The cyclical cascade of HIV care: Temporal care engagement trends within a population-wide cohort.

BACKGROUND: The traditional HIV treatment cascade aims to visualise the journey of each person living with HIV from diagnosis, through initiation on antiretroviral therapy (ART) to treatment success, represented by virological suppression. This representation has been a pivotal tool in highlighting and quantifying sequential gaps along the care continuum. There is longstanding recognition, however, that this may oversimplify the complexity of real-world engagement with HIV services in settings with mature high-burden HIV epidemics. A complementary "cyclical" cascade has been proposed to represent the processes of disengagement at different points on the care continuum, with multiple pathways to re-engagement, although the feasibility of implementing this at scale has been uncertain. This study aimed to populate, refine, and explore the utility of a cyclical representation of the HIV cascade, using routine data from a high-burden HIV setting. METHODS AND FINDINGS: This observational cohort study leveraged person-level data on all people living with HIV in the Western Cape (WC), South Africa, who accessed public health services in the 2 years prior to 31 December 2023. Programme data from disease registers were complemented by data from pharmacy and laboratory systems. At study closure, 494 370 people were included, constituting 93% of those of those estimated to be living with HIV in the province, of whom 355 104 were on ART. Substantial disengagement from HIV care was evident at every point on the cascade. Early treatment emerged as a period of higher risk of disengagement, but it did not account for the majority of disengagement. Almost all those currently disengaged had prior experience of treatment. While re-engagement was also common, overall treatment coverage had increased slowly over 5 years. The transition to dolutegravir-based regimens was dramatic with good virological outcomes for those in care, notwithstanding a clearly discernible impact of the Coronavirus Disease 2019 (COVID-19) pandemic on viral load (VL) testing. People currently engaged and disengaged in care are similar with respect to age and gender. Those who died or disengaged recently were previously distributed across a range of cascade statuses, and a substantial proportion of those newly initiating and re-initiating treatment were no longer on treatment 6 months later. The main limitation of this study was incomplete evidence of HIV testing, linkage to HIV-specific services, and out-of-facility mortality. CONCLUSIONS: Using routine data, it was possible to populate and automate a cyclical cascade of HIV care that continuously captured the nonlinear care journeys of individuals living with HIV. In this generalised mature HIV epidemic, most people are treatment experienced. Disengagement is common and occurs at various points along the cascade, making it challenging to identify high-impact intervention opportunities. While historical HIV cascades remain valuable for target setting and service monitoring, they can be complemented with insights from more detailed cyclical cascades.

"Sex without fear": exploring the psychosocial impact of oral HIV pre-exposure prophylaxis on gay men in England.

Gay, bisexual, and other men who have sex with men (GBMSM) experience a high prevalence of psychosocial health problems, such as harmful substance use and depression, as well as being disproportionately affected by HIV. HIV Pre-Exposure Prophylaxis (PrEP) may provide psychosocial benefits beyond its intended purpose of reducing HIV infection. We explore the psychosocial impact of oral PrEP use on gay men in England using qualitative data from the PROUD study. From February 2014 to January 2016, semi-structured in-depth interviews were conducted with 40 gay men and one trans woman. Participants were purposively recruited based on trial arm allocation, adherence, and sexual risk behaviours. By removing HIV risk from sex, PrEP improves users' wellbeing by reducing HIV-related anxiety and internalised stigma and increasing HIV prevention self-efficacy, sexual pleasure, and intimacy. In turn, these psychological changes may influence behaviour in the form of greater sexual freedom, reduced harmful drug use, and more protective sexual health behaviours. However, PrEP may create internal conflict for some gay men, due to its disruption of social norms around condom use and its perceived influence on their sexual behaviour leading to reduced condom self-efficacy. These findings provide a baseline of PrEP's psychosocial impact amongst some of the first PrEP users in England and supports calls to consider the psychosocial impact of PrEP in prescribing guidelines.

Establishing the health and wellbeing needs of mining host community in Brazil, Chile and Peru: a mixed-method approach to identify priority areas for action to help communities meet their SDG3 targets.

BACKGROUND: The global mining industry is an important partner in advancing the 2030 Agenda for Sustainable Development. In 2018, Anglo American plc published their Sustainable Mining Plan, containing a goal for improving health and wellbeing aligned with the Sustainable Development Goal 3 (SDG3) targets. Having formed an independent multidisciplinary research consortium, we designed and implemented a mixed-methods approach to attain a deeper understanding of SDG3 priorities within the local context of communities hosting Anglo American mining operations located in Latin America. METHODS: In 2019, within the host communities of three mining operations in Chile, three in Brazil, and one in Peru, we conducted a qualitative study which included stakeholder workshops and key informant interviews. We also quantitatively appraised existing health data. Findings emerging from the qualitative and quantitative assessments were compared to identify health and wellbeing priority areas for action relevant to each community. RESULTS: Across the three countries, 120 people took part in workshops and 35 in interviews. In these workshops and interviews, non-communicable diseases (SDG3.4), harmful alcohol consumption (SDG3.5), and pollution, particularly air pollution (SDG3.9), were consistently identified as areas for priority action. There were similarities in the reporting of individual, interpersonal, community, societal, and structural factors underlying these priority areas across the different communities. The availability of quantitative data was generally good at the state level, becoming increasing sparse as we focused on smaller geographies. The priorities identified in the quantitative assessments generally aligned with those highlighted in the qualitative data. CONCLUSIONS: We highlight the importance of engaging with local populations to understand and address health needs. To address the priorities identified, intervention packages tailored to the specific needs of host communities, that tackle associated upstream societal level factors, are required. To facilitate this, appropriate monitoring systems and epidemiological investigations should be implemented to better understand the local context and quantify health issues. In the host communities, it is essential for the mining sector to be a key health partner in promoting integrated programmes that contribute to achieving the priority objectives and targets aligned with the SDG3 agenda.

Health and wellbeing needs and priorities in mining host communities in South Africa: a mixed-methods approach for identifying key SDG3 targets.

BACKGROUND: The global mining industry has an opportunity to mobilize resources to advance progress against the Sustainable Development Goals (SDGs). In 2018, the Anglo-American Group outlined aspirations for mining host communities to meet the SDG3 health targets. To progress from aspiration to action we designed and implemented a mixed-methods approach to attain a deeper understanding of the health and wellbeing priorities within the local context of host communities of fifteen mines in South Africa. METHODS: To identify local needs and priorities relating to SDG3 targets in host communities, stakeholder workshops and key informant interviews were conducted between June and August 2019. A baseline assessment of health data, related to each of the SDG3 targets and indicators and to each host community location, was also conducted. Findings emerging from the qualitative and quantitative baseline assessments were compared to identify the extent to which health issues aligned and health and wellbeing priority areas for action. RESULTS: A total of 407 people participated in the workshops, and 85 key informants were interviewed. Quantitative data were available at sub-national level for seven of the nine SDG3 targets and eleven of the 21 indicators. Key priority areas for action identified through alignment of the qualitative and quantitative data were maternal mortality (SDG3.1), HIV (SDG3.3.1), tuberculosis (SDG3.3.2), substance abuse (SDG3.5), and road traffic accidents (SDG3.6) We found consistency in the individual, interpersonal, community, societal, and structural factors underlying these priority areas. At a structural level, poor access to quality healthcare was raised at every workshop as a key factor underlying the achievement of all SDG3 targets. Of the five priority areas identified, HIV, TB and substance abuse were found to overlap in the study communities in terms of risk, burden, and underlying factors. CONCLUSIONS: We demonstrate a mixed method approach for identifying local health needs and prioritised SDG3 targets in mining host communities. Consistency in reporting suggests the need for effective, efficient and feasible interventions to address five priority areas. Given the prominent economic role of the mining sector in South Africa, it can play a critical role in implementing programmatic activities that further progress towards achieving the SDG3 targets.

Arsenic Toxicity From the Ingestion of Terracotta Pottery.

BACKGROUND: Symptomatic arsenic toxicity has not been associated with terracotta pottery despite thousands of years of use in food storage and preparation. We describe a case of chronic arsenic toxicity from undiagnosed pica involving the ingestion of terracotta pots. CASE REPORT: A 49-year-old woman with a history of anemia and abnormal uterine bleeding presented to the Emergency Department complaining of lower extremity pain. She was also noted to have chronic lower extremity paresthesia, constipation, and fatigue. She admitted to ingesting glazed and unglazed terracotta pots for the past 5 years. This unusual craving was thought to be a manifestation of pica in the setting of chronic anemia. The patient was found to have an elevated urinary arsenic concentration of 116 µg/24 h. An abdominal radiograph showed opacifications throughout her bowel, and she received whole bowel irrigation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pica is a common behavior in certain populations. Practicing clinicians should be familiar with the complications of pica, including chronic arsenic toxicity and its associated array of nonspecific symptoms.

The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals.

Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.

Diversifying maize genomic selection models.

Genomic selection (GS) is one of the most powerful tools available for maize breeding. Its use of genome-wide marker data to estimate breeding values translates to increased genetic gains with fewer breeding cycles. In this review, we cover the history of GS and highlight particular milestones during its adaptation to maize breeding. We discuss how GS can be applied to developing superior maize inbreds and hybrids. Additionally, we characterize refinements in GS models that could enable the encapsulation of non-additive genetic effects, genotype by environment interactions, and multiple levels of the biological hierarchy, all of which could ultimately result in more accurate predictions of breeding values. Finally, we suggest the stages in a maize breeding program where it would be beneficial to apply GS. Given the current sophistication of high-throughput phenotypic, genotypic, and other -omic level data currently available to the maize community, now is the time to explore the implications of their incorporation into GS models and thus ensure that genetic gains are being achieved as quickly and efficiently as possible.

Patterns of engagement in HIV care during pregnancy and breastfeeding: findings from a cohort study in North-Eastern South Africa.

BACKGROUND: Eliminating mother-to-child transmission of HIV (MTCT) in sub-Saharan Africa is hindered by limited understanding of HIV-testing and HIV-care engagement among pregnant and breastfeeding women. METHODS: We investigated HIV-testing and HIV-care engagement during pregnancy and breastfeeding from 2014 to 2018 in the Agincourt Health and Demographic Surveillance System (HDSS). We linked HIV patient clinic records to HDSS pregnancy data. We modelled time to a first recorded HIV-diagnosis following conception, and time to antiretroviral therapy (ART) initiation following diagnosis using Kaplan-Meier methods. We performed sequence and cluster analyses for all pregnancies linked to HIV-related clinic data to categorise MTCT risk period engagement patterns and identified factors associated with different engagement patterns using logistic regression. We determined factors associated with ART resumption for women who were lost to follow-up (LTFU) using Cox regression. RESULTS: Since 2014, 15% of 10,735 pregnancies were recorded as occurring to previously (51%) or newly (49%) HIV-diagnosed women. New diagnoses increased until 2016 and then declined. We identified four MTCT risk period engagement patterns (i) early ART/stable care (51.9%), (ii) early ART/unstable care (34.1%), (iii) late ART initiators (7.6%), and (iv) postnatal seroconversion/early, stable ART (6.4%). Year of delivery, mother's age, marital status, and baseline CD4 were associated with these patterns. A new pregnancy increased the likelihood of treatment resumption following LTFU. CONCLUSION: Almost half of all pregnant women did not have optimal ART coverage during the MTCT risk period. Programmes need to focus on improving retention, and leveraging new pregnancies to re-engage HIV-positive women on ART.

Experiences and lessons learned from the real-world implementation of an HIV recent infection testing algorithm in three routine service-delivery settings in Kenya and Zimbabwe.

INTRODUCTION: Testing for recent HIV infection can distinguish recently acquired infection from long-standing infections. Given current interest in the implementation of recent infection testing algorithms (RITA), we report our experiences in implementing a RITA in three pilot studies and highlight important issues to consider when conducting recency testing in routine settings. METHODS: We applied a RITA, incorporating a limited antigen (LAg) avidity assay, in different routine HIV service-delivery settings in 2018: antenatal care clinics in Siaya County, Kenya, HIV testing and counselling facilities in Nairobi, Kenya, and female sex workers clinics in Zimbabwe. Discussions were conducted with study coordinators, laboratory leads, and facility-based stakeholders to evaluate experiences and lessons learned in relation to implementing recency testing. RESULTS: In Siaya County 10/426 (2.3%) of women testing HIV positive were classified as recent, compared to 46/530 (8.7%) of women and men in Nairobi and 33/313 (10.5%) of female sex workers in Zimbabwe. Across the study setting, we observed differences in acceptance, transport and storage of dried blood spot (DBS) or venous blood samples. For example, the acceptance rate when testing venous blood was 11% lower than when using DBS. Integrating our study into existing services ensured a quick start of the study and kept the amount of additional resources required low. From a laboratory perspective, the LAg avidity assay was initially difficult to operationalise, but developing a network of laboratories and experts to work together helped to improve this. A challenge that was not overcome was the returning of RITA test results to clients. This was due to delays in laboratory testing, the need for multiple test results to satisfy the RITA, difficulties in aligning clinic visits, and participants opting not to return for test results. CONCLUSION: We completed three pilot studies using HIV recency testing based on a RITA in Kenya and Zimbabwe. The main lessons we learned were related to sample collection and handling, LAg avidity assay performance, integration into existing services and returning of test results to participants. Our real-world experience could provide helpful guidance to people currently working on the implementation of HIV recency testing in sub-Saharan Africa.

Post-migration acquisition of HIV: Estimates from four European countries, 2007 to 2016.

BackgroundThe assumption that migrants acquire human immunodeficiency virus (HIV) before migration, particularly those from high prevalence areas, is common.AimWe assessed the place of HIV acquisition of migrants diagnosed in four European countries using surveillance data.MethodsUsing CD4+ T-cell count trajectories modelled to account for seroconversion bias, we estimated infection year of newly HIV-diagnosed migrants residing in the United Kingdom (UK), Belgium, Sweden and Italy with a known arrival year and CD4+ T-cell count at diagnosis. Multivariate analyses identified predictors for post-migration acquisition.ResultsBetween 2007 and 2016, migrants constituted 56% of people newly diagnosed with HIV in the UK, 62% in Belgium, 72% in Sweden and 29% in Italy. Of 23,595 migrants included, 60% were born in Africa and 70% acquired HIV heterosexually. An estimated 9,400 migrants (40%; interquartile range (IQR): 34-59) probably acquired HIV post-migration. This proportion was similar by risk group, sex and region of birth. Time since migration was a strong predictor of post-migration HIV acquisition: 91% (IQR: 87-95) among those arriving 10 or more years prior to diagnosis; 30% (IQR: 21-37) among those 1-5 years prior. Younger age at arrival was a predictor: 15-18 years (81%; IQR: 74-86), 19-25 years (53%; IQR: 45-63), 26-35 years (37%; IQR: 30-46) and 36 years and older (25%; IQR: 21-33).ConclusionsMigrants, regardless of origin, sex and exposure to HIV are at risk of acquiring HIV post-migration to Europe. Alongside accessible HIV testing, prevention activities must target migrant communities.

The Association of Malnutrition and Disease Conditions in Mortality of Pediatric Patients Presenting to a Rural Emergency Department in Uganda.

OBJECTIVES: The main objectives of this study were to determine the effect of concurrent malnutrition on disease condition and the primary outcome of mortality in children younger than 5 years hospitalized after presenting to a rural emergency department (ED) in Uganda and to identify a high-risk patient population who may benefit from acute ED intervention. METHODS: A retrospective, observational study was performed to examine the effect of any form of malnutrition on the primary disease conditions of lower-respiratory tract infection (LRTI), malaria, and diarrheal illness. This study was conducted via review of a quality assurance database between January 2010 and July 2014. RESULTS: Of 3428 hospitalized children, the mean age (SD) was 19.8 months (13.9 months) and 56% were boys. Children diagnosed with malaria, an LRTI, or diarrheal illness all had a higher rate of mortality with concurrent malnutrition versus those without malnutrition (malaria, 6.2% [3.6-8.8%] vs 2.8% [2.0-3.7%]; P < 0.01; LRTI, 8.7% [5.0-12.4%] vs. 3.7% [2.6-4.9%], P < 0.01; and diarrheal illness, 10.9% [1.9-19.9%] vs 1.7% [0.1-3.4%], P < 0.01). In children with an LRTI or malaria with concurrent malnutrition, they were statistically significantly less likely to have abnormal temperature and heart rate during the ED encounter than those without concurrent malnutrition. CONCLUSIONS: Based on these results, children with malnutrition and concurrent diseases with known high morbidity may not present with abnormal vital signs. This may have clinical relevance in patient management to the acute care provider in identifying and triaging children with malnutrition and acute disease conditions.

Multi-Trait Genome-Wide Association Studies Reveal Loci Associated with Maize Inflorescence and Leaf Architecture.

Maize inflorescence is a complex phenotype that involves the physical and developmental interplay of multiple traits. Given the evidence that genes could pleiotropically contribute to several of these traits, we used publicly available maize data to assess the ability of multivariate genome-wide association study (GWAS) approaches to identify pleiotropic quantitative trait loci (pQTL). Our analysis of 23 publicly available inflorescence and leaf-related traits in a diversity panel of n = 281 maize lines genotyped with 376,336 markers revealed that the two multivariate GWAS approaches we tested were capable of identifying pQTL in genomic regions coinciding with similar associations found in previous studies. We then conducted a parallel simulation study on the same individuals, where it was shown that multivariate GWAS approaches yielded a higher true-positive quantitative trait nucleotide (QTN) detection rate than comparable univariate approaches for all evaluated simulation settings except for when the correlated simulated traits had a heritability of 0.9. We therefore conclude that the implementation of state-of-the-art multivariate GWAS approaches is a useful tool for dissecting pleiotropy and their more widespread implementation could facilitate the discovery of genes and other biological mechanisms underlying maize inflorescence.

Consolidating strategic information to monitor progress against the UNAIDS 90-90-90 targets: evaluating the operational feasibility of an electronic HIV testing register in Cape Town, South Africa.

BACKGROUND: HIV diagnosis in South Africa is based on a point-of-care testing (PoCT) algorithm with paper-based record-keeping. Aggregated testing data are reported routinely. To facilitate improved HIV case-based surveillance, the Western Cape Province implemented a unique pilot intervention to digitise PoCT results, at an individual level, and generate an electronic register using the newly developed Provincial Health Data Centre (PHDC). We describe the intervention (phased) and present an evaluation of the operational feasibility of the intervention. We also offer implementation insights into establishing electronic capture of individual level testing data. METHODS: Cross-sectional analyses were conducted on records of all patients attending a local Community Health Centre who had an HIV-PoCT during the study period. Data from the intervention were linked to the PHDC using a unique identifier and compared with aggregate data from the paper-based register. Correlation coefficients were calculated to quantify the correlation between the two monthly datasets. To support an understanding of the findings, the Department of Health project management team generated reflections on the implementation process, which were then grouped thematically into implementation lessons. RESULTS: In total, 11,337 PoCT records were digitised (70% (7954) during Phase I; and 30% (3383) during Phase II). Linkage of forms to the PHDC was 96% in Phase I and 98% in Phase II. Comparison with aggregate data showed high correlation during Phase I, but notable divergence during Phase II. Divergence in Phase II was due to stringent data quality requirements and high clinical staff turnover. Factors supporting implementation success in Phase I included direct oversight of data capturing by a manager with clinical and operational insight. Implementation challenges included operational, health system, and high cost-related issues. CONCLUSIONS: We demonstrate that rapid digitisation of HIV PoCT data, without compromising currently collected aggregate data, is operationally feasible, and can contribute to person-level longitudinal HIV case-based surveillance. To take to scale, we will need to improve PoCT platforms and clerical and administrative systems. Although we highlight challenges, we demonstrate that electronic HIV testing registers can successfully replace manual registers and improve efforts to monitor and evaluate HIV testing strategies.

Pediatric Poisonings in a Rural Ugandan Emergency Department.

OBJECTIVE: This study aims to describe pediatric poisonings presenting to a rural Ugandan emergency department (ED), identifying demographic factors and causative agents. METHODS: This retrospective study was conducted in the ED of a rural hospital in the Rukungiri District of Uganda. A prospectively collected quality assurance database of ED visits was queried for poisonings in patients under the age of 5 who were admitted to the hospital. Cases were included if the chief complaint or final diagnosis included anything referable to poisoning, ingestion, or intoxication, or if a toxicologic antidote was administered. The database was coded by a blinded investigator, and descriptive statistics were performed. RESULTS: From November 9, 2009, to July 11, 2014, 3428 patients under the age of 5 were admitted to the hospital. A total of 123 cases (3.6%) met the inclusion criteria. Seventy-two patients were male (58.5%). The average age was 2.3 (SD, 0.97) years with 45 children (36.6%) under the age of 2 years. There were 19 cases (15.4%) lost to 3-day follow-up. The top 3 documented exposures responsible for pediatric poisonings were cow tick or organophosphates (36 cases, 29.2%), general poison or drug overdose (26 cases, 21.1%), and paraffin or hydrocarbon (24 cases, 19.5%).Of the admitted patients, 1 died in the ED and 2 died at 72-hour follow-up, for an overall 72-hour mortality of 2.4%. Patients who died were exposed to iron, cow tick, and rat poison. CONCLUSIONS: Pediatric poisoning affects patients in rural sub-Saharan Africa. The mortality rate at one rural Ugandan hospital was greater than 2%.

Medevac Utilization and Patient Characteristics in Rural Alaska 2010 to 2018.

OBJECTIVE: Little is known about medevac utilization in remote, rural Alaska where there is no road access and communities are reliant on medevacs for emergency care. With high financial costs and risks to flight crews, there is an urgent need to understand medevac utilization in rural Alaska. This article aimed to describe medevac utilization and patient characteristics over 9 years in the remote, air transport dependent in Alaska. METHODS: Deidentified data (2010-2018) were obtained for all medevacs originating within the Yukon-Kuskokwim Delta. Descriptive statistics were calculated, and chi-square tests of independence were conducted to identify differences. RESULTS: Four thousand nine hundred ninety-one medevacs were performed, averaging 555 (standard deviation = 67.7) per year. Medevacs for respiratory complaints were predominant for children, whereas trauma predominated for adults 18 to 40 years old. Traumatic injury was more common in males than females aged < 65 years but was more common in females than males aged ≥ 65 years. Significant variability occurred in medevacs based on the community and the hour of the day. CONCLUSION: Medevacs are a critical part of health care in rural, remote Alaska but appear subject to clinical and nonclinical determinants. These baseline data provide a foundation for future studies aiming to increase medevac safety and provide decision-making support.

Outcomes of patients lost to follow-up after antiretroviral therapy initiation in rural north-eastern South Africa.

OBJECTIVE: The vital status of patients lost to follow-up often remains unknown in antiretroviral therapy (ART) programmes in sub-Saharan Africa because medical records are no longer updated once the patient disengages from care. Thus, we aimed to assess the outcomes of patients lost to follow-up after ART initiation in north-eastern South Africa. METHODS: Using data from a rural area in north-eastern South Africa, we estimated the cumulative incidence of patient outcomes (i) after treatment initiation using clinical records, and (ii) after loss to follow-up (LTFU) using data from clients that have been individually linked to Agincourt Health and Demographic Surveillance System (AHDSS) database. Aside from LTFU, we considered mortality, re-engagement and migration out of the study site. Cox proportional hazards regression was used to identify covariates of these patient outcomes. RESULTS: Between April 2014 and July 2017, 3700 patients initiated ART and contributed a total of 6818 person-years of follow-up time. Three years after ART initiation, clinical record-based estimates of LTFU, mortality and documented transfers were 41.0% (95% CI: 38.5-43.4%), 1.9% (95% CI 1.0-3.2%) and 0.1% (95% CI 0.0-0.9%), respectively. Among those who were LTFU, the cumulative incidence of re-engagement, out-migration and mortality at 3 years were 38.1% (95% CI 33.1-43.0%), 49.4% (95% CI 43.1-55.3%) and 4.7% (95% CI 3.5-6.2%), respectively. Pregnant or breastfeeding women, foreigners and those who initiated ART most recently were at an increased risk of LTFU. CONCLUSION: LTFU among patients starting ART in north-eastern South Africa is relatively high and has increased in recent years as more asymptomatic patients have initiated treatment. Even though this tendency is of concern in light of the prevention of onwards transmission, we also found that re-engagement in care is common and mortality among persons LTFU relatively low.

OBJECTIF: Le statut vital des patients perdus au suivi reste souvent inconnu dans les programmes de traitement antirétroviral (ART) en Afrique subsaharienne parce que les dossiers médicaux ne sont plus mis à jour une fois que le patient se désengage des soins. Notre objectif était d'évaluer les résultats des patients dans le nord-est de l'Afrique du Sud. MÉTHODES: A l'aide de données provenant d'une zone rurale du nord-est de l'Afrique du Sud, nous avons estimé l'incidence cumulée des résultats pour les patients (i) après le début du traitement à l'aide des dossiers cliniques et (ii) après la perte au suivi (PS) à l'aide des données des patients qui ont été reliées individuellement à la base de données du système de surveillance démographique et de santé (AHDSS) d'Agincourt. Outre les PS, nous avons pris en compte la mortalité, le réengagement et la migration hors du site de l'étude. La régression des risques proportionnels de Cox a été utilisée pour identifier les covariables de ces résultats pour le patient. RÉSULTATS: Entre avril 2014 et juillet 2017, 3.700 patients ont commencé l'ART constituant un suivi total de 6.818 années-personnes. Trois ans après le début de l'ART, les estimations des PS, de la mortalité et des transferts documentés selon les registres cliniques étaient de 41,0% (IC95%: 38,5% à 43,4%), 1,9% (IC95%: 1,0% à 3,2%) et 0,1% (IC95%: 0,0% -0,9%), respectivement. Parmi ceux qui étaient PS, l'incidence cumulative de réengagement, d'émigration et de mortalité à trois ans était de 38,1% (IC95%: 33,1% à 43,0%), 49,4% (IC95%: 43,1% à 55,3%) et 4,7% (IC95%: 3,5% -6,2%), respectivement. Les femmes enceintes ou allaitantes, les étrangers et les personnes qui ont commencé l'ART le plus récemment couraient un risque accru de PS. CONCLUSION: La PS chez les patients commençant une ART dans le nord-est de l'Afrique du Sud est relativement élevée et a augmenté ces dernières années à mesure que davantage de patients asymptomatiques ont commencé le traitement. Même si cette tendance est préoccupante à la lumière de la prévention de la transmission, nous avons également constaté que le réengagement dans les soins était courant et que la mortalité parmi les PS était relativement faible.

Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis.

Background: Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs. Methods: This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART. Results: Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/µL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but had stopped cART, 14.8% (95% CI, 14.0%-15.6%) had transferred to another clinic, 9.2% (95% CI, 8.5%-9.8%) were retained on cART, and 31.6% (95% CI, 30.6%-32.7%) could not been found. Mortality was associated with male sex, more advanced disease, and shorter cART duration; stopping cART with less advanced disease andlonger cART duration; and silent transfer with female sex and less advanced disease. Conclusions: Mortality in patients LTFU must be considered for unbiased assessments of program outcomes and UNAIDS targets in sub-Saharan Africa. Immediate start of cART and early tracing of patients LTFU should be priorities.

Development of a Premixed Combustion Capability for Dual-Mode Scramjet Experiments.

Hypersonic air-breathing engines rely on scramjet combustion processes, which involve high-speed, compressible, and highly turbulent reacting flows. The combustion environment and the turbulent flames at the heart of these engines are difficult to simulate and study in the laboratory under well controlled conditions. Typically, wind-tunnel testing is performed that more closely approximates engine development rather than a careful investigation of the underlying physics that drives the combustion process. The experiments described in this paper, along with companion data sets, aim to isolate the chemical kinetic effects and turbulence-chemistry interaction from the fuel-air mixing process in a dual-mode scramjet combustion environment. A unique fuel injection approach is adopted that produces a uniform fuel-air mixture at the entrance to the combustor and results in premixed combustion. This approach relies on the mixing enhancement of a precombustion shock train upstream of the dual-mode scramjet's combustor. For the first time a stable flame, anchored on a cavity flameholder, is reported for a scramjet combustor operating in premixed fuel-air mode. The new experimental capability has enabled numerous companion studies involving advanced diagnostics such as coherent anti-Stokes Raman scattering (CARS), particle image velocimetry (PIV), and planar laser induced fluorescence (PLIF).

Monitoring of the HIV Epidemic Using Routinely Collected Data: The Case of the United Kingdom.

We report on measures used to monitor the response to the UK HIV epidemic. We present analyses of routine data on HIV testing, diagnosis and care, and of CD4 back-calculation models to estimate country of HIV acquisition and incidence. Over the past decade, HIV and AIDS diagnoses and deaths declined while HIV testing coverage increased. Linkage into care, retention in care, and viral suppression was high with few socio-demographic differences. However, in 2013, incidence among MSM, and undiagnosed infection, also remained high, and more than half of heterosexuals newly diagnosed with HIV (the majority of whom were born-abroad) probably acquired HIV in the UK and were diagnosed late. HIV care following diagnosis is excellent in the UK. Improvements in testing and prevention are required to reduce undiagnosed infection, incidence and late diagnoses. Routinely collected laboratory and clinic data is a low cost, robust and timely mechanism to monitor the public health response to national HIV epidemics.