Genetic testing and genetic discrimination: Public policy when insurance becomes "too expensive".

We examine public policy toward the use of genetic tests by insurers when a positive test makes actuarially fair insurance too expensive for some consumers. With state-dependent utility, consumers may decline actuarially fair insurance if the probability of becoming ill exceeds a threshold. In markets with adverse selection, a positive genetic test may cause all or some high risks to drop out of the market (complete and partial genetic discrimination, respectively). Full participation in the market by all consumers requires cross-subsidization. We show that the consent law and mandatory testing are equivalent. Under complete genetic discrimination, the duty to disclose is never Pareto dominated, but either the code of conduct or consent law can yield the same outcome. Under partial genetic discrimination, the duty to disclose is never Pareto dominated. However, partial genetic discrimination and cross-subsidization imply the information ban is noncomparable to the other policy alternatives.

Prevalence and Subtype Distribution of High-Risk Human Papillomavirus Among Women Presenting for Cervical Cancer Screening at Karanda Mission Hospital.

PURPOSE: High-risk human papillomaviruses (hrHPV) are the primary cause of cervical cancer. Human papillomavirus (HPV) vaccination is expected to prevent cervical cancers caused by the HPV types included in vaccines and possibly by cross-protection from other types. This study sought to determine the hrHPV type distribution in women at a rural Zimbabwe hospital. METHODS: We implemented a cross-sectional study at the Karanda Mission Hospital. Using the Visual Inspection with Acetic Acid Cervicography technique, clinicians collected cervical swabs from 400 women presenting for screening for cervical cancer. Samples were initially analyzed by Cepheid GeneXpert; candidate hrHPV genotypes were further characterized using the Anyplex II HPV28 Detection Kit. RESULTS: Twenty-one percent of the 400 women were positive for a high-risk genotype when using the GeneXpert analyzer; 17% were positive when using the multiplex analysis. Almost two thirds of the hrHPV women had a single DNA type identified, whereas one third had multiple genotypes, ranging from 2 to 5. hrHPV was observed more frequently in HIV-positive than in HIV-negative women (27% v 15%). Of the 113 isolates obtained, 77% were hrHPV genotypes not included in the bivalent or quadrivalent vaccines, and 47% represented DNA types not covered in the nonavalent vaccine. Forty-seven percent of the women with hrHPV harbored a single genotype that was not covered by the nonavalent vaccine. CONCLUSION: A large fraction of hrHPV isolates from women participating in a cervical cancer screening program in northern Zimbabwe are DNA types not covered by the bivalent, quadrivalent, or nonavalent vaccines. These findings suggest the importance of characterizing the hrHPV DNA types isolated from cervical neoplasia in this population and determining whether cross-immunization against these genotypes develops after administration of the vaccines in current use.

Vesicouterine Fistula and Fetus in Bladder: A Case Report.

BACKGROUND: Vesicouterine fistulas are the rarest of all urogenital fistulas, with most cases occurring after cesarean section. CASE: A 38-year-old woman in rural Zimbabwe presented at 20 weeks gestation with a suspected fetus in the urinary bladder by transabdominal ultrasonography. This finding was confirmed intraoperatively together with a vesicouterine fistula. Cesarean section 20 years earlier was the only risk factor. Diagnosis was delayed for lack of access to appropriate imaging and a tertiary facility. CONCLUSION: A vesicouterine fistula is a rare presentation in the context of an advanced health care system. To our knowledge, this is the fourth case report of a fetus in the bladder secondary to vesicouterine fistula. Patient morbidity in this case possibly could have been avoided with earlier diagnosis and access to care.

HIV status and mortality of surgical inpatients in rural Zimbabwe: A retrospective chart review.

BACKGROUND: People living with HIV treated with antiretroviral therapy (ART) are now living longer and thus many are requiring surgical procedures. For healthcare resource planning, it would be helpful to better understand the prevalence of HIV in surgical patients, the types of surgery HIV-positive patients are undergoing and whether HIV status impacts mortality. OBJECTIVE: The goal of this study was to determine the prevalence of HIV in surgical inpatients and the extent of ART coverage, as well as to assess any differences between HIV-positive and HIV-negative patients in type of surgery undergone and in-hospital mortality at Karanda Mission Hospital, Mount Darwin, Zimbabwe. METHOD: A 1-year retrospective chart review was undertaken to collect clinical and demographic data for adult (excluding maternity cases) and paediatric surgical inpatients including age, sex, type of surgery, HIV status, CD4+ counts and, if patient was HIV-positive, whether he or she was taking ART.Results and conclusion: Charts for 1510 surgical inpatient stays were reviewed. HIV prevalence among the adults was higher than that in the general population in Zimbabwe in 2016 (23.2% vs. 14.7%). There was no significant difference in inpatient mortality between the HIV-negative group and the HIV-positive group. Within the group of patients with malignancies, people living with HIV were significantly younger than uninfected patients (mean age 50.5 vs. 64.4 years; p < 0.01). There were correlations between HIV and certain malignancies. Thus, in addition to AIDS-defining illnesses, clinicians must be alert to squamous cell carcinoma and oesophageal, anal and penile cancers in HIV-positive patients.

Endogenous information, adverse selection, and prevention: Implications for genetic testing policy.

We examine public policy toward the use of genetic information by insurers. Individuals engage in unobservable primary prevention and have access to different prevention technologies. Thus, insurance markets are affected by moral hazard and adverse selection. Individuals can choose to take a genetic test to acquire information about their prevention technology. Information has positive decision-making value, that is, individuals may adjust their behavior based on the result of the test. However, testing also exposes individuals to uncertainty over the available insurance contract, so-called classification risk, which lowers the value of information. In our analysis we distinguish between four different policy regimes, determine the value of information under each regime and associated equilibrium outcomes on the insurance market. We show that the policy regimes can be Pareto ranked, with a duty to disclose being the preferred regime and an information ban the least preferred one.

Healthcare providers' perspectives on the acceptability and uptake of HPV vaccines in Zimbabwe.

BACKGROUND: Human papillomavirus (HPV) vaccines are a critical strategy in the prevention of cervical cancer, especially in countries like Zimbabwe where cervical cancer screening rates are low. In Zimbabwe, cervical cancer is the leading cause of cancer-related deaths in women but the HPV vaccine is not yet widely available. This study examined healthcare providers': (1) perceptions of current hospital practices and issues in cervical cancer prevention and treatment in Zimbabwe; (2) knowledge of HPV and HPV vaccines; and (3) perspectives on introducing HPV vaccination programs in Zimbabwe, including potential facilitators and barriers to successful implementation. METHOD: In-depth semi-structured interviews were conducted at a rural hospital with 15 healthcare providers in Zimbabwe. Interviews included eight main questions and a number of additional probes that reflected the study's purpose. Data were analyzed using thematic analysis. RESULTS: Participants reported that women are not consistently being screened for cervical cancer. There were generally low levels of knowledge about HPV and HPV vaccines, but participants asked many questions indicating a desire to learn more. Although they were highly supportive of implementing HPV vaccination programs in Zimbabwe, they also identified a number of likely psychosocial, cultural, and logistical barriers to successful implementation, including cost, vaccine schedule, and hospital infrastructure. However, participants also provided a number of culturally relevant solutions, including education and community engagement. CONCLUSION: This study provides insight from healthcare providers about barriers to implementation and possible solutions that can be used by policy makers, practitioners, and other stakeholders to facilitate the successful implementation of forthcoming HPV immunization programs in Zimbabwe.

The spectrum of neurological presentations in an outpatient clinic of rural Zimbabwe.

BACKGROUND: Previous studies to estimate burden of neurological disorders in Africa are limited to inpatients in urban hospitals. The spectrum of neurological conditions in rural Africa remains unclear. OBJECTIVE: To determine the spectrum of neurological presentations in an outpatient setting in rural Zimbabwe. METHODS: Clinical data was collected from outpatient records at Karanda Mission Hospital, a rural community hospital in Northern Zimbabwe from February 2013 to February 2014. Each patient visit was entered in an outpatient record book by a registered nurse or a nurse trainee. Demographic details such as age, sex, weight and address of the patient, and clinical details such as diagnosis on discharge and medications prescribed were recorded in the record book following assessment by a physician or nurse practitioner. Each visit corresponded to a separate entry in the study. RESULTS: We recorded a total of 19,206 visits in the outpatient registry. The average age was 46.41 years (standard deviation=21.46), and there were more visits from women (57.81%). 11.63% (2233) of all visits had a neurological diagnosis at discharge. The most common neurological diagnoses were epilepsy/seizures (24.38%), followed by neuropathies (13.63%), headaches (11.4%) and strokes (4.6%). CONCLUSIONS: One in ten cases in an outpatient setting in rural Zimbabwe were neurologically related. Further studies are required to determine the public health burden of neurological disorders in rural Africa. The development and funding of educational initiatives in resource-limited areas is needed to improve neurological diagnosis and care.

Increased incidence of tuberculosis in zimbabwe, in association with food insecurity, and economic collapse: an ecological analysis.

BACKGROUND: Zimbabwe underwent a socioeconomic crisis and resultant increase in food insecurity in 2008-9. The impact of the crisis on Tuberculosis (TB) incidence is unknown. METHODS: Prospective databases from two mission hospitals, which were geographically widely separated, and remained open during the crisis, were reviewed. RESULTS: At the Howard Hospital (HH) in northern Zimbabwe, TB incidence increased 35% in 2008 from baseline rates in 2003-2007 (p<0.01) and remained at that level in 2009. Murambinda Hospital (MH) in Eastern Zimbabwe also demonstrated a 29% rise in TB incidence from 2007 to 2008 (p<0.01) and remained at that level in 2009. Data collected post-crisis at HH showed a decrease of 33% in TB incidence between 2009 to 2010 (p<0.001) and 2010/2011 TB incidence remained below that of the crisis years of 2008/2009 (p<0.01). Antenatal clinic HIV seroprevalence at HH decreased between 2001(23%) to 2011(11%) (p<0.001). Seasonality of TB incidence was analyzed at both MH and HH. There was a higher TB incidence in the dry season when food is least available (September-November) compared to post harvest (April-June) (p<0.001). CONCLUSION: This study suggests that an epidemic of TB mirrored socioeconomic collapse and recovery in Zimbabwe. The seasonal data suggests that food security may have been associated with TB incidence both annually and during the crisis in this high HIV prevalence country.

Highly active anti-retroviral therapy in the prevention of mother-to-child transmission of HIV in rural Zimbabwe during the socio-economic crisis.

The purpose of this study is to evaluate the effectiveness of highly active antiretroviral therapy (HAART) in preventing mother-to-child transmission (PMTCT) of HIV in breastfeeding women in rural Zimbabwe. During a severe socio-economic crisis in 2005-2007, 82 eligible HIV-positive pregnant women between 14-36 weeks gestation were initiated on HAART with AZT/3TC/nelfinavir combination therapy at a rural hospital and continued through to six months post-partum. In addition, mothers also received intrapartum single-dose nevirapine (sdNVP). Infants received sdNVP/AZT in the first 72 hours and were assessed for HIV infection at six weeks of age. Results were compared to historical controls of HIV-positive pregnant women who received sdNVP only at the same center. Of the 67 infants with available data on HIV status at six weeks postpartum, three (4.4%) were HIV positive by HIV RNA assay in the HAART + sdNVP group compared to 49/297 (16.5%) in the sdNVP group (p = 0.01). HAART given to HIV-infected mothers in pregnancy and during breastfeeding along with intrapartum sdNVP resulted in a lower postnatal HIV transmission at six weeks postpartum compared to sdNVP treatment. Our HAART regimen demonstrates that PMTCT of HIV can be effective even during times of socioeconomic crisis in resource-poor rural settings.

Sexual behaviour as the limiting and linking factor in HIV-infected people in rural Zimbabwe.

Although the incidence of AIDS continues to increase in Zimbabwe, no systematic investigation has been done of the contextual (behavioural and situational) variables important to the tailoring of AIDS educational prevention programmes for those at risk. As part of a World Health Organization-recommended cotrimoxazole prophylaxis programme to 1146 HIV-positive individuals in rural Zimbabwe, data were collected on risk behaviours and characteristics of all participants. Outcomes included condom use, relationship, marital status, duration of the programme and reason for HIV testing. Forty-five participants (4.1%) reported always using condoms, 379 (34.5%) reported occasional use and 673 (61.4%) reported no condom use. Statistical analysis showed significant positive correlations between condom use and participant age, duration of the programme, the reason for HIV testing, knowledge about the partners' HIV status and the partner's awareness of the patient's HIV-positive status. Results reflect the need to target subpopulations, for specific HIV/AIDS education initiatives in rural Africa.

A randomized, double-blind, placebo-controlled trial of combined nevirapine and zidovudine compared with nevirapine alone in the prevention of perinatal transmission of HIV in Zimbabwe.

BACKGROUND: A single dose of nevirapine (sdNVP) administered to both mother and infant can decrease mother-to-child transmission of human immunodeficiency virus (HIV) by 47%, compared with ultra-short course zidovudine therapy (usZDV). There is limited data about the benefit of usZDV added to sdNVP to prevent mother-to-child transmission. METHODS: We performed a double-blind, randomized, placebo-controlled trial to determine whether usZDV combined with sdNVP improved neonatal outcome, compared with sdNVP alone. Mothers were randomized to 1 of 2 treatment groups. Mothers in the usZDV/sdNVP group received a loading dose of zidovudine (600 mg administered orally) and continued to receive 300-mg doses of zidovudine orally every 3 h while in labor, and their infants received zidovudine at a dosage of 2 mg per kg of body weight 4 times per day orally for 72 h. Mothers and infants in the sdNVP group received zidovudine placebo dosed in the same manner. All mothers also received nevirapine at a dosage of 200 mg orally while in labor, and all infants received nevirapine 2 mg per kg of body weight orally within 72 h of delivery. RESULTS: The study was stopped on the basis of futility, because interim data showed that, at present trends, superiority would not be demonstrated. Results at 6 weeks of age were available for 609 infants. The primary end point of HIV RNA positivity or death occurred in 21.8% of infants in the usZDV/sdNVP arm and 23.6% of the infants in the sdNVP arm. CONCLUSION: usZDV, when added to a standard 2-dose regimen of sdNVP, did not demonstrate a clinically important decrease in the combined end point of mother-to-child transmission or infant death. High rates of adverse maternal and infant outcome in both study arms suggest that improved approaches are necessary.