Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland.

BACKGROUND: In sub-Saharan Africa (SSA) there are strong arguments for the provision of integrated sexual and reproductive health (SRH) and HIV services. Most HIV transmissions are sexually transmitted or associated with pregnancy, childbirth, and breastfeeding. Many of the behaviours that prevent HIV transmission also prevent sexually transmitted infections and unintended pregnancies. There is potential for integration to increase the coverage of HIV services, as individuals who use SRH services can benefit from HIV services and vice-versa, as well as increase cost-savings. However, there is a dearth of empirical evidence on effective models for integrating HIV/SRH services. The need for robust evidence led a consortium of three organizations - International Planned Parenthood Federation, Population Council and the London School of Hygiene & Tropical Medicine - to design/implement the Integra Initiative. Integra seeks to generate rigorous evidence on the feasibility, effectiveness, cost and impact of different models for delivering integrated HIV/SRH services in high and medium HIV prevalence settings in SSA. METHODS/DESIGN: A quasi-experimental study will be conducted in government clinics in Kenya and Swaziland - assigned into intervention/comparison groups. Two models of service delivery are investigated: integrating HIV care/treatment into 1) family planning and 2) postnatal care. A full economic-costing will be used to assess the costs of different components of service provision, and the determinants of variations in unit costs across facilities/service models. Health facility assessments will be conducted at four time-periods to track changes in quality of care and utilization over time. A two-year cohort study of family planning/postnatal clients will assess the effect of integration on individual outcomes, including use of SRH services, HIV status (known/unknown) and pregnancy (planned/unintended). Household surveys within some of the study facilities' catchment areas will be conducted to profile users/non-users of integrated services and demand/receipt of integrated services, before-and-after the intervention. Qualitative research will be conducted to complement the quantitative component at different time points. Integra takes an embedded 'programme science' approach to maximize the uptake of findings into policy/practice. DISCUSSION: Integra addresses existing evidence gaps in the integration evaluation literature, building on the limited evidence from SSA and the expertise of its research partners. TRIAL REGISTRATION: Current Controlled Trials NCT01694862

The Measurement of Condom Use in Four Countries in East and Southern Africa

Measurement of condom use is important to assess progress in increasing use. Since 2003, the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) have included new measures of self-reported condom use. We use data from Namibia, Swaziland, Tanzania, and Zambia to compare measures of condom use accounting for type of sexual partner. Condom use at last sex ranged from 20% in Tanzania to 57% in Namibia for men, and from 12% in Tanzania to 41% in Namibia for women. Reported condom use was lower in response to questions about condom use every time with last partner (from 13% to 47% for men and from 8% to 33% for women). Condom use was highest among people with two or more partners in the last year and lowest with marital partners. Overall, the prevalence of condom use was low, and there was wide variability across the various measures, countries, sexes, and types of partner. Promotion of condom use in all partnerships, but especially in non-marital relationships and among individuals with multiple partners, remains a critical strategy. New condom use questions in the DHS and AIS expand options for measuring and studying condom use

Mild and Highly Flexible Enzyme-Catalyzed Modification of Poly (ethersulfone) Membranes

Poly(ethersulfone) (PES) membranes are widely used in industry for separation and purification purposes. However, the drawback of this type of membranes is fouling by proteins. For that reason, modification of PES membranes has been studied to enhance their protein repellence. This paper presents the first example of enzyme-catalyzed modification of PES membranes. Various phenolic acids (enzyme substrates) were bound to a membrane under very mild conditions (room temperature, water, nearly neutral pH) using only laccase from Trametes versicolor as catalyst. The extent of modification, monitored, for example, by the coloration of the modified membranes, can be tuned by adjusting the reaction conditions. The most significant results were obtained with 4-hydroxybenzoic acid and gallic acid as substrates. The presence of a covalently bound layer of 4-hydroxybenzoic acid on the grafted membranes was confirmed by X-ray photoelectron spectroscopy (XPS), infrared reflection absorption spectroscopy (IRRAS), and NMR. In the case of gallic acid, PES membrane modification is mainly caused by adsorption of enzymatically formed homopolymer. The ionization potential of the substrates, and the electronic energies and spin densities of the radicals that are intermediates in the attachment reaction were calculated (B3LYP/6-311G(d,p)) to determine the reactive sites and the order of reactivity of radical substrates to couple with the PES membrane. The calculated order of reactivity of the substrates is in line with the experimental observations. The calculated spin densities in the phenolic radicals are highest at the oxygen atom, which is in line with the formation of ether linkages as observed by IRRAS. The liquid fluxes of the modified membranes are hardly influenced by the grafted layers, in spite of the presence of a substantial and stable new layer, which opens a range of application possibilities for these modified membrane