‘We keep her status to ourselves’: Experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine

In HIV-discordant relationships, the HIV-negative partner also carries the burden of a stigmatised disease. For this reason, couples often hide their HIV-discordant status from family, friends and community members. This perpetuates the silence around HIVdiscordant relationships and impacts on targeted HIV prevention, treatment and counselling efforts. This article reports on experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine. During 2008, HIV discordant couples who had been in a relationship for at least one year were recruited purposively through health-care providers and civil society organisations in the three countries. Participants completed a brief self-administered questionnaire, while semi-structured interviews were conducted with each partner separately and with both partners together. Interviews were analysed using thematic content analysis. Fifty-one couples were recruited: 26 from South Africa, 10 from Tanzania, and 15 from Ukraine. Although most participants had disclosed their HIV status to someone other than their partner, few were living openly with HIV discordance. Experiences of stigma were common and included being subjected to gossip, rumours and namecalling, and HIV-negative partners being labelled as HIV-positive. Perpetrators of discrimination included family members and health workers. Stigma and discrimination present unique and complex challenges to couples in HIV sero-discordant relationships in these three diverse countries. Addressing stigmatisation of HIV-discordant couples requires a holistic human rights approach and specific programme efforts to address discrimination in the health system. Keywords: HIV-discordance, stigma, discrimination, couples, South Africa, Tanzania, Ukrain

Peering into the black hole - the quality of black mortality data in Por~ Elizabeth and the rest of South Africa

In the year ending 30 June 1989, 26,8% of 5345 deaths in the Port Elizabeth area were classified as ill-defined. A study was undertaken in an attempt to identify the reasons for the high proportion of such deaths. Copies of all death notifications and death register forms of black people in the area served by the Port Elizabeth City Health Department were collected for a 6-week period. Of the 316 deaths, 154 (48,7%) were certified by medical practitioners at a hospital, 158 (50%) by the police and 4 (1,3%) by private medical practitioners. Of the police-certified deaths 116 (73,4%) were recorded as due to 'natural causes', with the remainder being submitted to autopsy. Of the hospital deaths, 26% were not adequately described in the section for the cause of death on the death certificate. Review of national mortality data for 1985 showed that only 29,9% of ill-defined deaths (in all population groups) were certified by a medical practitioner. The prime source of deaths classifed as ill-defined, both in Port Elizabeth and nationally, were those not certified by a medical practitioner. Strategies aimed' at minimising the number of deaths certified by the police need to be developed

Assessing missed opportunities for the prevention of mother-to-child HIV transmission in an Eastern Cape local service area

Background. Prevention of new HIV infections is a critical imperative for South Africa; the prevention of mother-to-child transmission (PMTCT) is one of the most efficacious HIV prevention interventions.Objective. Assessment of a PMTCT programme to determine missed opportunities.Setting. The Kouga local service area (LSA), bordering Nelson Mandela Bay Municipality (Port Elizabeth) in the Eastern Cape.Methods. An assessment was conducted in 2007 before implementing technical support for strengthening the PMTCT programme, including: interviews with 20 PMTCT managers, 4 maternity staff and 27 other health workers on service provision, management, infrastructure, human resources and the health information system; 296 antenatal clinic users on their service perceptions; 70 HIV-positive women onHIV knowledge, infant feeding, coping, support and service perceptions; 8 representatives from community organisations and 101 traditional health practitioners (THPs). Observations were conducted during site visits to health facilities, and the District Health Information System (DHIS) data were reviewed.Results. Staff had high levels of awareness of HIV policies and most had received some relevant training. Nevirapine uptake varied by clinic, with an average of 56%. There were many missed opportunities for PMTCT, with 67% of pregnant women tested for HIV and only 43% of antenatal care attendees tested during a previous pregnancy. Only 6% of HIV-positive women reported support group participation.Conclusions. Reducing missed opportunities for PMTCT requires strengthening of the formal health sector, intersectoral liaison, and greater community support. Priority areas that require strengthening in the formal health sector include HIV counselling and testing; family planning and nutrition counselling; infant follow-up; human resources; and monitoring and evaluation

Effect of a program of short bouts of exercise on bone health in adolescents involved in different sports: the PRO-BONE study protocol

This is the author accepted manuscript. The final version is available from BioMed Central via the DOI in this record.Background: Osteoporosis is a skeletal disease associated with high morbidity, mortality and increased economic costs. Early prevention during adolescence appears to be one of the most beneficial practices. Exercise is an effective approach for developing bone mass during puberty, but some sports may have a positive or negative impact on bone mass accrual. Plyometric jump training has been suggested as a type of exercise that can augment bone, but its effects on adolescent bone mass have not been rigorously assessed. The aims of the PRO-BONE study are to: 1) longitudinally assess bone health and its metabolism in adolescents engaged in osteogenic (football), non-osteogenic (cycling and swimming) sports and in a control group, and 2) examine the effect of a 9 month plyometric jump training programme on bone related outcomes in the sport groups. Methods/Design: This study will recruit 105 males aged 12-14 years who have participated in sport specific training for at least 3 hours per week during the last 3 years in the following sports groups: football (n=30), cycling (n=30) and swimming (n=30). An age-matched control group (n=15) that does not engage in these sports more than 3 hours per week will also be recruited. Participants will be measured on 5 occasions: 1) at baseline; 2) after 12 months of sport specific training where each sport group will be randomly allocated into two sub-groups: intervention group (sport + plyometric jump training) and sport group (sport only); 3) exactly after the 9 months of intervention; 4) 6 months following the intervention; 5) 12 months following the intervention. Body composition (dual energy X-ray absorptiometry, air displacement plethysmography and bioelectrical impedance), bone stiffness index (ultrasounds), physical activity (accelerometers), diet (24 h recall questionnaire), pubertal maturation (Tanner stage), physical fitness (cardiorespiratory and muscular) and biochemical markers of bone formation and resorption will be measured at each visit. Discussion: The PRO-BONE study is designed to investigate the impact of osteogenic and non-osteogenic sports on bone development in adolescent males during puberty, and how a plyometric jump training programme is associated with body composition parameters.European Union Seventh Framework Programme [FP7/2007-2013

Cholera outbreak in districts around Lake Chilwa, Malawi: Lessons learned

BackgroundCholera is endemic in Malawi with seasonal outbreaks during the wet season. People living around Lake Chilwa rely on the lake for their water supply. From May 2009 to May 2010, a cholera outbreak occurred in fishing communities around Lake Chilwa. This paper describes the outbreak response and lessons learned for prevention and management of future outbreaks.MethodsStarting in January 2010, Médecins Sans Frontières (MSF) helped District Health Management Teams (DHMTs) to distribute educational materials, water disinfectant and hygiene supplies, and oral rehydration solution (ORS) in fishing communities. MSF also supported case management by mentoring health workers and providing equipment and supplies.ResultsA total of 1,171 cholera cases and 21 deaths were reported in the districts around the lake, with cases also being reported on the Mozambican side of the lake. The attack rate was highest among people living on or around the lake, particularly among fishermen. Samples of lake water had high turbidity conducive to the propagation of Vibrio cholerae.ConclusionA number of practical measures could be taken to prevent future outbreaks and to manage outbreaks more effectively. These measures should address surveillance, environmental management, outbreak preparedness, and case management

CD4 testing at clinics to assess eligibility for Antiretroviral therapy

BackgroundIn 2011, the Ministry of Health raised the CD4 threshold for antiretroviral therapy (ART) eligibility from <250 cells/μl and <350 cells/μl, but at the same time only 8.8% of facilities in Malawi with HIV services provided CD4 testing. We conducted a record review at 10 rural clinics in Thyolo District to assess the impact of introducing CD4 testing on identifying patients eligible for ART.Methods:We abstracted CD4 counts of all ART-naïve, HIV-infected patients with WHO clinical stages 1 and 2 and an initial CD4 test between May 2008 and June 2009. At four clinics, we also abstracted CD4 counts of patients not initially eligible for ART who were retested before April 2010.ResultsOf 1,113 patients tested, the initial CD4 was “≤250 cells/μl” and “≤350 cells/μl” in 534 (48.0%). Of 203 patients with follow-up results, the most recent CD4 was ≤250 cells/μl in 34 (24.5%), and ≤350 cells/μl in 64 (46.0%).ConclusionsCD4 testing in rural clinics is feasible and identifies many patients eligible for ART who would not be identified without CD4 testing. CD4 testing needs to be scaled-up to identify patients eligible for ART. ART services need to be scaled-up concurrently to meet the resulting increased demand

Determinants of bone outcomes in adolescent athletes at baseline: the PRO-BONE study

This is the author accepted manuscript. The final version is available from the American College of Sports Medicine (ACSM) via the DOI in this record.Purpose: The determinants of areal bone mineral density (aBMD) and hip geometry 26 estimates in adolescent athletes are poorly understood. This study aimed to identify the 27 determinants of aBMD and hip geometry estimates in adolescent male athletes. Methods: 28 One hundred twenty one males (13.1±0.1 years) were measured: 41 swimmers, 37 29 footballers, 29 cyclists and 14 controls. Dual energy X-ray absorptiometry (DXA) measured 30 aBMD at lumbar spine, femoral neck (FN) and total body. Hip structural analysis evaluated 31 hip geometry estimates at the FN. Multiple linear regression examined the contribution of the 32 sports practised, stature, lean and fat mass, serum calcium and vitamin D, moderate to 33 vigorous physical activity (MVPA), vertical jump and cardiorespiratory fitness (CRF) with 34 aBMD and hip geometry estimates. Results: Region specific lean mass was the strongest 35 positive predictor of aBMD (β = 0.614 - 0.931) and football participation was the next 36 strongest predictor (β = 0.304 - 0.579). Stature (β = 0.235 - 0.380), fat mass (β = 0.189), 37 serum calcium (β = 0.103), serum vitamin D (β = 0.104 - 0.139) and vertical jump (β = 0.146 38 - 0.203) were associated with aBMD across various specific sites. All hip geometry estimates 39 were associated with lean mass (β = 0.370 - 0.568) and stature (β = 0.338 - 0.430). Football 40 participation was associated with hip cross-sectional area (β = 0.322) and MVPA (β = 0.140 - 41 0.142). CRF (β = 0.183 - 0.207) was associated with section modulus and cross-sectional 42 moment of inertia. Conclusions: Region specific lean mass is the strongest determinant of 43 aBMD and hip geometry estimates in adolescent male athletes. Football participation and 44 stature were important determinants for aBMD and hip geometry estimates while the 45 contribution of the other predictors was site specific.The research leading to these results has received funding from the European Union Seventh Framework Programme ([FP7/2007-2013] under grant agreement n°. PCIG13-GA-2013-61849

Effects of a short individually tailored counselling session for HIV prevention in gay and bisexual men receiving Hepatitis B vaccination

Background. There is currently a trend towards unsafe unprotected anal intercourse (UAI) among men who have sex with men. We evaluated a short individual counselling session on reducing UAI among gay and bisexual men. Methods. A quasi-experimental design was used to evaluate the counselling session. This session was conducted during consulting hours at four municipal health clinics during a Hepatitis B vaccination campaign. These clinics offered free vaccination to high-risk groups, such as gay and bisexual men. All gay and bisexual men attending health clinics in four cities in the Netherlands were asked to participate. Each participant in the intervention group received a fifteen-minute individual counselling based on the Theory of Planned Behaviour and Motivational Interviewing. Changes in UAI were measured over a 5-months period, using self-administered questionnaires. UAI was measured separately for receptive and insertive intercourse in steady and casual partners. These measures were combined in an index-score (range 0-8). Results. While UAI in the counselling group remained stable, it increased in the controls by 66% from 0.41 to 0.68. The results show that the intervention had a protective effect on sexual behaviour with steady partners. Intervention effects were strongest within steady relationships, especially for men whose steady-relationship status changed during the study. The intervention was well accepted among the target group. Conclusion. The fifteen-minute individually tailored counselling session was not only well accepted but also had a protective effect on risk behaviour after a follow-up of six months

Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia

BACKGROUND: Delay in the diagnosis of tuberculosis may worsen the disease, increase the risk of death and enhance tuberculosis transmission in the community. This study aims to determine the length of delay between the onset of symptoms and patients first visit to health care (patient delay), and the length of delay between health care visit and the diagnosis of tuberculosis (health service delay). METHODS: A cross sectional survey that included all the public health centres was conducted in Addis Ababa from August 1 to December 31 1998. Patients were interviewed on the same day of diagnosis using structured questionnaire. RESULTS: 700 pulmonary TB patients were studied. The median patient delay was 60 days and mean 78.2 days. There was no significant difference in socio-demographic factors in those who delayed and came earlier among smear positives. However, there was a significant difference in distance from home to health institute and knowledge about TB treatment among the smear negatives. The health service delay was low (median 6 days; mean 9.5 days) delay was significantly lower in smear positives compared to smear negatives. Longer health service delay (delay more than 15 days) was associated with far distance. CONCLUSIONS: The time before diagnosis in TB patients was long and appears to be associated with patient inadequate knowledge of TB treatment and distance to the health centre. Further decentralization of TB services, the use of some components of active case finding, and raising public awareness of the disease to increase service utilization are recommended

Cost-Effectiveness of Strategies to Improve HIV Testing and Receipt of Results: Economic Analysis of a Randomized Controlled Trial

The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results. To examine the costs and benefits of strategies to improve HIV testing and receipt of results. Cost-effectiveness analysis based on a Markov model. Acceptance of testing, return rates, and related costs were derived from a randomized trial of 251 patients; long-term costs and health outcomes were derived from the literature. Primary-care patients with unknown HIV status. Comparison of three intervention models for HIV counseling and testing: Model A = traditional HIV counseling and testing; Model B = nurse-initiated routine screening with traditional HIV testing and counseling; Model C = nurse-initiated routine screening with rapid HIV testing and streamlined counseling. Life-years, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness. Without consideration of the benefit from reduced HIV transmission, Model A resulted in per-patient lifetime discounted costs of $48,650 and benefits of 16.271 QALYs. Model B increased lifetime costs by$53 and benefits by 0.0013 QALYs (corresponding to 0.48 quality-adjusted life days). Model C cost $66 more than Model A with an increase of 0.0018 QALYs (0.66 quality-adjusted life days) and an incremental cost-effectiveness of$36,390/QALY. When we included the benefit from reduced HIV transmission, Model C cost $10,660/QALY relative to Model A. The cost-effectiveness of Model C was robust in sensitivity analyses. In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies