Sinister unilateral tonsillar enlargement

A CAJM article.Tonsillectomy is one of those routine simple and safe procedures that can be delegated to juniors. The procedure is now even being done as day surgery. Tonsillectomy is commonly bilateral, but unilateral tonsillar enlargement can occur especially in the presence of an infective process. This case report, however, serves to highlight the hazards that could occur with tonsillectomy

Hydro-Physicochemical Changes in Domasi River Associated with Outbreak of Blackflies (Diptera; Simuliidae) in Zomba, Malawi

Blackflies impact human and animal health due to their biting nuisance and transmission of Ochocerca volvulus. This study presents an attempt to analyze hydro physicochemical changes associated with outbreak of black flies in Zomba, Malawi. The study compared historical data of hydro physicochemical parameters before (1985-2002) and after (2008) the outbreak to deduce the changes associated with mass occurrence of these flies. Changes in water quality between these two periods were assessed using T-tests. To establish the relationship between the black fly larval densities and water quality parameters data was subjected to both principal component and correlation analysis. Three principal components before the outbreak and two principal components during the outbreak (both dry and wet season) accounted for most of the variation in water quality in this river system. Nutrient load, increases in Total Suspended Solids (TSS) and Total Hardness (TH) were the main factors that had high loadings on these principal components over the years. A significant correlation was established between black fly larval densities and total hardness (r=0.86, p<0.05) as well as total suspended solids (r = 0.755, p<0.02). The potential role of anthropogenic influences on water quality and its cascading effect on black fly population dynamics is discussed

A comparison of HIV outpatient care in primary and secondary healthcare-level settings in Zimbabwe.

SETTING: Decentralisation of HIV care to nurse-led primary care services is being implemented across low- and middle-income countries in sub-Saharan Africa. OBJECTIVE: To compare services offered to clients attending for HIV care at a physician-led and a nurse-led service in Harare, Zimbabwe. DESIGN: A cross-sectional study was performed at Harare Central Hospital (HCH) and Budiriro Primary Care Clinic (PCC) from June to August 2018. An interviewer-administered questionnaire was used to collect sociodemographics, HIV treatment and clinical history from clients attending for routine HIV care. The Mann-Whitney U-test was used to evaluate for differences between groups for continuous variables. For categorical variables, the χ2 test was used. RESULTS: The median age of the 404 participants recruited was 38 years (IQR 28-47); 69% were female. Viral suppression was comparable between sites (HCH, 70% vs. PCC, 80%; P = 0.07); however, screening for comorbidities such as cervical cancer screening (HCH, 61% vs. PCC, 41%; P = 0.001) and provision of referral services (HCH, 23% vs. PCC, 13%; P = 0.01) differed between sites. CONCLUSION: Efforts to improve service provision in primary care settings are needed to ensure equity for users of health services

Menstrual product choice and uptake among young women in Zimbabwe: a pilot study.

BACKGROUND: Menstrual health and hygiene (MHH) is a human rights issue; yet, it remains a challenge for many, especially in low- and middle-income countries (LMICs). MHH includes the socio-political, psychosocial, and environmental factors that impact women's menstrual experiences. High proportions of girls and women in LMICs have inadequate MHH due to limited access to menstrual knowledge, products, and stigma reinforcing harmful myths and taboos. The aim of this pilot was to inform the design of an MHH sub-study and the implementation and scale-up of an MHH intervention incorporated into a community-based cluster-randomized trial of integrated sexual and reproductive health (SRH) services for youth in Zimbabwe. The objectives were to investigate (1) uptake of a novel MHH intervention, (2) menstrual product preference, and (3) the factors that informed uptake and product choice among young women. METHODS: Female participants aged 16-24 years old attending the community-based SRH services between April and July 2019 were offered the MHH intervention, which included either a menstrual cup or reusable pads, analgesia, and MHH education. Descriptive statistics were used to quantitatively assess uptake and product choice. Focus group discussions and in-depth interviews with participants and the intervention team were used to investigate the factors that influenced uptake and product choice. RESULTS: Of the 1732 eligible participants, 1414 (81.6%) took up the MHH intervention at first visit. Uptake differed by age group with 84.6% of younger women (16-19 years old) compared to 79.0% of older women (20-24 years old) taking up the intervention. There was higher uptake of reusable pads (88.0%) than menstrual cups (12.0%). Qualitative data highlighted that internal factors, such as intervention delivery, influenced uptake. Participants noted the importance of access to free menstrual products, analgesics, and MHH education in a youth-friendly environment. External factors such as sociocultural factors informed product choice. Barriers to cup uptake included fears that the cup would compromise young women's virginity. CONCLUSIONS: Pilot findings were used to improve the MHH intervention design and implementation as follows: (1) cup ambassadors to improve cup promotion, sensitization, and uptake; (2) use of smaller softer cups; and (3) education for community members including caregivers and partners. TRIAL REGISTRATION: Registry: Clinicaltrials.gov Registration Number: NCT03719521 Registration Date: 25 October 2018

Acceptability of self-collected vaginal swabs for sexually transmitted infection testing among youth in a community-based setting in Zimbabwe.

BACKGROUND: Youth are a high-risk group for sexually transmitted infections (STIs). To increase access to STI testing, convenient approaches for sampling and testing are needed. We assessed the acceptability of self-collected vaginal swabs (SCVS) for STI testing among young women (16-24 years) attending a community-based sexual and reproductive health service in Zimbabwe. METHODS: A SCVS was used for point-of-care testing for Trichomonas vaginalis and a urine sample for testing for Chlamydia trachomatis and Neisseria gonorrhoeae. A questionnaire was administered to investigate the acceptability of SCVS versus self-collected urine samples. In-depth interviews (IDIs) explored the experience of SCVS and reasons for sample collection preference. Qualitative analysis was predominantly deductive. RESULTS: We recruited 129 women who took up STI testing (median age 20 years, IQR 18-22 years) and conducted 12 IDIs. Most participants reported that they understood the instructions (93.0%) and found SCVS easy (90.7%). Many participants felt relaxed (93.0%), in control (88.4%) and that they had enough privacy (90.7%). Pain or discomfort were reported by 16.3% and embarrassment by 15.5%. Among the 92 (71.3%) participants who provided both a SCVS and urine sample, 60.9% preferred SCVS. Sample collection method preferences were similar between 16-19 and 20-24year-olds. In IDIs, clear instructions, privacy, trust in the service and same-day results were perceived as important facilitators to taking up SCVS. Participants frequently described feeling relaxed and confident whilst taking a SCVS. Pain and discomfort were uncommon experiences. CONCLUSIONS: SCVS for STI testing are acceptable to young women and a feasible method of sample collection in community-based settings

"It's not safe for me and what would it achieve?" Acceptability of patient-referral partner notification for sexually transmitted infections to young people, a mixed methods study from Zimbabwe.

Partner notification (PN) is considered integral to the management of sexually transmitted infections (STI). Patient-referral is a common PN strategy and relies on index cases notifying and encouraging their partners to access treatment; however, it has shown limited efficacy. We conducted a mixed methods study to understand young people's experiences of PN, particularly the risks and challenges encountered during patient-referral. All young people (16-24 years) attending a community-based sexual and reproductive health service in Zimbabwe who were diagnosed with an STI were counselled and offered PN slips, which enabled their partners to access free treatment at the service. PN slip uptake and partner treatment were recorded. Among 1807 young people (85.0% female) offered PN slips, 745 (41.2%) took up ≥1 PN slip and 103 partners (5.7%) returned for treatment. Most participants described feeling ill-equipped to counsel and persuade their partners to seek treatment. Between June and August 2021, youth researchers conducted in-depth interviews with 41 purposively selected young people diagnosed with an STI to explore their experiences of PN. PN posed considerable social risks, threatening their emotional and physical safety. Except for a minority in long-term, publicly acknowledged relationships, participants did not expect PN would achieve successful outcomes. Public health discourse, which constructs PN as "the right thing to do", influenced participants to adopt narratives that concealed the difficulties of PN and their unmet needs. Urgent interrogation is needed of whether PN is a suitable or constructive strategy to continue pursuing with young people. To improve the outcomes of preventing reinfection and onward transmission of STIs, we must consider developing alternative strategies that better align with young people's lived experiences.Plain language summary Partner notification is a public health strategy used to trace the sexual partners of people who have received a sexually transmitted infection (STI) diagnosis. It aims to interrupt the chains of STI transmission and prevent reinfection by treating both the person diagnosed and their sexual partners. The least effective but most common partner notification strategy used in many resource-limited settings is called "patient referral". This involves a sexual healthcare provider encouraging the person diagnosed to give a "partner notification slip" to their potentially exposed sexual partner/s and persuading them to access treatment. This research sought to better understand young people's experiences of partner notification, particularly the risks and challenges they faced during patient-referral.All young people (16-24 years) attending a community-based sexual and reproductive health service in Zimbabwe who were diagnosed with an STI were counselled and offered PN slips, which enabled their partners to access free treatment at the service. Young people trained as researchers interviewed 41 young people who had received a STI diagnosis to explore their experiences of partner notification.Only a small number (5.7%) of the partners of those who took a slip attended the service for treatment. Most participants felt they did not have the preparation, skills, or resources to persuade their partners to seek treatment. Many described negative experiences during and after partner notification, including relationship breakdown, reputation damage, and physical violence.These findings suggest that we should reconsider if partner notification is suitable or effective for use with young people. We should explore alternative approaches that do not present risks to young people's social, emotional, and physical safety and well-being

Brief Report: Diagnostic Accuracy of Oral Mucosal Transudate Tests Compared with Blood-Based Rapid Tests for HIV Among Children Aged 18 Months to 18 Years in Kenya and Zimbabwe.

BACKGROUND: Gaps persist in HIV testing for children who were not tested in prevention of mother-to-child HIV transmission programs. Oral mucosal transudate (OMT) rapid HIV tests have been shown to be highly sensitive in adults, but their performance has not been established in children. METHODS: Antiretroviral therapy-naive children aged 18 months to 18 years in Kenya and Zimbabwe were tested for HIV using rapid OraQuick ADVANCE Rapid HIV-1/2 Antibody test on oral fluids (OMT) and blood-based rapid diagnostic testing (BBT). BBT followed Kenyan and Zimbabwean national algorithms. Sensitivity and specificity were calculated using the national algorithms as the reference standard. RESULTS: A total of 1776 children were enrolled; median age was 7.3 years (interquartile range: 4.7-11.6). Among 71 children positive by BBT, all 71 were positive by OMT (sensitivity: 100% [97.5% confidence interval (CI): 94.9% to 100%]). Among the 1705 children negative by BBT, 1703 were negative by OMT (specificity: 99.9% [95% CI: 99.6% to 100.0%]). Due to discrepant BBT and OMT results, 2 children who initially tested BBT-negative and OMT-positive were subsequently confirmed positive within 1 week by further tests. Excluding these 2 children, the sensitivity and specificity of OMT compared with those of BBT were each 100% (97.5% CI: 94.9% to 100% and 99.8% to 100%, respectively). CONCLUSIONS: Compared to national algorithms, OMT did not miss any HIV-positive children. These data suggest that OMTs are valid in this age range. Future research should explore the acceptability and uptake of OMT by caregivers and health workers to increase pediatric HIV testing coverage

"It was difficult to offer same day results": evaluation of community-based point-of-care testing for sexually transmitted infections among youth using the GeneXpert platform in Zimbabwe.

BACKGROUND: Point-of-care testing for sexually transmitted infections (STIs) may improve diagnosis and treatment of STIs in low- and middle-income counties. We explored the facilitators and barriers to point-of-care testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) for youth in community-based settings in Zimbabwe. METHODS: This study was nested within a cluster randomised trial of community-based delivery of integrated HIV and sexual and reproductive health services for youth aged 16 to 24 years. On-site CT/NG testing on urine samples using the Xpert® CT/NG test was piloted in four intervention clusters, with testing performed by service providers. On-site testing was defined as sample processing on the same day and site as sample collection. Outcomes included proportion of tests processed on-site, time between sample collection and collection of results, and proportion of clients receiving treatment. In-depth interviews were conducted with nine service providers and three staff members providing study co-ordination or laboratory support to explore facilitators and barriers to providing on-site CT/NG testing. RESULTS: Of 847 Xpert tests, 296 (35.0%) were performed on-site. Of these, 61 (20.6%) were positive for CT/NG; one (1.6%) received same day aetiological treatment; 33 (54.1%) presented later for treatment; and 5 (8.2%) were treated as a part of syndromic management. There was no difference in the proportion of clients who were treated whether their sample was processed on or off-site (64% (39/61) vs 60% (66/110); p = 0.61). The median (IQR) number of days between sample collection and collection of positive results was 14 (7-35) and 14 (7-52.5) for samples processed on and off-site, respectively, The interviews revealed four themes related to the provision of on-site testing associated with the i) diagnostic device ii) environment, iii) provider, and iv) clients. Some of the specific barriers identified included insufficient testing capacity, inadequate space, as well as reluctance of clients to wait for their results. CONCLUSIONS: In addition to research to optimise the implementation of point-of-care tests for STIs in resource-limited settings, the development of new platforms to reduce analytic time will be necessary to scale up STI testing and reduce the attrition between testing and treatment. TRIAL REGISTRATION: Registered in clinical trials.gov ( NCT03719521 )

Uptake of and factors associated with testing for sexually transmitted infections in community-based settings among youth in Zimbabwe: a mixed-methods study.

BACKGROUND: The prevalence of sexually transmitted infections (STIs) among youth is high in sub-Saharan Africa. We investigated the uptake of testing for and prevalence of Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhoea) infections among youth in community-based settings in Zimbabwe, and explored the facilitators and barriers to testing. METHODS: This study was nested within a cluster randomised trial of community-based delivery of integrated HIV and sexual and reproductive health services for youth aged 16-24 years. Chlamydia and gonorrhoea testing via urine samples using the Xpert CT/NG test was offered in the four intervention clusters in Harare, Zimbabwe. Factors associated with testing uptake were investigated in a subset of participants (n=257) using hierarchical multivariate logistic regression. In-depth interviews with a separate purposively selected sample (n=26) explored facilitators and barriers to STI testing and partner notification and were analysed using thematic analysis. FINDINGS: Between June 1, 2019, and Jan 31, 2020, there were 6200 attendances by 4440 participants (78·2% women, 21·8% men) median age 20·3 (IQR 17·9-22·8) years. 1478 participants had 1501 tests done, and 248 tests were positive and 1253 tests were negative for chlamydia or gonorrhoea, or both. STI test uptake was 33·3% (95% CI 31·9-34·7), increasing from 11·7% in June, 2019, to 37·1% in January, 2020. The prevalence of chlamydia or gonorrhoea, or both, was 16·5% (95% CI 14·7-18·5; 248 of 1501), with only seven participants (3%) showing symptoms. The overall yield of testing was 4·0% (95% CI 3·5-4·5; 248 of 6200). Uptake was associated with having symptoms (adjusted odds ratio [OR] 14·8, 95% CI 1·66-132·07) and negatively associated with being single (adjusted OR 0·33, 95% CI 0·13-0·84) or having a boyfriend or girlfriend (adjusted OR 0·19, 95% CI 0·087-0·43) compared with being married, and being a student compared with being employed (adjusted OR 0·26, 95% CI 0·10-0·68). Perceived risk and symptoms of STIs were motivators for testing whereas misinformation, anticipated stigma, and concern about confidentiality were barriers. INTERPRETATION: The prevalence of chlamydia or gonorrhoea, or both, was high among youth but only a minority were symptomatic. Therefore most infections would remain untreated without access to STI testing. Provision of education, counselling, and confidentiality are essential to improve uptake and acceptability of STI testing. FUNDING: Wellcome Trust

Identifying youth at high risk for sexually transmitted infections in community-based settings using a risk prediction tool: a validation study.

BACKGROUND : Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most common bacterial sexually transmitted infections (STIs) worldwide. In the absence of affordable point-of-care STI tests, WHO recommends STI testing based on risk factors. This study aimed to develop a prediction tool with a sensitivity of > 90% and efficiency (defined as the percentage of individuals that are eligible for diagnostic testing) of < 60%. METHODS: This study offered CT/NG testing as part of a cluster-randomised trial of community-based delivery of sexual and reproductive health services to youth aged 16-24 years in Zimbabwe. All individuals accepting STI testing completed an STI risk factor questionnaire. The outcome was positivity for either CT or NG. Backwards-stepwise logistic regression was performed with p ≥ 0.05 as criteria for exclusion. Coefficients of variables included in the final multivariable model were multiplied by 10 to generate weights for a STI risk prediction tool. A maximum likelihood Receiver Operating Characteristics (ROC) model was fitted, with the continuous variable score divided into 15 categories of equal size. Sensitivity, efficiency and number needed to screen were calculated for different cut-points. RESULTS: From 3 December 2019 to 5 February 2020, 1007 individuals opted for STI testing, of whom 1003 (99.6%) completed the questionnaire. CT/NG prevalence was 17.5% (95% CI 15.1, 19.8) (n = 175). CT/NG positivity was independently associated with being female, number of lifetime sexual partners, relationship status, HIV status, self-assessed STI risk and past or current pregnancy. The STI risk prediction score including those variables ranged from 2 to 46 with an area under the ROC curve of 0.72 (95% CI 0.68, 0.76). Two cut-points were chosen: (i) 23 for optimised sensitivity (75.9%) and specificity (59.3%) and (ii) 19 to maximise sensitivity (82.4%) while keeping efficiency at < 60% (59.4%). CONCLUSIONS: The high prevalence of STIs among youth, even in those with no or one reported risk factor, may preclude the use of risk prediction tools for selective STI testing. At a cut-point of 19 one in six young people with STIs would be missed