the experience of implementing bio-behavioral surveys in the Caribbean region and document the context, processes, successes, and challenges, and make recommendations for future survey implementation. Successes include the provision of estimates of nationally representative HIV data and KP size estimates to improve HIV programming and provision of tools for routinization of BBS. Challenges include small KP sizes, the legal context, and the cost and speed of implementation. Future bio-behavioral surveys should include well-planned formative assessments and stakeholder involvement.

Comparison of HIV Testing among Children and Adults with Tuberculosis, Vietnam.

HIV testing among persons with tuberculosis (TB) results in high-yield identification of persons infected with HIV. To evaluate differences in HIV testing among children versus adults with TB in Vietnam, we collected and analyzed age-disaggregated facility and aggregated provincial data from the National Tuberculosis Program. HIV testing was incompletely documented for >70% of children, whereas adult testing data were >90% complete. Standardized training of personnel for universal HIV testing and documentation for children with TB could improve HIV case-detection and permit linking of children with HIV to antiretroviral treatment to prevent morbidity and mortality.

Disparities in Tuberculosis Treatment Completion by Incarceration Status, U.S., 1999-2011.

INTRODUCTION: Treatment completion is the cornerstone of tuberculosis (TB) control strategy globally. Although the majority of reported TB cases in the U.S. have documented treatment completion, individuals diagnosed while incarcerated are less likely to have documentation of whether or not they completed treatment. This study assessed trends and correlates of no documented treatment completion among individuals incarcerated at diagnosis. METHODS: U.S. National TB Surveillance System (1999-2011) data on cases eligible for treatment completion were analyzed during 2014-2015. Treatment outcomes and trends in no documented completion were assessed by incarceration status. Multivariable logistic regression identified correlates of no documented completion among people incarcerated at diagnosis. RESULTS: A lower proportion of individuals incarcerated at diagnosis had documented TB treatment completion than non-incarcerated individuals (75.6% vs 93.7%), and a higher proportion were lost to follow-up (10.7% vs 2.2%) or moved (9.4% vs 2.3%) during treatment (p<0.001). The 1999-2011 trend in no documented completion significantly increased among those incarcerated at diagnosis and declined among non-incarcerated individuals. Being foreign born was the strongest correlate of no documented completion among people incarcerated at diagnosis (AOR=2.86, 95% CI= 2.35, 3.49). Social risk factors for TB (e.g., homelessness, substance abuse), although common among incarcerated individuals, did not emerge as correlates of no documented completion. CONCLUSIONS: People diagnosed with TB disease at U.S. correctional facilities, especially the foreign born, require enhanced strategies for documenting TB treatment completion. Strengthened collaboration between correctional and public health agencies could improve continuity of care among released inmates.

Drug-Induced Hypothyroidism during Anti-Tuberculosis Treatment of Multidrug-Resistant Tuberculosis: Notes from the Field.

We followed 188 euthyroidic persons undergoing treatment for multidrug resistant tuberculosis (MDR-TB) in the state of Karnataka, India to determine the incidence of hypothyroidism during anti-tuberculosis treatment. Overall, among MDR-TB patients with valid thyroid stimulating hormone (TSH) values, about 23% developed hypothyroidism (TSH value ≥10 mIU/ml) during anti-tuberculosis treatment; the majority (74%) occurring after 3 months of treatment. Among 133 patients who received a regimen that contained ethionamide, 42 (32%) developed hypothyroidism. Among 17 patients that received a regimen that contained para-aminosalicylate sodium, 6 (35%) developed hypothyroidism. Among 9 HIV positive patients on anti-retroviral treatment, 4 (44%) developed hypothyroidism. These results differ from previously reported 4% incidence of hypothyroidism amongst patients who passively reported thyroidal symptoms during treatment, suggesting routine serologic monitoring of TSH throughout the course of treatment for MDR-TB is warranted.

Excess Alcohol Use and Death among Tuberculosis Patients in the United States, 1997-2012.

RATIONALE: Excess alcohol use (EAU) is associated with adverse TB treatment outcomes. OBJECTIVE: We investigated the relationship between EAU and death among TB patients 15 years and older prescribed anti-TB treatment in the United States. DESIGN: Using data reported to the National Tuberculosis Surveillance System for 1997-2012, we calculated adjusted odds ratios and excess attributable risk percent for death among TB patients with reported EAU. RESULTS: EAU was associated with death among patients younger than 65. The excess attributable risk percent for death among those with reported EAU for those younger than 65 was >35%. CONCLUSIONS: Interventions to reduce EAU in patients <65 years may reduce deaths.

Relationship between Nutritional Support and Tuberculosis Treatment Outcomes in West Bengal, India.

INTRODUCTION: Poverty and poor nutrition are associated with the risk of developing tuberculosis (TB). Socioeconomic factors may interfere with anti-tuberculosis treatment compliance and its outcome. We examined whether providing nutritional support (monthly supply of rice and lentil beans) to TB patients who live below the poverty line was associated with TB treatment outcome. METHODS: This was a retrospective cohort study of sputum smear-positive pulmonary TB patients living below the poverty line (income of <$1.25 per day) registered for anti-tuberculosis treatment in two rural districts of West Bengal, India during 2012 to 2013. We compared treatment outcomes among patients who received nutritional support with those who did not. A log-binomial regression model was used to assess the relation between nutritional support and unsuccessful treatment outcome (loss-to-follow-up, treatment failure and death). RESULTS: Of 173 TB patients provided nutritional support, 15 (9%) had unsuccessful treatment outcomes, while 84 (21%) of the 400 not provided nutrition support had unsuccessful treatment outcomes (p < 0.001). After adjusting for age, sex and previous treatment, those who received nutritional support had a 50% reduced risk of unsuccessful treatment outcome than those who did not receive nutritional support (Relative Risk: 0.51; 95% Confidence Intervals: 0.30 - 0.86). CONCLUSION: Under programmatic conditions, monthly rations of rice and lentils were associated with lower risk of unsuccessful treatment outcome among impoverished TB patients. Given the relatively small financial commitment needed per patient ($10 per patient per month), the national TB programme should consider scaling up nutritional support among TB patients living below the poverty line.

Correlates of self-efficacy for condom use among male clients of female sex workers in Tijuana, Mexico.

Male clients of female sex workers (FSWs) in Tijuana, Mexico engage in high levels of unprotected sex. While behavioral change theories posit that self-efficacy predicts condom use, correlates of self-efficacy for condom use remain largely unstudied. We examined these correlates among male clients of FSWs in Tijuana. Eligible male clients were at least 18 years of age, HIV-negative, lived in Tijuana or San Diego, reported unprotected sex with a Tijuana FSW at least once in the past 4 months, and agreed to be treated for sexually transmitted infections (STIs). Participants completed an interviewer-administered questionnaire including demographics, substance use, psychosocial and psychosexual characteristics (e.g., outcome expectancies for negotiation of safer sex, social support, and sexual sensation seeking), and sexual behaviors. Participants also underwent HIV/STI testing. A stepwise hierarchical multiple regression analysis identified correlates of self-efficacy for condom use. Of 393 male clients, median age was 37 years. Participants were mostly Spanish-speaking and employed. Factors independently associated with higher self-efficacy for condom use were higher positive outcome expectancies for negotiation of safer sex, lower sexual sensation seeking scores, and higher social support scores. Both psychosocial and psychosexual factors may influence self-efficacy for condom use among male clients of FSWs. These factors represent central constructs in sociocognitive models that explain behavioral change and could be intervention targets for improving self-efficacy for condom use and, ultimately, safer sex behavior.

Drug-scene familiarity and exposure to gang violence among residents in a rural farming community in Baja California, Mexico.

We examined drug-scene familiarity and exposure to gang violence among residents of a migrant farming community in rural Baja California, Mexico. In October 2010, 164 members of a single colonia (community) underwent an interviewer-administered survey to assess 'exposure to gang violence' and 'drug-scene familiarity', as well as other health indicators. Logistic regression was used to identify correlates of exposure to gang violence. Overall, 20% of participants were male, the median age was 27 years, 24% spoke an indigenous language, 42% reported exposure to gang violence and 39% reported drug-scene familiarity. Factors independently associated with exposure to gang violence included being younger (adjusted odds ratio [AOR] =0.80 per 5-year increase, 95% confidence interval [CI]=0.67-0.96), living in the community longer (AOR=1.47 per 5-year increase, 95% CI=1.11-1.72), higher educational attainment (AOR=1.70 per 5-year increase, 95% CI=1.07-1.12) and drug-scene familiarity (AOR=5.10, 95% CI=2.39-10.89). Exposure to gang violence was very common in this community and was associated with drug-scene familiarity, suggesting a close relationship between drugs and gang violence in this rural community. In a region characterised by mass migration from poorer parts of Mexico, where drugs and gangs have not been previously reported, emerging social harms may affect these communities unless interventions are implemented.

The social and environmental context of cross-border drug use in Mexico: findings from a mixed methods study of young injection drug users living in San Diego, CA.

The authors report the results of qualitative (n = 19) and quantitative (n = 545) interviews with young injection drug users (IDUs) in San Diego, California about their experiences using drugs in Tijuana, Mexico, and associated risks for HIV infection. Young IDUs who have ever traveled to Mexico (n = 365) used a variety of injection (54%) and noninjection (30%) drugs there and appear to be heavier users than those who have never traveled to Mexico. Sociocultural themes influencing drug use in Mexico included interactions among the purpose of travel, drug preference, and route of administration; familiarity with the border region; evolving relationships with the United States and Mexican drug markets; and the experience of crossing the U.S.-Mexico border. Interventions for IDUs in border regions need to be sensitive to the ethnicity, familiarity with the border region, and life history of participants, as well as differences in national policies that could influence drug use and risk for HIV on both sides of the border.

Identifying the HIV transmission bridge: which men are having unsafe sex with female sex workers and with their own wives or steady partners?

OBJECTIVE: To gain insights into bridging behaviors and their correlates among male clients of female sex workers (FSWs). METHODS: Men aged ≥18 years who recently paid or traded for sex with FSWs were recruited in Tijuana in 2008-2009. Participants underwent interviews and testing for HIV, chlamydia, syphilis, and gonorrhea. Logistic regression compared "bridgers" (clients who had unprotected sex with FSWs and with a wife or steady partner) with men who did not. RESULTS: Of 383 men, 134 (35%) had a steady partner. Half (n = 70) of those had unprotected sex with both FSWs and the steady partner. Prevalence of any sexually transmitted infection or HIV was 16.5% among bridgers and 2.3% among nonbridgers. Compared with other clients, bridgers were more likely to use drugs during sex with FSWs (81.4% versus 46.9%, P < 0.0001), had higher sensation-seeking (P < 0.0001) and misogyny scores (P = 0.05) and were more likely to offer FSWs extra money for unprotected sex (34.4% versus 1.6%, P < 0.0001). Factors independently associated with bridging were as follows: using drugs during sex with FSWs [adjusted odds ratio (AOR): 3.4, P = 0.007], sensation seeking (AOR: 4.3 per unit increase, P = 0.05), and offering FSWs more money for unprotected sex (AOR: 24.5, P = 0.003). CONCLUSION: Sensation-seeking clients who use drugs during sex and coerce FSWs into unprotected sex may be less responsive to standard risk reduction interventions. Interventions are needed that target clients rather than rely on FSWs to change behaviors that may not be under their control.

Border crossing to inject drugs in Mexico among injection drug users in San Diego, California.

We examined correlates of ever injecting drugs in Mexico among residents of San Diego, California. From 2007 to 2010, injecting drug users (IDUs) in San Diego underwent an interviewer-administered survey. Logistic regression identified correlates of injection drug use in Mexico. Of 302 IDUs, 38% were Hispanic, 72% male and median age was 37; 27% ever injected in Mexico; 43% reported distributive syringe sharing there. Factors independently associated with ever injecting drugs in Mexico included being younger at first injection, injecting heroin, distributive syringe sharing at least half of the time, and transporting drugs over the last 6 months. One-quarter of IDUs reported ever injecting drugs in Mexico, among whom syringe sharing was common, suggesting possible mixing between IDUs in the Mexico-US border region. Prospective studies should monitor trends in cross-border drug use in light of recent Mexican drug policy reforms partially decriminalizing drug possession.

"High on my own supply": correlates of drug dealing among heterosexually identified methamphetamine users.

Although rates of methamphetamine use continue to increase throughout the United States, little is known about the individuals who sell methamphetamine at the street level. This exploratory study examined the prevalence and correlates of drug-dealing behavior in a sample of 404 heterosexually identified methamphetamine users who were participants in a sexual risk reduction intervention in San Diego, California. Twenty-nine percent of participants (N = 116) reported "dealing" methamphetamine in the past 2 months. In a multivariate logistic regression, methamphetamine dealing was associated with being male (OR = 1.99; 95% CI 1.16-3.39), younger age (OR = 1.87 per year; 95% CI 1.10-3.17), more frequent use of methamphetamine (OR = 2.69; 95% CI 1.59-4.57), injecting methamphetamine (OR = 3.10; 95% CI 1.79-5.37), and higher hostility scores (OR = 1.07 per unit increase; 95% CI 1.01-1.13). These characteristics, particularly intensity of drug use and hostility, may be associated with greater resistance to drug treatment and lower success in treatment programs.

Factors associated with drug-related harms related to policing in Tijuana, Mexico.

OBJECTIVE: To assess factors associated with drug-related harms related to policing among injection drug users (IDUs) in Tijuana, Mexico. METHODS: IDUs who were over 18 years old and had injected drugs within the last six months were recruited via respondent-driven sampling and underwent questionnaires and testing for HIV (human immunodeficiency virus), syphilis and TB (tuberculosis). Random effects logistic regression was used to simultaneously model factors associated with five drug-related harms related to policing practices in the prior six months (i.e., police led them to rush injections; affected where they bought drugs; affected locations where they used drugs; feared that police will interfere with their drug use; receptive syringe sharing). RESULTS: Of 727 IDUs, 85% were male; median age was 38 years. Within the last 6 months, 231 (32%) of IDUs reported that police had led them to rush injections, affected where they bought or used drugs or were very afraid police would interfere with their drug use, or shared syringes. Factors independently associated with drug-related harms related to policing within the last six months included: recent arrest, homelessness, higher frequencies of drug injection, use of methamphetamine, using the local needle exchange program and perceiving a decrease in the purity of at least one drug. CONCLUSIONS: IDUs who experienced drug-related harms related to policing were those who were most affected by other micro and macro influences in the physical risk environment. Police education programs are needed to ensure that policing practices do not exacerbate risky behaviors or discourage protective behaviors such as needle exchange program use, which undermines the right to health for people who inject drugs.

Cross-border drug injection relationships among injection drug users in Tijuana, Mexico.

BACKGROUND: International borders are unique social and environmental contexts characterized by high levels of mobility. Among drug users, mobility increases risk for human immunodeficiency virus (HIV) in part through its effects on the social environment. However, the social dynamics of drug users living in border regions are understudied. METHODS: 1056 injection drug users (IDUs) residing in Tijuana, Mexico were recruited using respondent-driven sampling (RDS) from 2006 to 2007, and underwent surveys and testing for HIV, syphilis, and tuberculosis (TB). Using logistic regression on baseline data, we identified correlates of having ever injected drugs with someone from the US. RESULTS: Almost half (48%) reported ever injecting drugs with someone from the US. In RDS-adjusted logistic regression, factors independently associated with having ever injected with someone from the US included: having greater than middle school education (Adjusted Odds Ratio [AOR] 2.91; 95% confidence interval [C.I.] 1.52, 5.91), speaking English (AOR 3.24, 95% C.I. 1.96, 5.36), age (AOR 1.10 per year; 95% C.I. 1.07, 1.14), age at initiation of injection drug use (AOR 0.90 per year; 95% C.I. 0.86, 0.94), homelessness (AOR 2.61; 95% C.I. 1.27, 5.39), and having ever been incarcerated (AOR 11.82; 95% C.I., 5.22, 26.77). No associations with HIV, syphilis, TB, drug use, or injection risk behavior were detected. CONCLUSION: Findings suggest that IDU networks in Mexico and the US may transcend international borders, with implications for cross-border transmission of infectious disease. Binational programs and policies need to consider the structure and geographic distribution of drug using networks.