Comparison of short-term outcomes of open and laparoscopic assisted pancreaticoduodenectomy for periampullary carcinoma: A propensity score-matched analysis.

Backgrounds/Aims: Postoperative pancreatic fistula is the key worry in the ongoing debate about the safety and effectiveness of total laparoscopic pancreaticoduodenectomy (TLPD). Laparoscopic-assisted pancreaticoduodenectomy (LAPD), a hybrid approach combining laparoscopic resection and anastomosis with a small incision, is an alternative to TLPD. This study compares the short-term outcomes and oncological efficacy of LAPD vs. open pancreaticoduodenectomy (OPD). Methods: A retrospective analysis of data of all patients who underwent LAPD or OPD for periampullary carcinoma at a tertiary care center in Northeast India from July 2019 to August 2023 was done. A total of 30 LAPDs and 30 OPDs were compared after 1:1 propensity score matching. Demographic data, intraoperative and postoperative data (30 days), and pathological data were compared. Results: The study included a total of 93 patients, 30 underwent LAPD and 62 underwent OPD. After propensity score matching, the matched cohort included 30 patients in both groups. The LAPD presented several advantages over the OPD group, including a shorter incision length, reduced postoperative pain, earlier initiation of oral feeding, and shorter hospital stays. LAPD was not found to be inferior to OPD in terms of pancreatic fistula incidence (Grade B, 30.0% vs. 33.3%), achieving R0 resection (100% vs. 93.3%), and the number of lymph nodes harvested (12 vs. 14, p = 0.620). No significant differences in blood loss, short-term complications, pathological outcomes, readmissions, and early (30-day) mortality were observed between the two groups. Conclusions: LAPD has comparable safety, technical feasibility, and short-term oncological efficacy.

Exploring the Antioxidant Potential of Methanolic Extracts of Wild Medicinal and Edible Mushrooms from Darma Valley, Pithoragaph, Kumaun (Himalaya, India).

This study presents a comprehensive analysis of the methanolic extracts of nine species of wild edible mushrooms (WEM) native to the Darma Valley in the Kumaun Himalaya region. The investigation encompasses the assessment of various biochemical attributes, including total phenolics (TP), total flavonoids (TF), total tannins (TT) contents, the ABTS assay, and the DPPH radical scavenging assay. Among the nine WEM species examined, Clavatia craniiformis stands out for displaying the highest antioxidant capacities, indicated by exceptional TP (54.94 ± 0.54 mg gallic acid equivalenta/g dry weight) and TT (4.23 ± 0.17 mg tannic acid equivalents/g dry weight) contents, along with noteworthy ABTS (10.44 ± 0.34 mg abscorbic acid equivalents/g dw) and DPPH activity (0.335 ± 0.001 mg abscorbic acid equivalents/g dry weight). Subsequent antioxidant potential are mushrooms Ramaria fennica, Ramaria botrytis, Ramaria sanguinea, Ramaria flava, Gomphus. clavatus, Clavaria zollingeri, Pleurotus ostreatus, and Kuehneromyces mutabilis. Variations in antioxidant capacities align with distinct phenolic content. This study underscores as a remarkable source of antioxidants, suggesting its potential suitability for nutraceutical applications. The findings contribute to a deeper understanding of the antioxidant properties inherent in wild edible mushrooms, particularly emphasizing the prominence of C. craniiformis.

In vitro Propagation of Endemic Species Mahonia Jaunsarensis Ahrendt Through Callus Culture.

Mahonia jaunsarensis Ahrendt (Family Berberidaceae) an endemic species was successfully propagated in vitro. An efficient propagation protocol has been developed first time. The callus cultures were established from leaf explants on Murashige and Skoog (MS) medium supplemented with 2,4-Dichlorophenoxyacetic acid (2,4-D; 1 µM) and resulted 70% callus induction with green compact callus. When callus was transferred to MS medium containing Thidiazuron (TDZ; 0.75 µM), maximum average number of shoot (3.06) produced but shoot length (3.37 cm) and average leaf number (2.87) was increased upon transfer to MS medium containing N6-benzylaminopurine (BA; 6.0 µM) plus α-naphthalene acetic acid (NAA; 0.5 µM). In MS medium containing indole-3-butyric acid (IBA; 0.01 µM), the maximum rooting percentage (56%) and average root number (2.56) per shoot and root length (3.33 cm) were recorded. The rooted plantlets transferred in vermiculite + garden soil + farmyard manure (1:1:1) with maximum (55%) survival percentage under greenhouse condition. The phytochemical analysis of leaves obtained from tissue culture-raised plants revealed significantly higher levels of alkaloids (berberine and palmatine) than those obtained from wild plants. Similar trends were observed for antioxidant and antimutagenic activities. Results of this study offer a baseline for the conservation and sustainable utilization strategies for M. jaunsarensis.

Extended depth of focus intraocular lens versus a new monofocal intraocular lens: A prospective comparative and interventional study.

PURPOSE: To compare the visual outcome findings between a new monofocal intraocular lens (IOL) (Tecnis Eyhance) and extended depth of focus (EDOF) IOL (Appasamy Supraphob Infocus). METHODS: This prospective comparative interventional study evaluated 31 patients after implantation of Tecnis Eyhance (15 patients) and Supraphob EDOF IOL (16 patients). The uncorrected and corrected distance and intermediate and near visual acuity were measured at postoperative day 1, 1 week, 4 week, and 3 months. Contrast sensitivity, incidence of halos and glares, and patient satisfaction were assessed at 3 months postoperatively. RESULTS: The Tecnis Eyhance (n = 15) and Supraphob EDOF (n = 16) group were comparable with respect to all preoperative parameters including biometry, visual acuity, and cataract status. The average age distribution of participants was 56 ± 6 years. Postoperatively, both groups had similar distance and intermediate vision, but the near vision was significantly better in the EDOF group (P < 0.01) as compared to Tecnis Eyhance at 3 months. The contrast sensitivity and patient satisfaction were similar in both the groups. The incidence of halos and glares was present in the EDOF group, but it was statistically insignificant. CONCLUSION: The Tecnis Eyhance and Supraphob EDOF both were effective in improving distance and intermediate vision, but the near vision was significantly better in the EDOF group. Both the groups retained good contrast sensitivity and the majority of patients were satisfied.

Reaching Out-of-school Adolescent Girls and Young Women at Risk for HIV Through Their Social Networks.

Out-of-school adolescent girls/young women (AGYW) in Africa are at increased risk for HIV and are underserved by HIV prevention interventions. Identifying social networks of out-of-school AGYW may be a strategic approach for reaching them. A sequential mixed methods study design was used. The PLACE (Priorities for Local AIDS Control Efforts) methodology, implemented in one ward of Dar es Salaam, Tanzania, identified 69 networks of AGYW. We randomly selected 28 networks and conducted surveys and network assessments with 80.9% (n = 310) of the members. On average, the networks consisted of 13.7 members, and had a density of 0.65 and a transitivity of 0.80, indicating high cohesion. The networks were mostly female (92%). On average, 67% of network membership were AGYW aged 15-24 years, of whom 70% were out-of-school and 67% were sexually active. Among sexually active AGYW aged 15-24, self-reported HIV seropositivity was 12.2%. We then conducted focus group discussions with 6 purposively selected networks. AGYW described their networks as sources of support and advice. Social norms supported AGYW engaging in transactional sex to alleviate life's hardships; it was the easiest way to earn income without "sweating". AGYW discussed IPV as a common experience, and social norms stigmatized AGYWs' use of condoms. AGYW were largely unaware of pre-exposure prophylaxis. The self-reported HIV prevalence rates of this cohort were higher than national averages, suggesting we tapped into high-risk networks. Social norms promoted transactional and unprotected sex. Social networks are an acceptable channel for HIV prevention intervention delivery to out-of-school AGYW.

Development and implementation of a process evaluation for intervention quality improvement of a community-based behavioral HIV intervention trial in Tanzania.

Aim: Process evaluations for social and behavioral interventions are increasingly important as interventions become more complex and multi-faceted. Conducting process evaluations in low-resource international settings can be challenging. Process evaluations in low-resource international settings can help inform and improve quality of ongoing intervention implementation. We conducted a process evaluation of a cluster-randomized controlled trial to assess the efficacy of a microfinance and health leadership program on sexually transmitted infections and intimate partner violence perpetration among young men in Tanzania. Subject and Methods: Our trial included 1,491 participants and the intervention lasted two years. We collected process data on microfinance loan uptake and repayment, and health leaders' health conversations with peers to monitor intervention reach and dose received. We developed a database system that allowed offline data collection and synced to a central database when internet was accessible. Research staff in the U.S. accessed data from the central database to analyze and create regular implementation reports. Results: Process graphical reports facilitated identification of implementation challenges and enabled us to resolve issues before they worsened. For example, from a group with low microfinance loan repayment we learned area participants perceived the loan to be a grant, and then we clarified the misinformation with participants. Conclusions: The process evaluation helped inform ongoing intervention implementation, including approaches to improve reach and uptake of interventions. Field staff time was protected by systemizing the sharing of data processing and analyses across the global team.

Long-term complications after extrahepatic cyst excision for type IV-A choledochal cysts.

Forty-five adults with type IV-A choledochal cysts (CDC) who underwent extrahepatic cyst excision from January 2013 to December 2021 were followed up for a median interval of 25 months (range, 2 to 10 years) to observe the long-term complications in the remaining intrahepatic cyst. Late complications in varying combinations were seen in 10 patients, which included cholangitis and/or intrahepatic stones in 9 patients, intrahepatic bile duct stenosis with stones in 2 patients, anastomotic stricture in 6 patients, and left lobar atrophy with intrahepatic stones in 3 patients. Out of 6 patients who required re-do hepaticojejunostomy (HJ), three patients had left lobe atrophy with patent HJ anastomosis and a recurrent attack of cholangitis on follow-up at 3, 8, and 10 years. Complications occur frequently after extrahepatic cyst excision for type IV-A CDC and require a long-term follow-up.

A study of post-operative clinico-imaging status and visual outcome after idiopathic macular hole surgery with amniotic membrane plug.

Objective: The aim of this study was to determine the efficacy of hAM plug in the treatment of idiopathic macular hole and to see its post-operative visual improvement and anatomical apposition. Material and methods: 10 eyes of 10 patients who had idiopathic MH underwent a pars plana vitrectomy (PPV) with the hAM plug implanted in MH. The patients were followed up on 2nd day, 1st week, 3rd week, 6th week and 3rd month. Results: Final anatomical closure of MH was achieved in all the cases. BCVA improved from 0.91±0.11 logMAR to 0.28±0.06 logMAR after 3 months. No adverse event was documented in the specified period. Conclusion: hAM plug is an efficient method to treat and manage idiopathic MH with encouraging results both in terms of anatomical closure and visual acuity gain. Abbreviations: MH = Macular Hole, IOP = Intra Ocular Pressure, ILM = Internal Limiting Membrane, BCVA = Best Corrected Visual Acuity, OCT = Optical Coherence Tomography, LogMAR = Logarithm of Minimum Angle of Resolution, hAM = Human Amniotic Membrane, RPE = Retinal Pigment Epithelium.

Source-dependent variation in phenolic compounds and antioxidant activities of Prinsepia utilis Royle fruits.

Prinsepia utilis, a wild-growing Himalayan shrub, is a good source of phytoceuticals, cosmeceuticals, and antioxidants. The present study is an attempt to investigate the effect of altitude and edaphic factors on phenolics and antioxidant activity in fruit pulp of Prinsepia utilis. The ripened fruits and soil samples were collected for detailed investigation. The fruits (pulp) were extracted in methanol for analyzing total phenolics and antioxidant activity using a spectrophotometric method and phenolic compounds by high-performance liquid chromatography (HPLC). Similarly, standard methods for soil analysis were used. Results reveal that altitude negatively correlated with total phenolics and flavonoid contents determined by a spectrophotometric method and with specific phenolic compounds determined by HPLC. For instance, Dwarahat population (PU-1) at lower altitude (1400 m asl) exhibited higher values of total phenolics and flavonoids, while total tannin was higher at Nainital (PU-6) population (2000 m asl). The antioxidant activity measured by 2, 2-azinobis (3-ethylbenzothiazoline-6-sulfonic acid) (ABTS) was found higher in Narayan Ashram (PU-9) population (2750 m asl), while ferric reducing antioxidant power (FRAP) was significantly higher in Badechena (PU-2) population (1600 m asl). Soil nutrients (edaphic factors) showed a good correlation among measured parameters. Neighbor-joining and principal component analysis identified phenolics and antioxidant-rich populations that can be utilized for collection of fruits from these populations.

Demographic Patterns, Risk Factors, and Outcomes of Abdominal Aortic Aneurysms in Young Adults ≤55 Years: An Experience in a Tertiary Care Centre of India.

Introduction Abdominal aortic aneurysms (AAA) are uncommon in young adults ≤55 years of age. There is a lack of literature on clinical characteristics, risk factors, and therapeutic outcomes so we present a case series of 11 patients of AAA aged ≤55 years. Methods We included single-center retrospective case series between 2013 to 2020. We reviewed 44 patients who were operated for AAA in a tertiary care center in India. We identified 13 patients who were ≤55 years; two patients with incomplete records were excluded. A patient information sheet was used to retrieve demographic data, clinical presentation, outcomes, and follow-up. Results Out of 11 patients, 10 were men. Nine patients (81.8%) had symptomatic AAA. The majority (45.4%) exhibited an infrarenal aneurysm and the median size of the aneurysm was 5.8 cm (IQR: 5.5-6.4 cm). Eight patients (72.7%) had a history of smoking. Hypertension was observed in six patients and one patient had associated coronary artery disease. Clamping time was > 45 minutes among three patients; all smokers. Blood loss was > 500 ml in five patients. The median length of hospital stay was 10 days (7-40); more among patients with metabolic equivalents (METS) score < 4, 14.5 (8-19) days. No grade III-IV complications and mortality were noted with a median follow-up of 15 months, with all patients living. Conclusion The aneurysm was symptomatic in the majority of participants. An association of smoking in increasing both the median clamping time and length of hospital stay was seen. No mortality and good disease-free follow-up suggested good outcomes.

Results from a cluster-randomized trial to evaluate a microfinance and peer health leadership intervention to prevent HIV and intimate partner violence among social networks of Tanzanian men.

Despite calls to engage men in HIV and intimate partner violence (IPV) prevention efforts, effective approaches to reach and engage men in low-resource, high-HIV prevalence settings are limited. We identified and engaged social networks of mostly young men in a study designed to evaluate the efficacy of a combined microfinance and peer health leadership intervention to prevent HIV and IPV. We conducted a cluster-randomized trial among 60 social networks locally referred to as "camps" within Dar es Salaam, Tanzania. Camps were randomly assigned (1:1) to a microfinance and peer health leadership intervention or a control condition that received a brief delayed intervention after the study's conclusion. Allocation was not masked to participants or researchers. Behavioral assessments were conducted at baseline and 30-months post-intervention launch, with biological samples drawn at 30-months to test for sexually-transmitted infections (STIs). Primary outcomes included prevalence of STIs and past-year IPV perpetration. Secondary outcomes included STI sexual risk behaviors and past-year HIV testing. Proximal intervention targets included inequitable gender norm attitudes and hope. A modified Poisson regression approach was used to estimate intention-to-treat intervention effects on outcomes assessed at the 30-month follow-up. We enrolled 1,258 men within 60 camps. Of these men, 1,029 (81.8%) completed the 30-month follow-up. There were no differences by condition in STI prevalence, IPV perpetration, or sexual risk behaviors at the 30-month follow-up. Intervention participants reported greater levels of past-year HIV testing, controlling for baseline testing (aRR 1.13 95% CI 1.005-1.28). They also reported significantly lower levels of inequitable gender norm attitudes (adjusted effect -0.11, 95% CI -0.21-0.003). We successfully engaged and retained social networks of men in this multilevel intervention study. While we did not see an effect on the primary outcomes, our intervention successfully improved HIV testing and reduced inequitable gender norm attitudes.

Fistulating Richter's Hernia of Groin with Necrotizing Soft Tissue Infection: A Lethal Combination.

Strangulation of groin hernia can result in significant morbidity and mortality. Spontaneous external fistulation following strangulation is rare and typically occurs with Richter's hernia. Spreading Necrotizing Soft Tissue Infection (NSTI) secondary to Enterocutaneous Fistula (ECF) is an ominous sign, further worsening its prognosis. Early diagnosis and prompt surgical treatment is crucial to improve outcome. Herewith the authors are presenting a case of neglected inguinal hernia. It was complicated with ECF formation and rapidly spreading NSTI of flank. He underwent resection and anastomosis of the gangrenous bowel, anatomical repair of the hernia along with soft tissue debridement of flank region. This patient however succumbed to sepsis with multi organ dysfunction. Significant delay in seeking medical care led to dismal outcome.

Global Health Diplomacy, Monitoring & Evaluation, and the Importance of Quality Assurance & Control: Findings from NIMH Project Accept (HPTN 043): A Phase III Randomized Controlled Trial of Community Mobilization, Mobile Testing, Same-Day Results, and Post-Test Support for HIV in Sub-Saharan Africa and Thailand.

BACKGROUND: Provision and scale-up of high quality, evidence-based services is essential for successful international HIV prevention interventions in order to generate and maintain intervention uptake, study integrity and participant trust, from both health service delivery and diplomatic perspectives. METHODS: We developed quality assurance (QAC) procedures to evaluate staff fidelity to a cluster-randomized trial of the NIMH Project Accept (HPTN 043) assessing the effectiveness of a community-based voluntary counseling and testing strategy. The intervention was comprised of three components-Mobile Voluntary Counseling and Testing (MVCT), Community Mobilization (CM) and Post-Test Support Services (PTSS). QAC procedures were based on standardized criteria, and were designed to assess both provider skills and adherence to the intervention protocol. Supervisors observed a random sample of 5% to 10% of sessions each month and evaluated staff against multiple criteria on scales of 1-5. A score of 5 indicated 100% adherence, 4 indicated 95% adherence, and 3 indicated 90% adherence. Scores below 3 were considered unsatisfactory, and protocol deviations were discussed with the respective staff. RESULTS: During the first year of the intervention, the mean scores of MVCT and CM staff across the 5 study sites were 4 (95% adherence) or greater and continued to improve over time. Mean QAC scores for the PTSS component were lower and displayed greater fluctuations. Challenges to PTSS staff were identified as coping with the wide range of activities in the PTSS component and the novelty of the PTSS process. QAC fluctuations for PTSS were also associated with new staff hires or changes in staff responsibilities. Through constant staff monitoring and support, by Year 2, QAC scores for PTSS activities had reached those of MVCT and CM. CONCLUSIONS: The implementation of a large-sale, evidence based HIV intervention requires extensive QAC to ensure implementation effectiveness. Ongoing appraisal of study staff across sites ensures consistent and high quality delivery of all intervention components, in keeping with the goals of the study protocol, while also providing a forum for corrective feedback, additional supervision and retraining of staff. QAC ensures staff fidelity to study procedures and is critical to the successful delivery of multi-site HIV prevention interventions, as well as the delivery of services scaled up in programmatic situations.

Vijana Vijiweni II: a cluster-randomized trial to evaluate the efficacy of a microfinance and peer health leadership intervention for HIV and intimate partner violence prevention among social networks of young men in Dar es Salaam.

BACKGROUND: Intimate partner violence (IPV) and sexually transmitted infections (STIs), including HIV, remain important public health problems with devastating health effects for men and women in sub-Saharan Africa. There have been calls to engage men in prevention efforts, however, we lack effective approaches to reach and engage them. Social network approaches have demonstrated effective and sustained outcomes on changing risk behaviors in the U.S. Our team has identified and engaged naturally occurring social networks comprised mostly of young men in Dar es Salaam in an intervention designed to jointly reduce STI incidence and the perpetration of IPV. These stable networks are locally referred to as "camps." In a pilot study we demonstrated the feasibility and acceptability of a combined microfinance and peer health leadership intervention within these camp-based peer networks. METHODS DESIGN: We are implementing a cluster-randomized trial to evaluate the efficacy of an intervention combining microfinance with health leadership training in 60 camps in Dar es Salaam, Tanzania. Half of the camps have been randomized to the intervention arm, and half to a control arm. The camps in the intervention arm will receive a combined microfinance and health leadership intervention for a period of two years. The camps in the control arm will receive a delayed intervention. We have enrolled 1,258 men across the 60 study camps. Behavioral surveys will be conducted at baseline, 12-months post intervention launch and 30-month post intervention launch and biological samples will be drawn to test for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) at baseline and 30-months. The primary endpoints for assessing intervention impact are IPV perpetration and STI incidence. DISCUSSION: This is the first cluster-randomized trial targeting social networks of men in sub-Saharan Africa that jointly addresses HIV and IPV perpetration and has both biological and behavioral endpoints. Effective approaches to engage men in HIV and IPV prevention are needed in low resource, high prevalence settings like Tanzania. If we determine that this approach is effective, we will examine how to adapt and scale up this approach to other urban, sub-Saharan African settings. TRIAL REGISTRATION: Clinical Trials.gov: NCT01865383 . Registration date: May 24, 2013.

Is Socio-Economic Status a Determinant of HIV-Related Stigma Attitudes in Zimbabwe? Findings from Project Accept.

HIV related stigma and discrimination is a known barrier for HIV prevention and care. We aimed to assess the relationship between socio-economic status (SES) and HIV related stigma in Zimbabwe. This paper uses data from Project Accept, which examined the impact of community-based voluntary counseling and testing intervention on HIV incidence and stigma. Total of 2522 eligible participants responded to a psychometric assessment tool, which assessed HIV related stigma and discrimination attitudes on 4 point Likert scale. The tool measured three components of HIV-related stigma: shame, blame and social isolation, perceived discrimination, and equity. Participants' ownership of basic assets was used to assess the socio-economic status. Shame, blame and social isolation component of HIV related stigma was found to be significantly associated with medium [odds ratio (OR)=1.73, P<0.01] and low SES (OR=1.97, P<0.01), indicating more stigmatizing attitudes by participants belonging to medium and low SES in comparison to high SES. For HIV related stigma and discrimination programs to be effective, they should take into account the socio-economic context of target population.

Effects of preoperative carbohydrates drinks on immediate postoperative outcome after day care laparoscopic cholecystectomy.

BACKGROUND: Postoperative nausea and vomiting is the most common cause for unexpected hospital admission of patients undergoing day care surgery. Overnight fasting changes patient metabolic state and influences their perioperative stress response. Preoperative carbohydrate loading may have accelerated recovery and better overall outcome after major abdominal surgery. The aim of the study was to investigate the effects of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting and pain after day care laparoscopic cholecystectomy. METHODS: A total of 120 patients posted for day care laparoscopic cholecystectomy were included in the study and were randomized into three groups. Group A (Cases)-receiving the carbohydrate-rich drink before surgery (CHO), group B (placebo)-receiving the placebo drink before surgery and group C (controls)-fasting from midnight before surgery. Postoperative nausea and vomiting and visual analogue score for pain were noted and analyzed for 24 h. RESULTS: Mean score of nausea in 0-4 h in group A was significantly lower as compared to group B and group C (p = 0.001). Difference in mean score of nausea in 4-12 and 12-24 h between groups was not significant (p = 0.066), (p = 0.257). Mean score of vomiting in 0-4 and 4-12 h in group A was significantly less than that of group B and group C (p = 0.004), (p = 0.001). Mean score of pain in group A was significantly less when compared to group B and group C in 0-4 h (p = 0.001) and 4-12 h (0.005). CONCLUSION: Perioperative consumption of a carbohydrate-rich drink can minimize postoperative nausea, vomiting and pain in patients undergoing outpatient cholecystectomy. Consumption of carbohydrate drinks up to 2 h prior to surgery is not associated with additional complications.

Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India.

BACKGROUND: Data on mental health among injecting drug users in South Asia is scarce yet poor mental health among users has significant implications for the success of HIV prevention and treatment programmes. A cohort of 449 injecting drug users in Delhi was examined on the following issues (1) examine trends in suicidal ideation, suicide plan and suicidal attempts over a 12-month period, (2) examine association between injecting practices (receive and give used syringes) and suicidal ideation over a 12 month study period. METHODS: An observational study was conducted providing phased interventions with follow up interviews every 3 months to 449 injecting drug users (IDUs), from August 2004 to November 2005. The study was conducted in Yamuna Bazaar, a known hub of drug peddling in Delhi. Interventions included nutrition, basic medical services, needle exchange, health education, HIV voluntary counseling and testing, STI diagnosis and treatment, oral buprenorphine substitution, and detoxification, each introduced sequentially. RESULTS: Suicidal ideation and suicide attempts, did not significantly change over 12 months of observation, while suicide plans actually increased over the time period. Keeping other factors constant, IDUs with suicidal ideation reported more giving and receiving of used syringes in the recent past. CONCLUSIONS: Mental health services are warranted within harm reduction programmes. Special attention must be paid to suicidal IDUs given their higher risk behaviours for acquiring HIV and other blood borne infections. IDU intervention programmes should assess and address suicide risk through brief screening and enhanced counseling.

Socio-economic status and health care utilization in rural Zimbabwe: findings from Project Accept (HPTN 043).

Zimbabwe's HIV epidemic is amongst the worst in the world, and disproportionately effects poorer rural areas. Access to almost all health services in Zimbabwe includes some form of cost to the client. In recent years, the socio-economic and employment status of many Zimbabweans has suffered a serious decline, creating additional barriers to HIV treatment and care. We aimed to assess the impact of i) socio-economic status (SES) and ii) employment status on the utilization of health services in rural Zimbabwe. Data were collected from a random probability sample household survey conducted in the Mutoko district of north-western Zimbabwe in 2005. We selected variables that described the economic status of the respondent, including: being paid to work, employment status, and SES by assets. Respondents were also asked about where they most often utilized healthcare when they or their family was sick or hurt. Of 2,874 respondents, all forms of healthcare tended to be utilized by those of high or medium-high SES (65%), including private (65%), church-based (61%), traditional (67%), and other providers (66%) (P=0.009). Most respondents of low SES utilized government providers (74%) (P=0.009). Seventy-one percent of respondents utilizing health services were employed. Government (71%), private (72%), church (71%), community-based (78%) and other (64%) health services tended to be utilized by employed respondents (P=0.000). Only traditional health services were equally utilized by unemployed respondents (50%) (P=0.000). A wide range of health providers are utilized in rural Zimbabwe. Utilization is strongly associated with SES and employment status, particularly for services with user fees, which may act as a barrier to HIV treatment and care access. Efforts to improve access in low-SES, high HIV-prevalence settings may benefit from the subsidization of the health care payment system, efforts to improve SES levels, political reform, and the involvement of traditional providers.

Community-based intervention to increase HIV testing and case detection in people aged 16-32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study.

BACKGROUND: In developing countries, most people infected with HIV do not know their infection status. We aimed to assess whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. METHODS: Project Accept is underway in ten communities in Tanzania, eight in Zimbabwe, and 14 in Thailand. Communities at each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT (SVCT), and the other community was assigned to receive community-based VCT (CBVCT) plus access to SVCT. Randomisation and assignment of communities to intervention groups was done by the statistics centre by computer; no one was masked to treatment assignment because the interventions were community based. Intervention was provided for about 3 years (2006-09). The primary endpoint of HIV incidence is pending completion of assessments after the intervention. In this interim analysis, we examined the secondary endpoint of uptake in HIV testing, differences in characteristics of clients receiving their first HIV test, and repeat testing. Analyses were limited to clients aged 16-32 years. This study is registered with ClinicalTrials.gov, number NCT00203749. FINDINGS: The proportion of clients receiving their first HIV test during the study was higher in CBVCT communities than in SVCT communities in Tanzania (2341 [37%] of 6250 vs 579 [9%] of 6733), Zimbabwe (5437 [51%] of 10,700 vs 602 [5%] of 12,150), and Thailand (7802 [69%] of 11,290 vs 2319 [23%] 10,033). The mean difference in the proportion of clients receiving HIV testing between CBVCT and SVCT communities was 40·2% (95% CI 15·8-64·7; p=0·019) across three community pairs (one per country). HIV prevalence was higher in SVCT communities than in CBVCT communities, but CBVCT detected almost four times more HIV cases than did SVCT across the three study sites (952 vs 264; p=0·003). Repeat HIV testing in CBVCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. INTERPRETATION: CBVCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing. FUNDING: US National Institute of Mental Health, HIV Prevention Trials Network (via US National Institute of Allergy and Infectious Diseases), and US National Institutes of Health.