Self-sampling kits to increase HIV testing among black Africans in the UK: the HAUS mixed-methods study

Background: Timely diagnosis of human immunodeficiency virus (HIV) enables access to antiretroviral treatment, which reduces mortality, morbidity and further transmission in people living with HIV. In the UK, late diagnosis among black African people persists. Novel methods to enhance HIV testing in this population are needed. / Objectives: To develop a self-sampling kit (SSK) intervention to increase HIV testing among black Africans, using existing community and health-care settings (stage 1) and to assess the feasibility for a Phase III evaluation (stage 2). / Design: A two-stage, mixed-methods design. Stage 1 involved a systematic literature review, focus groups and interviews with key stakeholders and black Africans. Data obtained provided the theoretical base for intervention development and operationalisation. Stage 2 was a prospective, non-randomised study of a provider-initiated, HIV SSK distribution intervention targeted at black Africans. The intervention was assessed for cost-effectiveness. A process evaluation explored feasibility, acceptability and fidelity. / Setting: Twelve general practices and three community settings in London. / Main outcome measure: HIV SSK return rate. / Results: Stage 1 – the systematic review revealed support for HIV SSKs, but with scant evidence on their use and clinical effectiveness among black Africans. Although the qualitative findings supported SSK distribution in settings already used by black Africans, concerns were raised about the complexity of the SSK and the acceptability of targeting. These findings were used to develop a theoretically informed intervention. Stage 2 – of the 349 eligible people approached, 125 (35.8%) agreed to participate. Data from 119 were included in the analysis; 54.5% (65/119) of those who took a kit returned a sample; 83.1% of tests returned were HIV negative; and 16.9% were not processed, because of insufficient samples. Process evaluation showed the time pressures of the research process to be a significant barrier to feasibility. Other major barriers were difficulties with the SSK itself and ethnic targeting in general practice settings. The convenience and privacy associated with the SSK were described as beneficial aspects, and those who used the kit mostly found the intervention to be acceptable. Research governance delays prevented implementation in Glasgow. / Limitations: Owing to the study failing to recruit adequate numbers (the intended sample was 1200 participants), we were unable to evaluate the clinical effectiveness of SSKs in increasing HIV testing in black African people. No samples were reactive, so we were unable to assess pathways to confirmatory testing and linkage to care. / Conclusions: Our findings indicate that, although aspects of the intervention were acceptable, ethnic targeting and the SSK itself were problematic, and scale-up of the intervention to a Phase III trial was not feasible. The preliminary economic model suggests that, for the acceptance rate and test return seen in the trial, the SSK is potentially a cost-effective way to identify new infections of HIV. / Future work: Sexual and public health services are increasingly utilising self-sampling technologies. However, alternative, user-friendly SSKs that meet user and provider preferences and UK regulatory requirements are needed, and additional research is required to understand clinical effectiveness and cost-effectiveness for black African communities. / Study registration: This study is registered as PROSPERO CRD42014010698 and Integrated Research Application System project identification 184223. / Funding: The National Institute for Health Research Health Technology Assessment programme and the BHA for Equality in Health and Social Care

A short history off-line

Emerging technologies for learning report - Article exploring the history of ICT in education and the lessons we can learn from the pas

PRImary care Streptococcal Management (PRISM) study:In vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Background: Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. Objective: This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. Design: The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. Setting: The setting was UK primary care general practices. Participants: Participants were patients aged ≥ 3 years with acute sore throat. Interventions: An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. Main outcome measures: The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). Results: The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. Conclusions: Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed

The relative clinical effectiveness and cost-effectiveness of three contrasting approaches to partner notification for curable sexually transmitted infections: a cluster randomised trial in primary care

Since 1998 there has been a substantial increase in reported cases of sexually transmitted infection (STI), most strikingly in the 16–24 years age group.1 Across genitourinary medicine (GUM) clinics in the UK in 2007, young people accounted for 65% of chlamydia cases, 50% of cases of genital warts and 50% of gonorrhoea infections.1 Chlamydia is the most common STI in under-25s. Since 1998, the rate of diagnosed chlamydia has more than doubled in the 16–24 years age group (from 447 per 100,000 in 1998 to 1102 per 100,000 in 2007). This may be because of a combination of a higher proportion of young people testing, improved diagnostic methods and increased risk behaviour.1 Chlamydia infection can frequently go undetected, particularly in women, as it is often asymptomatic.1 If left untreated, chlamydia can lead to pelvic inflammatory disease and infertility in women. This highlights the importance of testing this higher-risk age group to ensure prompt diagnosis and treatment. It is estimated that 11–12% of 16- to 19-year-olds presenting at a GUM clinic with an acute STI will become reinfected within a year.2 In order to minimise reinfection, preventative measures are required, including effective methods of notifying partners to ensure rapid diagnosis and treatment and reduce the likelihood of index patients being reinfected from the same source

Emergency Management Training for Transportation Agencies

State transportation agencies have a variety of responsibilities related to emergency management. Field personnel manage events--from day-to-day emergencies to disasters--using the Incident Command System (ICS) as their organizational basis. At the headquarters level, the Emergency Operations Center (EOC) coordinates the use of resources across the department and its districts, with other state departments and agencies, and through the federal Emergency Support Function 1. District-level EOCs coordinate with the department. In extreme events, the transportation department may only be able to deliver limited essential services in austere conditions, so a continuity of operations/ continuity of government plan (COOP/COG) is essential. This research applied the principles of andragogy to deliver ICS field level training, EOC training and COOP/COG training to state transportation agency’s staff in all districts and at headquarters. The data supports the need for adult-oriented methods in emergency management training

Transitioning Care from Hospital to Home, Increasing Awareness of Take-home Pressure Injury Prevention Kits

With proper implementation of evidence-based interventions, most pressure injuries (PI) can be prevented. While prevention is considered standard of care while inpatient, there is a need to transition this care from hospital to home. This CNL project aimed to increased awareness of take home PI prevention kits made available to staff nurses at on medical surgical hospital unit with 15 staff nurses. An author-blinded, internal chart review and a comprehensive review of evidence-based literature were studied to provide background data and support for implementation using the staff huddle. Direct observation and staff interaction was incorporated with Lewin’s change theory to propel the project forward. Implementation began on March 29th, and data from pre and post-testing during huddles was evaluated using a run chart and revealed a successful goal of at least 75% increased staff awareness. Questionnaires and informal discussions revealed that while the majority of staff felt the kits offered patients positive preventative tools, responses captured that approximately 25% of staff felt providing the kits would increase workload. The author concludes a strong connection to nursing relevance in advocating for patient safety by transitioning care from hospital to home, however, appreciative inquiry suggests that it would beneficial to address staff concerns surrounding increased workload in order to increase solidification of stakeholder buy-in toward promoting global aim success

Sexual & reproductive health self-care measurement tool

The Sexual and Reproductive Health Self-Care Measurement Tool aims to provide a global standard approach to practical and accurate measurement of sexual and reproductive (SRH) self-care interventions, with a focus on three specific interventions: self-injectable hormonal contraception, HIV self-testing, and self-managed abortion. Led by the SCTG’s Evidence and Learning Working Group (ELWG), the SRH Self-Care Measurement Tool was developed through a consensus-driven process by a group of global experts, including academics, implementers, donors, and intergovernmental bodies, with the goal of identifying a minimum set of priority indicators for each of these self-care interventions

Logistics Information and Knowledge Management Issues in Humanitarian Aid Organizations

In this paper, we assess the need for logistics information and knowledge management in humanitarian aid organizations. To do so, we combine literature sources with an extensive case study that we conducted at Médecins sans Frontières–Holland, which is following a trajectory to improve logistics information management within the organization. We observed that logistics information and logistics knowledge management has not yet matured. We indicate how, by making use of knowledge management strategies such as ‘personalization’ and ‘codification’, this can be improved.Humanitarian aid organizations;Knowledge management;Logistics information