Multimodal pre-screening can predict BCI performance variability: A novel subject-specific experimental scheme.

BACKGROUND: Brain-computer interface (BCI) systems currently lack the required robustness for long-term daily use due to inter- and intra-subject performance variability. In this study, we propose a novel personalized scheme for a multimodal BCI system, primarily using functional near-infrared spectroscopy (fNIRS) and electroencephalography (EEG), to identify, predict, and compensate for factors affecting competence-related and interfering factors associated with performance. METHOD: 11 (out of 13 recruited) participants, including five participants with motor deficits, completed four sessions on average. During the training sessions, the subjects performed a short pre-screening phase, followed by three variations of a novel visou-mental (VM) protocol. Features extracted from the pre-screening phase were used to construct predictive platforms using stepwise multivariate linear regression (MLR) models. In the test sessions, we employed a task-correction phase where our predictive models were used to predict the ideal task variation to maximize performance, followed by an interference-correction phase. We then investigated the associations between predicted and actual performances and evaluated the outcome of correction strategies. RESULT: The predictive models resulted in respective adjusted R-squared values of 0.942, 0.724, and 0.939 for the first, second, and third variation of the task, respectively. The statistical analyses showed significant associations between the performances predicted by predictive models and the actual performances for the first two task variations, with rhos of 0.7289 (p-value = 0.011) and 0.6970 (p-value = 0.017), respectively. For 81.82 % of the subjects, the task/workload correction stage correctly determined which task variation provided the highest accuracy, with an average performance gain of 5.18 % when applying the correction strategies. CONCLUSION: Our proposed method can lead to an integrated multimodal predictive framework to compensate for BCI performance variability, particularly, for people with severe motor deficits.

Metabolomic profiling of preterm birth in pregnant women living with HIV.

BACKGROUND: Preterm birth is a leading cause of death in children under the age of five. The risk of preterm birth is increased by maternal HIV infection as well as by certain antiretroviral regimens, leading to a disproportionate burden on low- and medium-income settings where HIV is most prevalent. Despite decades of research, the mechanisms underlying spontaneous preterm birth, particularly in resource limited areas with high HIV infection rates, are still poorly understood and accurate prediction and therapeutic intervention remain elusive. OBJECTIVES: Metabolomics was utilized to identify profiles of preterm birth among pregnant women living with HIV on two different antiretroviral therapy (ART) regimens. METHODS: This pilot study comprised 100 mother-infant dyads prior to antiretroviral initiation, on zidovudine monotherapy or on protease inhibitor-based antiretroviral therapy. Pregnancies that resulted in preterm births were matched 1:1 with controls by gestational age at time of sample collection. Maternal plasma and blood spots at 23-35 weeks gestation and infant dried blood spots at birth, were assayed using an untargeted metabolomics method. Linear regression and random forests classification models were used to identify shared and treatment-specific markers of preterm birth. RESULTS: Classification models for preterm birth achieved accuracies of 95.5%, 95.7%, and 80.7% in the untreated, zidovudine monotherapy, and protease inhibitor-based treatment groups, respectively. Urate, methionine sulfone, cortisone, and 17α-hydroxypregnanolone glucuronide were identified as shared markers of preterm birth. Other compounds including hippurate and N-acetyl-1-methylhistidine were found to be significantly altered in a treatment-specific context. CONCLUSION: This study identified previously known as well as novel metabolomic features of preterm birth in pregnant women living with HIV. Validation of these models in a larger, independent cohort is necessary to ascertain whether they can be utilized to predict preterm birth during a stage of gestation that allows for therapeutic intervention or more effective resource allocation.

Doxycycline post-exposure prophylaxis for sexually transmitted infections in South Africa.

South Africa has a large burden of bacterial sexually transmitted infections (STIs) with high rates among men who have sex with men (MSM). Randomised controlled trials have recently demonstrated high effectiveness of doxycycline post-exposure prophylaxis (PEP) for prevention of bacterial STIs in MSM, with 70% - 85% reductions in Chlamydia trachomatis infection and syphilis, and approximately 50% reduction in Neisseria gonorrhoeae infection. Doxycycline PEP was not demonstrated to be effective in reducing C. trachomatis and N. gonorrhoeae infection among Kenyan cisgender women. Although no worrisome trends in antimicrobial resistance (AMR) were observed in the trials, important concerns remain about doxycycline PEP and AMR development in STIs, other pathogens, commensals, and the microbiome. Tetracycline resistance in N. gonorrhoeae is already widespread in South Africa, but emergence of AMR in other STIs would be concerning. Larger sample sizes of doxycycline PEP users with longer follow-up time are needed to understand the impact that doxycycline PEP may have on AMR at individual and population level. In this opinion article, we weigh the benefits of doxycycline PEP for prevention of bacterial STIs against the existing AMR concerns and data gaps in the South African context. Based on the current evidence, we conclude that it would be reasonable to offer doxycycline PEP to high-risk MSM on a case-by-case basis, provided that it is offered by experienced sexual health clinicians in settings that have access to diagnostic STI testing and ongoing AMR surveillance.

A Single Question on Maternal HIV Status Can Improve Identification of Children Living With HIV in South Africa.

INTRODUCTION: Screening tools to improve identification of children living with HIV (CLHIV) have been validated and used in various settings. The aim of our study was to optimize a screening tool for Primary Healthcare Clinics (PHCs) in South Africa (SA). METHODS: A cross-sectional study was conducted at PHCs in Johannesburg and Mopani Districts, between June 2021 and June 2022. Children 5-14 years of age with HIV negative or unknown status accompanied by their mothers, or appropriate caregivers, were enrolled. Demographic data, responses to the screening tool questions, and HIV test results were captured. Logistic regression modeling was used to optimize an existing 10-item screening tool, and sensitivity, specificity, and number needed to test (NNT) used to choose the final tool. RESULTS: We enrolled 14,147 children in the study, with 62 children testing HIV positive (HIV positivity of 0.4%). The 10-item tool with a single positive response had a sensitivity of 91.9% and specificity of 43.3%. An optimal combination of 5-items with two positive responses had the lowest NNT of 72, 82.3% sensitivity and 74.2% specificity. Maternal HIV status alone, HIV positive or unknown, had a 95.2% sensitivity, 65.0% specificity and NNT of 84. The 1-item tool only would have missed 5% of CLHIV (N = 3) compared with the 5-item tool that missed 18% (n = 11). CONCLUSIONS: A 1-item screening tool asking about maternal HIV status can improve efficiency of testing of children in primary healthcare facilities in SA and improve identification of CLHIV who are not on treatment.

Postnatal clubs for integrated postnatal care in Johannesburg, South Africa: a qualitative assessment of implementation.

BACKGROUND: South Africa has reported challenges in retaining women in Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs postnatally. Due to the success of PMTCT in the antenatal period, proportionally more infant transmissions now occur after delivery. The Médecins sans Frontières (MSF) Postnatal Club (PNC) model allows for integrated postnatal care and support. Anova Health Institute implemented the model in primary health facilities in Johannesburg as part of a planned national scale-up. We aimed to assess the implementation of these PNCs. METHODS: We used the RE-AIM (Reach, Adoption, Implementation, Maintenance) framework to assess implementation success and explore factors influencing implementation. In-depth interviews were conducted with 15 PNC staff, both clinicians and lay counsellors, using convenience sampling, from 12 facilities in Johannesburg. Data were analysed thematically using the RE-AIM framework. RESULTS: PNC were perceived to have many benefits for postnatal clients and their infants: providers reported reduced waiting times, reduced number of clinic visits and that PNC provided clients with a space to form cohesive group dynamics thereby contributing to retention and adherence to antiretroviral therapy. However, it was found that lacking resources (e.g., space, medical equipment, staff) negatively impacted reach, implementation and sustainability. At times the PNC model was altered to accommodate the availability of resources (e.g., counselling mothers individually). Additionally, providers expressed concerns about lack of stakeholder adoption and emphasized the importance of involving facility leadership for successful integration of the model into routine primary healthcare. CONCLUSION: Our study found incomplete implementation of PNC in most of the participating facilities attributed to lack of resources and stakeholder buy-in. This underscores the need for increased support at management level to ensure sustainability. Effective collaboration between all stakeholders would allow better use of existing resources. Further studies are needed to evaluate whether all components of the model need to be implemented fully to ensure optimal outcomes, and to identify implementation strategies to facilitate scale-up.

Public Perceptions of Opioid Use Following Orthopedic Surgery: A Survey.

Background: The United States accounts for the majority of prescription opioids consumed worldwide. Recent literature has focused on opioid prescribing patterns among orthopedic surgeons; however, public and patient expectations about postoperative opioid use remain understudied. Purpose: We sought to explore public perceptions of opioid use after elective orthopedic surgery. Methods: We posted a 32-question survey on Amazon Mechanical Turk (MTurk), an online platform with over 500,000 unique registered users that is a validated tool for collecting survey responses in medical research. The survey asked about attitudes regarding opioid use after elective orthopedic surgery and sociodemographic factors, as well as validated assessments of health literacy and patient engagement. Results: Of 727 respondents who completed surveys, nearly half (46%) said they would prefer nonopioid pain medication after elective orthopedic surgery, although 86% said they would expect to be prescribed opioids for 1 week to 1 month postoperatively. About half said they would expect to be prescribed extra opioid medication in case of unexpected pain following surgery, and 50% reported that they would save their pills to treat future pain. Approximately 63% said they would understand their surgeon's opioid weaning, but over ⅓ said weaning would lead to decreased satisfaction with their surgeon. Roughly ⅔ reported that pain control after surgery would directly affect their opinion of the surgeon. Conclusions: Our survey found that some members of the general public reported expectations regarding postoperative opioid prescribing that could lead to decreased patient satisfaction. These findings suggest the need for further research on the value of preoperative patient education in pain management, on patient expectations of pain control after elective surgery, and on the use of opioids following orthopedic surgery.

Thermal Debridement in the Management of Low Grade Scapholunate Ligament Tears.

Low grade scapholunate interosseous ligament (SLIL) tears are often managed with mechanical or thermal arthroscopic debridement, although this remains controversial. This study aimed to assess the short-term outcomes of thermal debride- ment of low-grade SLIL tears. Patients with low grade SLIL tears who underwent arthroscopic thermal debridement between 2010 and 2017 were identified and divided into two groups: isolated thermal debridement and concomitant pro- cedures. Patient reported outcomes, wrist range of motion, grip strength, return to work, and baseline activities were evaluated. Twenty-seven patients underwent isolated thermal debridement and 20 underwent concomitant procedures. Pain significantly improved in both groups. Grip strength significantly improved in the concomitant procedure group. There was no significant change in wrist range of motion in either group. Most patients returned to baseline activities. Arthroscopic thermal debridement provides good outcomes in patients with low grade SLIL tears both in isolation and in association with other injuries.

Outcomes of a Telephonic Postnatal Intervention for Mothers and Babies in Mopani District, Limpopo, South Africa.

Background: The postnatal period is a critical period for the health of both mother and infant. Studies show that postnatal care reduces neonatal mortality and other adverse mother and child health outcomes. While the World Health Organization recommends four postnatal care contacts, South African guidelines only specify three, excluding a 7-14-day post-birth contact. This study aimed to assess whether a telephonic contact at 7-14 days following delivery had any effect on use of additional postnatal services. Methods: A randomized controlled trial design was used to address the study objectives. Two groups of new mothers were randomly allocated to either receive the 7-14-day telephonic contact or not from a research nurse. Data for this study was collected at Maphutha L Malatjie Hospital (MLMH). Descriptive analysis was performed first, then a multivariable logistic regression analysis was conducted to assess the factors associated with access to other health care services. Results: A total of 882 mothers were recruited, 854 (97%) were classified as high risk, 28 (3%) were classified as low risk. 417 (49%) of the high risk received the 7-14-day call (intervention group) whilst the remainder of 437 (51%) from the high risk plus all mothers classified as low risk (28) did not receive the call (control group). 686 (78%) of all mothers received the 3 month follow up call. The call showed that 17 mothers from the control group and 10 mothers from the intervention group accessed other healthcare services. We find that hypertension (3.28; 1.06 -10.10), mental health risk (2.82; 1.25 -6.38), PV bleeding during pregnancy (18.33; 1.79-187.61), problem during labor (4.40; 1.280-15.13) were positively associated with access to other health services, with statistically significant associations (p-value < 0.05). We found statistically insignificant associations between receiving the 7-14-day call and accessing other health care services. Conclusion: The 7-14-day call had no statistically significant impact on access to other health services, however, high levels of satisfaction with the call may point to an unmet need for care at this time. It is important to investigate other innovative solutions to postnatal care improvement in South Africa.

Supporting retention in HIV care through a holistic, patient-centred approach: a qualitative evaluation.

BACKGROUND: HIV is a complex disease which affects different facets (social, economic, physical, emotional and spiral) of an individual's life, making the goals of retention in care and adherence to treatment difficult to achieve. Holistic patient-centred approaches to providing care for people living with HIV bind together economic, social, emotional and physiological aspects and have the potential to improve retention in care and ART adherence. Case management is a holistic, patient-centred approach which is increasingly being implemented in the management of chronic illnesses. METHODS: We conducted a qualitative study based on semi-structured interviews with key informants (retention officers and social auxiliary workers) and patients. A total of 60 patients and 17 KIs (11 retention officers and 6 social auxiliary workers) participated in the study. The study was conducted in Johannesburg District, Gauteng province, South Africa. Key informants (KIs) and patients were drawn from 8 health facilities located in four management clusters of the district. RESULTS: The findings identified facilitators and barriers to adherence and retention in care, and demonstrated that case management offered holistic, patient-centred services which patients considered to be beneficial to their well-being and helped them overcome some of these barriers. The success of case management was driven by its holistic and patient-centred approach, which extended the focus to patients' non-clinical needs which impact on their quality of life. Complex interacting barriers and facilitators at different levels influenced implementation of the model and its outcomes. CONCLUSION: Holistic approaches such as case management have a strong potential to improve retention in care and adherence to ART. HIV is a complex disease which impacts different facets of an individual's life, hence requires holistic care to address all facets. Health systems need to transition towards holistic care to ensure that some patients do not slip through the cracks, improve patient outcomes and efficiency.

Exploring healthcare workers' experiences of managing patients returning to HIV care in Johannesburg, South Africa.

BACKGROUND: Retention of patients in HIV care is a critical barrier to reaching the UNAIDS 90-90-90 goals in South Africa. In January 2019, Anova Health Institute launched a campaign to encourage patients who had interrupted antiretroviral therapy to return to care. The Welcome Back campaign included training of health care workers and implementation of Médecins Sans Frontiers Welcome Services principles. OBJECTIVE: The aim of this study was to explore the experiences of healthcare workers managing patients reinitiating antiretroviral therapy following training, including barriers and facilitators to implementation. METHODS: Data were collected from six clinics. This study consisted of three components: 1) surveys; 2) semi-structured interviews and 3) reflexive feedback sessions. Each component covered staff attitudes and facility management of patients reinitiating antiretroviral therapy. A descriptive analysis was conducted of survey responses. A thematic approach was used to analyze interviews. RESULTS: Thirty-six healthcare workers completed the survey and interview. Following analysis, feedback sessions were conducted with 99 healthcare workers. Twenty-two (61%) participants were lay counsellors. The majority of healthcare workers reported managing patients returning to care appropriately. However, barriers persisted: 9 (25%) responded that patients were sent to the back of the queue and that service providers continued to insist on transfer letters. Twenty-five (69%) responded they had seen/heard other healthcare workers act poorly towards returning patients after training. Many poor behaviours from healthcare workers stemmed from frustration with the clinical flow and their overburdened work environment. Many participants (78%) believed that the Welcome Back approach helped improve client-provider relationships. CONCLUSIONS: The Welcome Back approach supported healthcare workers to improve service provision for patients reinitiating antiretroviral therapy. Further support is needed to help providers consistently deliver services in line with the Welcome Back approach. Institutional level changes are required to implement patient-centred and trust-based models of care.

Risk profile of postnatal women and their babies attending a rural district hospital in South Africa.

Background: Maternal and neonatal mortality remain unacceptably high and inequitably distributed in South Africa, with the postnatal period being a dangerous time for both mother and baby. The aim of this paper is to describe the risk factors for poor postnatal outcomes, including postnatal mental health disorders, in a population of postnatal women and their babies utilising rural district hospital services in Limpopo Province, with a focus on HIV. We also describe health care provider compliance with relevant guidelines. Methods: All women discharged from the postnatal ward of the district hospital who consented to participate were enrolled. A research nurse used a structured questionnaire to collect data about sociodemographic information, pregnancy and pre-existing conditions, complications during labour and birth, pregnancy outcomes and mental health risk factors. Results: The questionnaire was completed for 882 women at the time of discharge. Only 354 (40.2%) of participants had completed secondary education, and 105 (11.9%) reported formal employment. Chronic hypertension was recorded in 20 women (2.3%), with an additional 49 (5.6%) developing a hypertensive disorder during pregnancy. HIV prevalence was 22.8%. 216 women (24.5%) had a mental health risk factor, with 40 reporting more than one (4.5%). Having no income, no antenatal care, having HIV and any hypertensive disorder were significantly associated with a positive mental health risk screen in multivariable analysis. There were 31 stillbirths and early neonatal deaths (3.5%), and 119 babies (13.4%) were born at a low birth weight. Stillbirth or early neonatal death was significantly associated with no antenatal care in multivariable analysis. Conclusions: Women and babies in this study experienced multiple risk factors for poor outcomes in the postpartum period. Postnatal care should be strengthened in order to address the dominant risks to mothers and babies, including socioeconomic challenges, HIV and hypertension, and risks to mental health. Tools to identify mothers and babies at risk of postnatal complications would allow limited resources to be allocated where they are most needed.

Why do patients interrupt and return to antiretroviral therapy? Retention in HIV care from the patient's perspective in Johannesburg, South Africa.

BACKGROUND: Retention in care is required for optimal clinical outcomes in people living with HIV (PLHIV). Although most PLHIV in South Africa know their HIV status, only 70% are on antiretroviral therapy (ART). Improved retention in care is needed to get closer to sustained ART for all. In January 2019, Anova Health Institute conducted a campaign to encourage patients who had interrupted ART to return to care. METHODS: Data collection was conducted in one region of Johannesburg. This mixed methods study consisted of two components: 1) healthcare providers entered data into a structured tool for all patients re-initiating ART at nine clinics over a nine-month period, 2) Semi-structured interviews were conducted with a sub-set of patients. Responses to the tool were analysed descriptively, we report frequencies, and percentages. A thematic approach was used to analyse participant experiences in-depth. RESULTS: 562 people re-initiated ART, 66% were women, 75% were 25-49 years old. The three most common reasons for disengagement from care were mobility (30%), ART related factors (15%), and time limitations due to work (10%). Reasons for returning included it becoming easier to attend the clinic (34%) and worry about not being on ART (19%). Mobile interview participants often forgot their medical files and expressed that managing their ART was difficult because they often needed a transfer letter to gain access to ART at another facility. On the other hand, clinics that had flexible and extended hours facilitated retention in care. CONCLUSION: In both the quantitative data, and the qualitative analysis, changing life circumstances was the most prominent reason for disengagement from care. Health services were not perceived to be responsive to life changes or mobility, leading to disengagement. More client-centred and responsive health services should improve retention on ART.

Indicator-focussed technical assistance in South Africa's HIV programme: A stepped-wedge evaluation.

BACKGROUND: There is a lack of research on technical assistance (TA) interventions in low- and middle-income countries. Variation in local contexts requires tailor-made approaches to TA that are structured and replicable across intervention sites whilst retaining the flexibility to adapt to local contexts. We developed a systematic process of TA using multidisciplinary roving teams to provide support across the various elements comprising local HIV services. OBJECTIVES: To examine the effectiveness of targeting specific HIV and TB programme indicators for improvement using roving teams. METHOD: We conducted a cluster-randomised stepped-wedge evaluation of a TA support package focussing on clinical, managerial and pharmacy services in the Mopani district of the Limpopo province, South Africa (SA). Three roving teams delivered the intervention. Seventeen primary and community healthcare centres that had 400-600 patients on antiretroviral therapy (ART) were selected for inclusion. The TA package was implemented for six consecutive months across facilities until all had received the same level of support. Data were collected from the relevant health management information systems for 11 routine indicators. RESULTS: The mean proportion of PLWH screened for tuberculosis (TB) at ART initiation increased from 85.2% to 87.2% (P = 0.65). Rates of retention in care improved, with the mean proportion of patients retained in care at three months post-ART initiation increasing from 79.9% to 87.4% (P < 0.001) and from 70.3% to 77.7% (P < 0.01) after six months. Finally, the mean proportion of patients with TB who completed their treatment increased from 80.6% to 82.1% (P = 0.75). CONCLUSION: Tailored TA interventions in SA using a standardised structure and process led to a significant improvement in retention-in-care rates and to non-significant improvements in the proportion of PLWH screened for TB and of those who completed their treatment.

Mother-to-child transmission of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis in HIV-infected pregnant women in South Africa.

BACKGROUND: Sexually transmitted infections (STIs) can be transmitted from mother to neonate. We determined the frequency of mother-to-child transmission (MTCT) of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis to the newborn nasopharynx. METHODS: This study was nested in a cohort study of etiologic testing versus syndromic management for STIs among pregnant women living with human immunodeficiency virus in South Africa. Mothers were tested for STIs using the GeneXpert platform within 60 days after delivery. Nasopharyngeal swabs were obtained from newborns of mothers with a positive STI test; these were then tested by Xpert® on the same day based on the maternal STI diagnosis. RESULTS: We tested nasopharyngeal swabs from 85 STI-exposed newborns; 74 (87%) were tested within 2 weeks after birth (median five; range 2-12 days). MTCT frequency of any STI was 30/74 (41%); 43% (23/53) for C. trachomatis, 29% (2/7) for N. gonorrhoeae, and 24% (6/25) for T. vaginalis. Also, 4/11 (36%) swabs obtained between 14 and 60 days after delivery tested positive for STI. CONCLUSIONS: There was a high frequency of MTCT of STIs to the nasopharynx of newborns in our setting. The impact of nasopharyngeal colonization and the benefits of STI testing on newborn health remain to be determined.

High rate of loss to follow-up and virological non-suppression in HIV-infected children on antiretroviral therapy highlights the need to improve quality of care in South Africa.

Provision of high-quality care and ensuring retention of children on antiretroviral therapy (ART) are essential to reduce human immunodeficiency virus (HIV)-associated morbidity and mortality. Virological non-suppression (≥1000 viral copies/ml) is an indication of suboptimal HIV care and support. This retrospective cohort study included ART-naïve children who initiated first-line ART between July 2015 and August 2017 in Johannesburg and rural Mopani district. Of 2739 children started on ART, 29.5% (807/2739) were lost to care at the point of analysis in August 2018. Among retained children, overall virological non-suppression was 30.2% (469/1554). Virological non-suppression was associated with higher loss to care 30.3% (229/755) compared with suppressed children (9.7%, 136/1399, P < 0.001). Receiving treatment in Mopani was associated with virological non-suppression in children under 5 years (adjusted odds ratio (aOR) 1.7 (95% confidence interval (CI) 1.1-2.4), 5-9 years (aOR 1.8 (1.1-3.0)) and 10-14 years (aOR 1.9 (1.2-2.8)). Virological non-suppression was associated with lower CD4 count in children 5-9 years (aOR 2.1 (1.1-4.1)) and 10-14 years (aOR 2.1 (1.2-3.8)). Additional factors included a shorter time on ART (<5 years aOR 1.8-3.7 (1.3-8.2)), and male gender (5-9 years, aOR1.5 (1.01-2.3)), and receiving cotrimoxazole prophylaxis (10-14 years aOR 2.0 (1.2-3.6)). In conclusion, virological non-suppression is a factor of subsequent programme loss in both regions, and factors affecting the quality of care need to be addressed to achieve the third UNAIDS 90 in paediatric HIV.

Single-Dose Azithromycin for Genital Lymphogranuloma Venereum Biovar Chlamydia trachomatis Infection in HIV-Infected Women in South Africa: An Observational Study.

ABSTRACT: We conducted an observational study of lymphogranuloma venereum (LGV) biovar Chlamydia trachomatis infection in HIV-infected women in South Africa. The LGV biovar was detected in vaginal specimens of 17 (20%) of 85 women with C. trachomatis infection; 29% were symptomatic. All cases were negative for the LGV biovar after single-dose azithromycin.

Increases in HIV status disclosure and sexual communication between South African men who have sex with men and their partners following use of HIV self-testing kits.

Availability of HIV self-testing may increase HIV testing frequency among men who have sex with men (MSM). It is unclear, however, if self-testing may impact HIV-related sexual behaviors among MSM, including HIV status disclosure and condom use. We conducted a mixed methods analysis of changes in HIV-related behaviors after HIV self-testing introduction, using data from 110 MSM participating in a feasibility and acceptability study of HIV self-testing in Mpumalanga Province, South Africa. We found increased HIV status disclosure from study participants to sexual partners after HIV self-testing introduction, from 61.8% at baseline to 75.5% at 6-month follow-up (p = 0.04), but decreased condom use with female partners (p = 0.03). Qualitative interviews reveal that some participants used test results to inform condom use. Distribution of self-testing kits can improve mutual disclosure, but should be accompanied by information stressing that the tests may not detect early HIV infections or other sexually transmitted infections.

Building self-advocacy in HIV care: the use of role-play to examine healthcare access for HIV-positive MSM in rural South Africa.

There is high HIV prevalence and low rates of viral suppression for men who have sex with men (MSM) in South Africa, with few MSM-centered interventions to address these outcomes along the HIV treatment cascade. Participatory interventions may support community building among HIV-positive MSM through which they can share approaches of self-advocacy that are contextually grounded. We conducted a pilot study to assess the use of role-plays in influencing social isolation while also updating our understanding of MSM healthcare experiences in Mpumalanga, South Africa. The study was conducted with 21 MSM leaders who were HIV-positive. There were three groups of seven participants each who created and performed role-plays based on their healthcare experiences, with a focus group discussion (FGD) conducted afterward. Audio-recordings were transcribed, translated, and analyzed using a constant comparison approach. We found that MSM described role-play as cathartic and a future HIV care educational tool for other MSM, and that they outlined points of self-advocacy during HIV care in clinics. Our study suggests that future research should utilize role-play so to integrate contextual factors influencing HIV treatment, especially in high HIV prevalence settings.

Antimicrobial Resistance of Neisseria gonorrhoeae Isolates from High-Risk Men in Johannesburg, South Africa.

Neisseria gonorrhoeae antimicrobial drug resistance has emerged worldwide; however, the situation in sub-Saharan Africa is not well documented. We investigated the molecular epidemiology and occurrence of antimicrobial resistance in Neisseria gonorrhoeae infections in two core transmission groups of men in Johannesburg, South Africa. We recruited men who have sex with men (MSM) presenting with urethral discharge and men with recurrent episodes of urethral discharge. Molecular testing and culture for N. gonorrhoeae were performed, followed by antimicrobial susceptibility testing. Whole-genome sequencing (WGS) was used to identify resistance-conferring mutations and to determine the genetic relatedness of the isolates. In all, 51 men were recruited; 42 (82%) had N. gonorrhoeae infections. Most gonococcal isolates were resistant to ciprofloxacin (78%) and tetracycline (74%); 33% were penicillin resistant. All gonococcal isolates were susceptible to cephalosporins and spectinomycin. Azithromycin resistance was observed in 4 (15%) isolates (epidemiological cutoff), all with mutations in the mtrR promoter region. Most of the isolates (19/27) harbored the gonococcal genetic island, which is associated with antimicrobial resistance. WGS revealed a diverse epidemic with mostly novel NG-STAR (70%) and NG-MAST (70%) sequence types. Thus, we demonstrate a high prevalence of antimicrobial resistance in Neisseria gonorrhoeae strains obtained from high-risk men in South Africa. The introduction of diagnostics and scale-up of surveillance are warranted to prevent the emergence of multidrug-resistant infections.