Factors Related to Incomplete Adherence to Antiretroviral Therapy among Adolescents Attending Three HIV Clinics in the Copperbelt, Zambia.

Little is known about adherence to antiretroviral therapy (ART) among adolescents in sub-Saharan Africa, where the majority of the world's HIV-positive adolescents reside. We assessed individual, household, and HIV self-management characteristics associated with a 48-hour treatment gap in the preceding 3 months, and a pharmacy medication possession ratio (MPR) that assessed the number of ART pills dispensed divided by the number of ART pills required in the past 6 months, among 285 Zambians, ages 15-19 years. Factors significantly associated with a 48-hour treatment gap were being male, not everyone at home being aware of the adolescent's HIV status, and alcohol use in the past month. Factors associated with an MPR < 90% included attending the clinic alone, alcohol use in the past month, and currently not being in school. Findings support programs to strengthen adolescents' HIV management skills with attention to alcohol use, family engagement, and the challenges adolescents face transitioning into adulthood, especially when they are no longer in school.

Expanding Understanding of Community Health Worker Programs: A Cross-Sectional Survey on the Work, Satisfaction, and Livelihoods of CHWs in Madagascar.

With health worker shortages in rural areas, community health workers (CHWs) are instrumental to the sustainability of primary health care and to the ability to meet health needs. Identifying appropriate operational models and incentive structures is an important element of long-term success. This article reports on CHWs' work demands and affective response to their volunteer work within the broader context of their livelihoods in Madagascar. A cross-sectional survey of 874 CHWs, called Agents de Santé Communautaire (ACs), from 14 districts across 5 regions was conducted in June 2015. Only 44% of ACs had cash savings. Subsistence farming was the main livelihood strategy; ninety-two percent of ACs were food insecure and 89% had experienced a shock in the past year. Overall, 77% of ACs financed commodity resupply through sales of health products and 18% from their personal savings; stock-outs at point of supply and financial and time constraints were the main reported challenges in getting health products. The average satisfaction score with AC work was 3 out of 4. This assessment from Madagascar helps unveil a more comprehensive view of the reality of CHWs' lives. Managers need to take into account the potential implications of the demands of CHW work on already precarious livelihoods.

Experiences with the levonorgestrel-releasing intrauterine system in Kenya: qualitative interviews with users and their partners.

OBJECTIVES: The levonorgestrel-releasing intrauterine system (LNG-IUS) is an underused contraceptive method in sub-Saharan Africa. A recent market assessment in Kenya found that if a more affordable version of the method were available it may increase demand and uptake of the method. We therefore aimed to examine attitudes and perceptions around the LNG-IUS and experiences of method use, including exploring attributes such as bleeding changes, contraceptive-related amenorrhoea and perceived non-contraceptive benefits. METHODS: Qualitative interviews were conducted among 29 women who were current or recent users of the LNG-IUS, and among a subset (n = 9) of their husbands/partners. RESULTS: Our findings indicate that women's main reason for choosing the LNG-IUS for contraception was their perception that the method had fewer side effects compared with other contraceptive methods. Women had favourable attitudes towards using the LNG-IUS. Husbands were also very positive about their partner's use of the method. CONCLUSION: Understanding the motivations and experiences of early adopters of the LNG-IUS can help inform the development of demand creation and communication strategies to influence uptake and continuation of the LNG-IUS both in Kenya and perhaps more broadly. Communication efforts that emphasise the positive attributes of the LNG-IUS could help promote wider use of the method, especially if new, more affordable product(s) become available.

Integrating Family Planning and HIV Services at the Community Level: Formative Assessment with Village Health Teams in Uganda.

Little is known on integrating HIV and family planning (FP) services in community settings. Using a cluster randomized controlled design, we conducted a formative assessment in two districts in Uganda where community health workers, called VHTs, already offered FP. Thirty-six trained VHTs also provided HIV testing and counseling (HTC) during the intervention. We surveyed all 36 VHTs and 256 FP clients, and reviewed service statistics. In the intervention group, VHTs tested 80% of surveyed clients for HIV, including 76% they already saw for FP and 22% who first came to them for HTC before receiving FP. Comparing clients' experiences in the intervention and control groups, adding HTC does not appear to have negatively affected FP service quality. VHTs reported more monthly clients, but rated their workload as easy to manage. This integrated model seems feasible and beneficial for both VHTs and clients, while not resulting in any negative effects. This study was registered with ClinicalTrials.gov, number [NCT02244398].

A dynamic spatiotemporal extracellular matrix facilitates epicardial-mediated vertebrate heart regeneration.

Unlike humans, certain adult vertebrates such as newts and zebrafish possess extraordinary abilities to functionally regenerate lost appendages and injured organs, including cardiac muscle. Here, we present new evidence that a remodeled extracellular matrix (ECM) directs cell activities essential for cardiac muscle regeneration. Comprehensive mining of DNA microarrays and Gene Ontology term enrichment analyses for regenerating newt and zebrafish hearts revealed that distinct ECM components and ECM-modifying proteases are among the most significantly enriched genes in response to local injury. In contrast, data analyses for mammalian cardiac injury models indicated that inflammation and metabolic processes are the most significantly activated gene groups. In the regenerating newt heart, we show dynamic spatial and temporal changes in tenascin-C, hyaluronic acid, and fibronectin ECM distribution as early as 3 days postamputation. Linked to distinct matrix remodeling, we demonstrate a myocardium-wide proliferative response and radial migration of progenitor cells. In particular, we report dramatic upregulation of a regeneration-specific matrix in the epicardium that precedes the accumulation and migration of progenitor cells. For the first time, we show that the regenerative ECM component tenascin-C significantly increases newt cardiomyocyte cell cycle reentry in vitro. Thus, the engineering of nature-tested extracellular matrices may provide new strategic opportunities for the enhancement of regenerative responses in mammals.

The experience of diagnostic radiography students during the early stages of the COVID-19 pandemic - a cross-sectional study.

INTRODUCTION: The rationale for this study was to ascertain the impact of the COVID-19 pandemic on Undergraduate B.Sc (Hons) Diagnostic Radiography students at the University of Hertfordshire in the UK. This would provide an ideal opportunity for students to reflect on their experience and indicate if they required additional support from the University. METHODS: An online anonymous cross-sectional survey was deployed to all year groups (n = 283) during the first nationwide lockdown in May 2020, eliciting qualitative responses on questions about the effect of the pandemic; emotions experienced; support required and consideration of their choice of a career in the health sector. RESULTS: Two hundred and one students responded to the survey, with many having experienced the illness or loss of a loved one. Trying to balance family commitments and study was a concern to some students, as well as struggling with the financial burden of job losses or furlough. Many students commented that educational support was a requirement with the move to online teaching and assessment. The main focus of student responses was the emotions that they had experienced, many of which were negative. Anxiety and fear were commonly expressed feelings, along with sadness and feelings of isolation. A small number of students reported feeling grateful, happy and relieved. An overwhelming majority of respondents commented that they were proud to be healthcare students and they were resolute in wanting to continue the course and join the frontline of the NHS workforce. CONCLUSION: Some students have been deeply affected by their experiences of the pandemic, and University support mechanisms should be refined to better assist with their ongoing challenges.

Polyetheretherketone (PEEK) Rods for Lumbar Fusion: A Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this systematic review is to evaluate the safety and effectiveness of polyetheretherketone (PEEK) rod systems in patients receiving lumbar interbody fusion treatment. Meta-analyses of relevant clinical data were also conducted when possible. METHODS: Relevant studies were identified by searching the PubMed, EMBASE, and Cochrane Library databases. Clinical studies evaluating the safety and/or effectiveness of the PEEK rod spinal stabilization system in patients receiving lumbar spinal fusion procedure were included. Studies regarding dynamic stabilization and hybrid stabilization (fixed and dynamic; eg, topping-off technique) were not included in this analysis. The analyses included patients who had a lumbar fusion procedure with PEEK rods or titanium rods as a control reference (only for controlled studies). Fusion success, functional and pain improvement, and safety data were evaluated, if reported. RESULTS: The search yielded 5 studies (1 prospective and 4 retrospectives) that included 177 participants (156 received PEEK rods, and 21 received titanium rods). Meta-analysis of interbody fusion success rate in PEEK rod patients yields the estimate of 95.6% (confidence interval: 91.6% to 98.4%). Functional outcomes in PEEK rod patients demonstrated clinically significant improvement when comparing postoperative to preoperative scores, with an average improvement of 67.4% ± 8.5%. Similarly, pain improvement was clinically significant with an average visual analog scores-back pain and visual analog scores-leg pain improvement percentages of 68.9% ± 8.6% and 76.6% ± 1.5%, respectively. Rod fracture was not reported in any of the studies. The rates of screw fracture and loosening were 3/114 (2.6%) and 1/50 (2.0%), respectively. In the controlled study, no statistically significant difference was reported in the fusion success rate, function improvement, pain improvement, or device-related events between subjects treated with PEEK rods and the subjects treated with titanium rods. CONCLUSIONS: Experience with PEEK rod systems has shown satisfactory clinical outcomes. Therefore, these results support the use of PEEK rod systems as supplemental fixation during lumbar fusion procedures.

Adolescents living with HIV in the Copperbelt Province of Zambia: Their reproductive health needs and experiences.

BACKGROUND: Understanding and meeting the reproductive health needs of adolescents living with HIV (ALHIV) is a growing concern since advances in antiretroviral therapy mean that many ALHIV are now living into adulthood and starting to have sex. METHODS: We conducted a mixed-methods study in the Copperbelt Province of Zambia to advance our understanding of the reproductive health needs of ALHIV and to assess the extent to which these needs are being met. We conducted in-depth interviews (IDIs) with 32 ALHIV from two HIV clinics, 23 with their caregivers, and 10 with clinic staff. ALHIV were interviewed twice. We used the data from the qualitative interviews to create a cross-sectional survey that we conducted with 312 ALHIV in three HIV clinics. FINDINGS: The vast majority of ALHIV reported they wanted to have children in the future but lacked knowledge about preventing mother-to-child transmission. Some sexually active adolescents used condoms, although they wanted more information about and access to non-condom methods. Many ALHIV reported that their first sexual encounters were forced. Religious beliefs prevented some caregivers from discussing premarital sex and contraception with ALHIV. Clinic staff and caregivers had mixed views about integrating contraceptive counseling and method provision into HIV care and treatment services. Few sexually active ALHIV reported that they disclosed their HIV status to their sexual partners and few reported that they knew their sexual partner's status. CONCLUSIONS: ALHIV are in dire need of comprehensive sexual and reproductive health services and information including a range of contraceptive methods to prevent pregnancy, knowledge about preventing mother-to-child transmission and having a healthy pregnancy, skills related to HIV disclosure and condom negotiation to prevent horizontal transmission, and screening for sexual violence for both males and females if services are available.

Evaluation of a male engagement intervention to transform gender norms and improve family planning and HIV service uptake in Kabale, Uganda.

Men's limited understanding of family planning (FP) and harmful cultural gender norms pose obstacles to women's FP use. Thirty-two model men called 'Emanzis' were recruited from the community in Kabale, Uganda to lead men from their peer group through a 10-session curriculum designed to transform gender norms and motivate men to engage in FP and HIV services. Cross-sectional surveys were conducted before (n = 1251) and after (n = 1122) implementation. The Gender Equitable Men (GEM) Scale was used to assess the effect on gender attitudes. The intervention achieved negligible changes in responses to GEM items. Improvements in some gender-influenced health-seeking behaviours and practices in men were noted, specifically in visiting health facilities, HIV testing, and condom use. For future application, the intervention should be adapted to require higher peer educator qualifications, longer intervention duration, and more frequent supervision. Practical guidance is needed on where to direct investments in gender-transformative approaches for maximum impact.

Expanding HIV testing and counselling into communities: Feasibility, acceptability, and effects of an integrated family planning/HTC service delivery model by Village Health Teams in Uganda.

Improving HIV testing and counselling (HTC) requires a range of strategies. This article reports on HTC service delivery by Village Health Teams (VHTs) in Uganda in the context of a model integrating this new component into pre-existing family planning services. Eight health centres from matched pairs were randomly allocated to intervention or control. After being trained, 36 VHTs reporting to selected facilities in the intervention group started offering HTC along with family planning, while VHTs in the control group provided family planning only. Proficiency testing was conducted as external quality assurance. A survey of all 36 VHTs and 137 family planning clients in the intervention group and 119 clients in the control group and a review of record data were conducted after 10 months. Survey responses by VHTs and their clients in the intervention group demonstrate knowledge of counselling messages and safe testing. External quality assessment results provide additional evidence of competency. Eighty per cent of the family planning clients surveyed in the intervention group received an HIV test during the intervention; 27% of those were first-time testers. More clients had ever tested for HIV in the intervention group compared with the control; clients also retested more often. Findings indicate that this model is feasible and acceptable for expanding quality HTC into communities. This study was registered with ClinicalTrials.gov, number [NCT02244398].

Conducting an audit to improve the facilitation of emergency maternal and newborn referral in northern Ghana.

Ghana Health Service conducted an audit to strengthen the referral system for pregnant or recently pregnant women and newborns in northern Ghana. The audit took place in 16 facilities with two 3-month cycles of data collection in 2011. Midwife-led teams tracked 446 referred women until they received definitive treatment. Between the two audit cycles, teams identified and implemented interventions to address gaps in referral services. During this time period, we observed important increases in facilitating referral mechanisms, including a decrease in the dependence on taxis in favour of national or facility ambulances/vehicles; an increase in health workers escorting referrals to the appropriate receiving facility; greater use of referral slips and calling ahead to alert receiving facilities and higher feedback rates. As referral systems require attention from multiple levels of engagement, on the provider end we found that regional managers increasingly resolved staffing shortages; district management addressed the costliness and lack of transport and increased midwives' ability to communicate with pregnant women and drivers; and that facility staff increasingly adhered to guidelines and facilitating mechanisms. By conducting an audit of maternal and newborn referrals, the Ghana Health Service identified areas for improvement that service providers and management at multiple levels addressed, demonstrating a platform for problem solving that could be a model elsewhere.

Repeat use of emergency contraceptive pills in urban Kenya and Nigeria.

CONTEXT: Little is known about the frequency and patterns of use of emergency contraceptive pills among women in urban Kenya and Nigeria. METHODS: To recruit women who had used emergency contraceptive pills, individuals aged 18-49 were intercepted and interviewed at shopping venues in Nairobi, Kenya, and Lagos, Nigeria, in 2011. Information was collected on 539 Nairobi and 483 Lagos respondents' demographic and behavioral characteristics, attitudes toward the method, and frequency of use. Multinomial logistic regression analyses were used to identify associations between these characteristics and frequency of pill use. RESULTS: Eighteen percent of the women interviewed in Nairobi and 17% in Lagos had ever used emergency contraceptive pills. On average, these respondents had used the pills less than once per month, but greater use and acceptance were seen in Lagos. In multivariate analysis, women who had sex at least once in a typical week were generally more likely than others to have used the pills 2-5 times in the last six months, rather than once or never, or to have used them six or more times. Furthermore, Lagos respondents who said their main contraceptive method was the condom, the pill or injectable, or a natural method were generally less likely than those who did not report these methods to have used the emergency pills multiple times in the last six months. CONCLUSIONS: Repeated use of emergency contraceptive pills was not common in this sample.

Getting closer to people: family planning provision by drug shops in Uganda.

BACKGROUND: Private-sector drug shops are often the first point of health care in sub-Saharan Africa. Training and supporting drug shop and pharmacy staff to provide a wide range of contraceptive methods and information is a promising high-impact practice for which more information is needed to fully document implementation experience and impact. METHODS: Between September 2010 and March 2011, we trained 139 drug shop operators (DSOs) in 4 districts of Uganda to safely administer intramuscular DMPA (depot medroxyprogesterone acetate) contraceptive injections. In 2012, we approached 54 of these DSOs and interviewed a convenience sample of 585 of their family planning clients to assess clients' contraceptive use and perspectives on the quality of care and satisfaction with services. Finally, we compared service statistics from April to June 2011 from drug shops, community health workers (CHWs), and government clinics in 3 districts to determine the drug shop market share of family planning services. RESULTS: Most drug shop family planning clients interviewed were women with low socioeconomic status. The large majority (89%) were continuing family planning users. DMPA was the preferred contraceptive. Almost half of the drug shop clients had switched from other providers, primarily from government health clinics, mostly as a result of more convenient locations, shorter waiting times, and fewer stock-outs in drug shops. All clients reported that the DSOs treated them respectfully, and 93% trusted the drug shop operator to maintain privacy. Three-quarters felt that drug shops offered affordable family planning services. Most of the DMPA clients (74%) were very satisfied with receiving their method from the drug shop and 98% intended to get the next injection from the drug shop. Between April and June 2011, clinics, CHWs, and drug shops in 3 districts delivered equivalent proportions of couple-years of protection, with drug shops leading marginally at 36%, followed by clinics (33%) and CHWs (31%). CONCLUSION: Drug shops can be a viable and convenient source of short-acting contraceptive methods, including DMPA, serving as a complement to government services. Family planning programs in Uganda and elsewhere should consider including drug shops in the network of community-based family planning providers.

Multi-tissue microarray analysis identifies a molecular signature of regeneration.

The inability to functionally repair tissues that are lost as a consequence of disease or injury remains a significant challenge for regenerative medicine. The molecular and cellular processes involved in complete restoration of tissue architecture and function are expected to be complex and remain largely unknown. Unlike humans, certain salamanders can completely regenerate injured tissues and lost appendages without scar formation. A parsimonious hypothesis would predict that all of these regenerative activities are regulated, at least in part, by a common set of genes. To test this hypothesis and identify genes that might control conserved regenerative processes, we performed a comprehensive microarray analysis of the early regenerative response in five regeneration-competent tissues from the newt Notophthalmus viridescens. Consistent with this hypothesis, we established a molecular signature for regeneration that consists of common genes or gene family members that exhibit dynamic differential regulation during regeneration in multiple tissue types. These genes include members of the matrix metalloproteinase family and its regulators, extracellular matrix components, genes involved in controlling cytoskeleton dynamics, and a variety of immune response factors. Gene Ontology term enrichment analysis validated and supported their functional activities in conserved regenerative processes. Surprisingly, dendrogram clustering and RadViz classification also revealed that each regenerative tissue had its own unique temporal expression profile, pointing to an inherent tissue-specific regenerative gene program. These new findings demand a reconsideration of how we conceptualize regenerative processes and how we devise new strategies for regenerative medicine.

Use of antibiotic resistance analysis for representativeness testing of multiwatershed libraries.

The use of antibiotic resistance analysis (ARA) for microbial source tracking requires the generation of a library of isolates collected from known sources in the watershed. The size and composition of the library are critical in determining if it represents the diversity of patterns found in the watershed. This study was performed to determine the size that an ARA library needs to be to be representative of the watersheds for which it will be used and to determine if libraries from different watersheds can be merged to create multiwatershed libraries. Fecal samples from known human, domesticated, and wild animal sources were collected from six Virginia watersheds. From these samples, enterococci were isolated and tested by ARA. Based on cross-validation discriminant analysis, only the largest of the libraries (2,931 isolates) were found to be able to classify nonlibrary isolates as well as library isolates (i.e., were representative). Small libraries tended to have higher average rates of correct classification, but were much less able to correctly classify nonlibrary isolates. A merged multiwatershed library (6,587 isolates) was created and was found to be large enough to be representative of the isolates from the contributing watersheds. When isolates that were collected from the contributing watersheds approximately 1 year later were analyzed with the multiwatershed library, they were classified as well as the isolates in the library, suggesting that the resistance patterns are temporally stable for at least 1 year. The ability to obtain a representative, temporally stable library demonstrates that ARA can be used to identify sources of fecal pollution in natural waters.