Barriers and enablers experienced by health care workers in swabbing for COVID-19 in Papua New Guinea: A multi-methods cross-sectional study.

OBJECTIVE: We aimed to identify the barriers and enablers that Health Care Workers (HCWs) in Papua New Guinea experienced in swabbing for COVID-19. METHODS: We conducted a cross-sectional multi-methods study: a qualitative scoping exercise and a telephone survey. The target population was COVID-19-trained HCWs from all provinces of Papua New Guinea. A descriptive analysis of survey responses was conducted alongside a rapid qualitative analysis of interviews and open-ended survey questions. RESULTS: Four thematic areas were identified: human resources, logistics, HCW attitudes and community attitudes. The survey response rate was 70.3% (407/579). Commonly reported barriers to COVID-19 swabbing were insufficient staff trained (74.0%, n = 301), inadequate staffing in general (64.9%, n = 264), insufficient supply of personal protective equipment (60.9%, n = 248) and no cold chain to store swabs (57.5%, n = 234). Commonly reported enablers to swabbing were community awareness and risk communication (80.8%, n = 329), consistent and sufficient supplies of personal protective equipment (67.8%, n = 276), increased surge workforce (63.9%, n = 260) and having a fridge to store swabs (59.7%, n = 243). CONCLUSIONS: A comprehensive community and HCW engagement strategy combined with innovations to improve the supply chain are needed to increase COVID-19 swabbing in Papua New Guinea to reach national testing targets. Investments in increasing numbers of frontline workforce, consistent supplies of PPE, swabs, transport medium, cold boxes and ability to make ice packs, in addtion to establishing regular tranport of specimens from the facility to the testing site will strengthen the supply chain. Innovations are needed to address these issues

European interlaboratory comparison investigations (ICI) and external quality assurance schemes (EQUAS) for the analysis of bisphenol A, S and F in human urine: Results from the HBM4EU project

The Human Biomonitoring for Europe initiative (HBM4EU) aims to study the exposure of citizens to chemicals and potentially associated health effects. One objective of this project has been to build a network of laboratories able to answer to the requirements of European human biomonitoring studies. Within the HBM4EU quality assurance and quality control scheme (QA/QC), a number of interlaboratory comparison investigations (ICIs) and external quality assurance schemes (EQUASs) were organized to ensure data consistency, comparability and reliability. Bisphenols are among the prioritized substance groups in HBM4EU, including bisphenol A (BPA), bisphenol S (BPS) and bisphenol F (BPF) in human urine. In four rounds of ICI/EQUAS, two target concentration levels were considered, related to around P25 and P95 of the typical exposure distribution observed in the European general population. Special attention was paid to the conjugated phase II metabolites known to be most dominant in samples of environmentally exposed individuals, through the analysis of both native samples and samples fortified with glucuronide forms. For the low level, the average percentage of satisfactory results across the four rounds was 83% for BPA, 71% for BPS and 62% for BPF. For the high level, the percentages of satisfactory results increased to 93% for BPA, 89% for BPS and 86% for BPF. 24 out of 32 participating laboratories (75%) were approved for the analyses of BPA in the HBM4EU project according to the defined criterion of Z-scores for both low and high concentration levels in at least two ICI/EQUAS rounds. For BPS and BPF, the number of qualified laboratories was 18 out of 27 (67%) and 13 out of 28 (46%), respectively. These results demonstrate a strong analytical capability for BPA and BPS in Europe, while improvements may be needed for BPF.We gratefully acknowledge funding by the European Union's Horizon 2020 research and innovation programme under the grant agreement No. 733032 HBM4EU. The authors would like to thank the HBM4EU Secretariat at the German Environment Agency for administrative support. The authors acknowledge all the participating and expert laboratories (Table A1, SM) that made the HBM4EU QA/QC programme possible as well as the Management and Advisory Boards of HBM4EU.S

Proficiency and Interlaboratory Variability in the Determination of Phthalate and DINCH Biomarkers in Human Urine: Results from the HBM4EU Project

A quality assurance/quality control program was implemented in the framework of the EU project HBM4EU to assess and improve the comparability of biomarker analysis and to build a network of competent laboratories. Four rounds of proficiency tests were organized for 15 phthalate and two DINCH urinary biomarkers (0.2-138 ng/mL) over a period of 18 months, with the involvement of 28 laboratories. A substantial improvement in performance was observed after the first round in particular, and by the end of the program, an average satisfactory performance rate of 90% was achieved. The interlaboratory reproducibility as derived from the participants' results varied for the various biomarkers and rounds, with an average of 24% for the biomarkers of eight single-isomer phthalates (e.g., DnBP and DEHP) and 43% for the more challenging biomarkers of the mixed-isomer phthalates (DiNP, DiDP) and DINCH. When the reproducibility was based only on the laboratories that consistently achieved a satisfactory performance, this improved to 17% and 26%, respectively, clearly demonstrating the success of the QA/QC efforts. The program thus aided in building capacity and the establishment of a network of competent laboratories able to generate comparable and accurate HBM data for phthalate and DINCH biomarkers in 14 EU countries. In addition, global comparability was ensured by including external expert laboratories.This study was part of the HBM4EU project receiving funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No 733032. Co-funding was received from the Dutch Ministry of Agriculture, Nature and Food Quality (project KB 37-002-014-001/002).S

Interlaboratory comparison investigations (ICIs) and external quality assurance schemes (EQUASs) for flame retardant analysis in biological matrices: Results from the HBM4EU project

The European Human Biomonitoring Initiative (HBM4EU) is coordinating and advancing human biomonitoring (HBM). For this purpose, a network of laboratories delivering reliable analytical data on human exposure is fundamental. The analytical comparability and accuracy of laboratories analysing flame retardants (FRs) in serum and urine were investigated by a quality assurance/quality control (QA/QC) scheme comprising interlaboratory comparison investigations (ICIs) and external quality assurance schemes (EQUASs). This paper presents the evaluation process and discusses the results of four ICI/EQUAS rounds performed from 2018 to 2020 for the determination of ten halogenated flame retardants (HFRs) represented by three congeners of polybrominated diphenyl ethers (BDE-47, BDE-153 and BDE-209), two isomers of hexabromocyclododecane (α-HBCD and γ-HBCD), two dechloranes (anti-DP and syn-DP), tetrabromobisphenol A (TBBPA), decabromodiphenylethane (DBDPE), and 2,4,6-tribromophenol (2,4,6-TBP) in serum, and four metabolites of organophosphorus flame retardants (OPFRs) in urine, at two concentration levels. The number of satisfactory results reported by laboratories increased during the four rounds. In the case of HFRs, the scope of the participating laboratories varied substantially (from two to ten) and in most cases did not cover the entire target spectrum of chemicals. The highest participation rate was reached for BDE-47 and BDE-153. The majority of participants achieved more than 70% satisfactory results for these two compounds over all rounds. For other HFRs, the percentage of successful laboratories varied from 44 to 100%. The evaluation of TBBPA, DBDPE, and 2,4,6-TBP was not possible because the number of participating laboratories was too small. Only seven laboratories participated in the ICI/EQUAS scheme for OPFR metabolites and five of them were successful for at least two biomarkers. Nevertheless, the evaluation of laboratory performance using Z-scores in the first three rounds required an alternative approach compared to HFRs because of the small number of participants and the high variability of experts' results. The obtained results within the ICI/EQUAS programme showed a significant core network of comparable European laboratories for HBM of BDE-47, BDE-153, BDE-209, α-HBCD, γ-HBCD, anti-DP, and syn-DP. On the other hand, the data revealed a critically low analytical capacity in Europe for HBM of TBBPA, DBDPE, and 2,4,6-TBP as well as for the OPFR biomarkers.We gratefully acknowledge funding by the European Union's Horizon 2020 research and innovation programme under the grant agreement No. 733032.S

Interlaboratory comparison investigations (ICIs) and external quality assurance schemes (EQUASs) for flame retardant analysis in biological matrices: Results from the HBM4EU project

The European Human Biomonitoring Initiative (HBM4EU) is coordinating and advancing human biomonitoring (HBM). For this purpose, a network of laboratories delivering reliable analytical data on human exposure is fundamental. The analytical comparability and accuracy of laboratories analysing flame retardants (FRs) in serum and urine were investigated by a quality assurance/quality control (QA/QC) scheme comprising interlaboratory comparison investigations (ICIs) and external quality assurance schemes (EQUASs). This paper presents the evaluation process and discusses the results of four ICI/EQUAS rounds performed from 2018 to 2020 for the determination of ten halogenated flame retardants (HFRs) represented by three congeners of polybrominated diphenyl ethers (BDE-47, BDE-153 and BDE-209), two isomers of hexabromocyclododecane (α-HBCD and γ-HBCD), two dechloranes (anti-DP and syn-DP), tetrabromobisphenol A (TBBPA), decabromodiphenylethane (DBDPE), and 2,4,6-tribromophenol (2,4,6-TBP) in serum, and four metabolites of organophosphorus flame retardants (OPFRs) in urine, at two concentration levels. The number of satisfactory results reported by laboratories increased during the four rounds. In the case of HFRs, the scope of the participating laboratories varied substantially (from two to ten) and in most cases did not cover the entire target spectrum of chemicals. The highest participation rate was reached for BDE-47 and BDE-153. The majority of participants achieved more than 70% satisfactory results for these two compounds over all rounds. For other HFRs, the percentage of successful laboratories varied from 44 to 100%. The evaluation of TBBPA, DBDPE, and 2,4,6-TBP was not possible because the number of participating laboratories was too small. Only seven laboratories participated in the ICI/EQUAS scheme for OPFR metabolites and five of them were successful for at least two biomarkers. Nevertheless, the evaluation of laboratory performance using Z-scores in the first three rounds required an alternative approach compared to HFRs because of the small number of participants and the high variability of experts' results. The obtained results within the ICI/EQUAS programme showed a significant core network of comparable European laboratories for HBM of BDE-47, BDE-153, BDE-209, α-HBCD, γ-HBCD, anti-DP, and syn-DP. On the other hand, the data revealed a critically low analytical capacity in Europe for HBM of TBBPA, DBDPE, and 2,4,6-TBP as well as for the OPFR biomarkers.We gratefully acknowledge funding by the European Union's Horizon 2020 research and innovation programme under the grant agreement No. 733032.S

Adherence to HIV pre-exposure prophylaxis in New South Wales, Australia

Pre-exposure prophylaxis (PrEP) is a highly efficacious HIV prevention strategy. The caveat, however, is that PrEP requires high adherence to antiretroviral medications during periods when a person is at risk of acquiring HIV. Identifying who is at risk of HIV and ensuring adequate coverage during these risk periods is a key challenge of PrEP implementation. The overarching objective of this thesis was to examine adherence to PrEP among gay and bisexual men (GBM) in New South Wales, Australia. This body of research comprises four projects. Data for three projects came from the PrELUDE Demonstration Project (2014 – 2017), while data for the fourth project was drawn from SIN-PrEP (2015 – 2018). The first project assessed the NSW PrEP guidelines and found that individuals at high risk of HIV could be identified and enrolled into a PrEP demonstration project. The second project investigated PrEP dosing preferences and found that one-third of GBM expressed a preference for non-daily PrEP. A preference for taking daily PrEP was associated with lower levels of education, having an HIV-positive partner, and rating oneself better at taking medications. The third project compared four different adherence measures and found that in our setting, facilitated recall to clinicians was as good as biological measures in identifying adherent individuals. Over 90% of participants remaining under follow-up after 12 months reported taking seven PrEP pills per week throughout the year. A generalised estimating equation model identified that practices such as group sex were associated with taking daily PrEP. The fourth project used qualitative data from interviews with current and previous PrEP users to explore in-depth issues relating to PrEP adherence. Although most participants reported encountering barriers to PrEP use, they had developed effective strategies to ensure that high levels of adherence to PrEP could be maintained. This thesis assesses the interplay between social, behavioural, and biomedical factors that impact PrEP adherence, and how the influence of each of these factors may fluctuate during PrEP use. The high level of adherence in this cohort I have described through this thesis underpins the success of PrEP as an HIV prevention intervention in GBM in Australia

Barriers to care in gout : from prescriber to patient

Objective. To explore the understanding of gout and its management by patients and general practitioners (GP), and to identify barriers to optimal gout care. Methods. Semistructured interviews were conducted with 15 GP and 22 patients in Sydney, Australia. Discussions were focused on medication adherence, experiences with gout, and education and perceptions around interventions for gout. Interviews were audio recorded, transcribed verbatim, and analyzed for themes using an analytical framework. Results. Adherence to urate-lowering medications was identified as problematic by GP, but less so by patients with gout. However, patients had little appreciation of the risk of acute attacks related to variable adherence. Patients felt stigmatized that their gout diagnosis was predominantly related to perceptions that alcohol and dietary excess were causal. Patients felt they did not have enough education about gout and how to manage it. A manifestation of this was that uric acid concentrations were infrequently measured. GP were concerned that they did not know enough about managing gout and most were not familiar with current guidelines for management. For example and importantly, the strategies for reducing the risk of acute attacks when commencing urate-lowering therapy (ULT) were not well appreciated by GP or patients. Conclusion. Patients and GP wished to know more about gout and its management. Greater success in establishing and maintaining ULT will require further and better education to substantially benefit patients. Also, given the prevalence, and personal and societal significance of gout, innovative approaches to transforming the management of this eminently treatable disease are needed

High adherence to HIV PrEP among clinic attendees over 12 months in the PRELUDE open-label demonstration project

Introduction: The efficacy of HIV pre-exposure prophylaxis (PrEP) depends upon adherence. Facilitated recall is a practical measure to monitor patients’ adherence to PrEP in clinical practice. Data from the PRELUDE Demonstration Project were used to investigate patterns and predictors of adherence to daily PrEP over 12 months. Methods: PRELUDE was an open-label study of high-HIV risk individuals taking PrEP in New South Wales, Australia. PrEP adherence was assessed quarterly for one year. Participants were asked by clinicians about the number of pills taken in the previous week (facilitated recall). Adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for factors associated with daily adherence were calculated using generalised estimating equations for longitudinal data. Results: Of the 321 gay/bisexual men (GBM) enrolled in the study, 263 (82%) remained on study at month 12. Of these, 243 (92%) and 230 (87%) reported daily adherence (7 pills/week) at month and 12, respectively. Adherence declined by 10% during the study (aOR 0.90, 95%CI 0.84-0.95, p<0.001). In multivariate analysis, participants were more likely to report taking 7 pills in the previous week if they had engaged in group sex in the previous three months (aOR 1.33, 95%CI 1.15-1.53) or attended a private clinic (aOR 1.50, 95%CI 1.07-2.11). Conclusions: Among participants who completed one year of follow-up on PRELUDE, daily PrEP use was more likely among those at ongoing risk of HIV due to their behaviours. The moderate loss to follow-up in the cohort is not surprising, as individuals are not expected to remain on PrEP forever, but rather, during periods of risk. Combined, these results suggest that GBM in this study who are highly engaged with healthcare systems can identify times when they are at increased risk of contracting HIV and act accordingly, taking PrEP consistently as recommended during this time

Age-related prevalence and twelve-month incidence of illicit drug use in a cohort of Australian gay and bisexual men: Results from the Flux Study

Background: We report prevalence and incidence of drug use initiation in Australian gay and bisexual men (GBM) participating in an online cohort study. Methods: Between September 2014 and June 2015, 1,710 GBM were enrolled in the Following Lives Undergoing Change Study and followed-up six monthly. Participants were asked about measures of lifetime use at baseline and recent use (last six months) at all visits. Drug use initiation was defined as men who reported having never used a specific drug prior to baseline and reported recent use at follow-up. Results: Participants’ median age was 31 years (range: 16–81). Prevalence of lifetime use was significantly associated with older age for all individual drugs (p trend<0.001), and 84.1% reported lifetime use of any drugs. Just above half (51.9%) reported recent use at baseline, with the majority reporting occasional use (once or twice in the previous six-months). Among men who reported no history of drug use at baseline, drug initiation was highest for amyl nitrite, with an incidence of 10.5 per 100 person-years (95% CI 7.9–13.9), followed by cannabis (7.3 per 100 person-years, 95% CI 5.0–10.6) and ecstasy (5.0 per 100 person-years, 95% CI 3.6–7.0). Younger age was significantly associated with higher incidence of initiation of amyl nitrite, ecstasy, cocaine, ketamine, GHB, and LSD (p trend <0.05 for all). Conclusion: Prevalence of lifetime illicit drug use is lower in younger GBM than in their older counterparts. However, incidence of drug use initiation is high among younger men, providing an opportunity for early intervention

Predictors of Daily Adherence to HIV Pre-exposure Prophylaxis in Gay/Bisexual Men in the PRELUDE Demonstration Project

Adequate adherence to pre-exposure prophylaxis (PrEP) is critical to prevent HIV infection, but accurately measuring adherence remains challenging. We compared two biological [blood drug concentrations in plasma and peripheral blood mononuclear cells (PBMC)] and two self-reported measures (facilitated recall to clinicians and self-report in online surveys) and identified predictors of daily PrEP adherence among gay and bisexual men (GBM) in their first 12 months on PRELUDE, an open-label, single-arm PrEP demonstration project in New South Wales, Australia. 327 participants were enrolled; 263 GBM attended their 12-month follow-up visit (81% retention). Overall, 91% of blood samples had plasma drug concentrations indicative of taking 7 pills/week, and 99% had protective drug concentrations (≥ 4 pills/week). Facilitated recall to clinicians identified 99% of participants with protective adherence as measured by PBMC drug concentrations. Daily adherence measured by facilitated recall was associated with behavioural practices including group sex (aOR 1.33, 95% CI 1.15-1.53, p < 0.001). Retained participants maintained high adherence to daily PrEP over 12 months, confirmed by four different measures. Facilitated recall to clinicians is a suitable measure for assessing PrEP adherence in populations engaged in care where there is established trust and rapport with patients. Trial registration: ClinicalTrials.gov NCT02206555