Halving late diagnosis of HIV:a toolkit for local action

This document is a report of the work carried out in Greater Manchester to pilot a process for ensuring the local delivery of the national Halve It goals. It combines a commentary on the process undertaken within Greater Manchester with a checklist of suggested key actions and reflections on how the Greater Manchester experience can inform other local areas

Performance, power and condom use:reconceptualised masculinities amongst Western male sex tourists to Thailand

Each year large numbers of Western men travel to Thailand for sex tourism. Although many will use condoms during their sexual encounters, others will not, potentially exposing themselves to the risk of acquiring sexually transmitted infections, including HIV. Although sex tourism in Thailand has been well documented, the social drivers underpinning voluntary sexual risk-taking through the avoidance of condoms remain poorly understood. Engaging with R.W. Connell's concept of hegemonic masculinity and drawing on data collected from 1237 online discussion board posts and 14 face-to-face interviews, this study considers the ways in which understandings and performances of masculinities may inform the sexual risk-taking behaviours of Western male sex tourists. It argues that for some of these men, unprotected sex is viewed not as a reckless behaviour but, instead, as a safe and appropriate masculine practice, supported by relationships that are often framed as romantic and within a setting where HIV is still largely considered a homosexual disease. With sex workers often disempowered to request safer sexual practices, and some men's attitudes towards unprotected sex resistant to external health promotion advice, the paper concludes by considering what this might mean for policy and practice

Negotiating the edge:The rationalisation of sexual risk-taking amongst Western male sex tourists to Thailand

Every year thousands of Western men travel to Thailand as sex tourists to participate in paid-for sex. Although many of these men will use condoms to protect themselves against sexually transmitted infections (STIs), others will not, despite the risks. By applying Steven Lyng's (1990) concept of edgework to data collected from 14 face-to-face interviews with male sex tourists in Pattaya, Thailand, and 1,237 online discussion board posts, this article explores the ways in which these men understood and sought to rationalize the sexual risks they took. We argue that notions of likelihood of infection and significance of consequence underpin these behaviors, and we identify the existence of understandings of sexual risk that reject mainstream safer-sex messages and frame condomless sex as a broadly safe activity for heterosexual men. The article concludes by summarizing the difficulties inherent in driving behavior change among this group of men, for whom sexual risks appear to be easily rationalized away as either inconsequential or irrelevant

Meningococcal vaccination in primary care amongst adolescents in North West England:an ecological study investigating associations with general practice characteristics

Background In 2015 the meningococcal ACWY (MenACWY) vaccination was introduced amongst adolescents in England following increased incidence and mortality associated with meningococcal group W. Methods MenACWY vaccination uptake data for 17-18 years old and students delivered in primary care were obtained for 20 National Health Service clinical commissioning groups (CCGs) via the ImmForm vaccination system. Data on general practice characteristics, encompassing demographics and patient satisfaction variables, were extracted from the National General Practice Profiles resource. Univariable analysis of the associations between practice characteristics and vaccination was performed, followed by multivariable negative binomial regression. Results Data were utilized from 587 general practices, accounting for similar to 8% of all general practices in England. MenACWY vaccination uptake varied from 20.8% to 46.8% across the CCGs evaluated. Upon multivariable regression, vaccination uptake increased with increasing percentage of patients from ethnic minorities, increasing percentage of patients aged 15-24 years, increasing percentage of patients that would recommend their practice and total Quality and Outcomes Framework achievement for the practice. Conversely, vaccination uptake decreased with increasing deprivation. Conclusions This study has identified several factors independently associated with MenACWY vaccination in primary care. These findings will enable a targeted approach to improve general practice-level vaccination uptake

HIV risk behaviours among women who inject drugs in coastal Kenya:findings from secondary analysis of qualitative data

Background: Injecting drug users are at high risk of HIV infection globally. Research related to female drug users is rare in Kenya, yet it is required to inform the development of gender-sensitive HIV prevention and harm reduction services in East Africa, where injecting drug use is on the rise. Methods: This study aimed to document the nature of HIV risks encountered by women who inject drugs in the Mombasa and Kilifi, Kenya. Secondary data analysis was conducted on an existing dataset from a 2015 primary qualitative study involving 24 interviews and 3 focus group discussions with 45 women who inject drugs. These were complemented with five interviews with key stakeholders involved in the provision of services to women who inject drugs. Guided by the social ecology theory, a thematic analysis was conducted to identify the nature of HIV risks and their underlying determinants. Results: HIV risk behaviours fell into two broad categories: unsafe injecting and unprotected sex. These risks occurred in the form of sharing of needles, unprotected oral, anal and vaginal sex, sexual assaults, injecting drug use during sex, sex work, and other types of transactional sex. The primary determinants underlying these risks were a low-risk perception, inequitable gender power, economic pressures, and poor availability of needles and condoms. These social-ecological these determinants did not exist in isolation, but intersected with each other to create powerful influences which exposed women to HIV. Social-ecological determinants exerted constant influence and created a persistent ‘HIV risk environment’ that was involuntarily experienced by women. Conclusion: Individual, interpersonal, and societal-structural factors intersect to produce HIV risk behaviours. As a minimum, these risks will require a combination of multifaceted micro-level interventions including self-efficacy training, risk assessment skills, couple counselling, and universal access to the recommended harm reduction package. In addition, the current focus on micro-level interventions in Kenya needs to shift to incorporate macrolevel interventions, including livelihood, employability, and gender norms-transforming interventions, to mitigate economic and gender-related drivers of HIV risks. In the Kenyan context, injecting drug use during sex work is emerging as an increasingly important HIV risk behaviour needing to be addressed

Role of boyfriends and intimate sexual partners in the initiation and maintenance of injecting drug use among women in coastal Kenya

Introduction Gender dynamics and interpersonal relations within intimate partnerships are known to determine health behaviors, including substance use, within couples. In addition, influence from intimate partners may occur in the context of wider social ecological determinants of health behavior. The aim of this study was to document the role of intimate partners in influencing injecting drug use among women in Kenya, where injecting drug use is on the rise. Methods We performed secondary data analysis of an existing dataset from a 2015 qualitative study involving 45 women who inject drugs and 5 key stakeholders in coastal Kenya. Primary data had been collected via a combination of in-depth interviews and focus group discussions exploring sexual, reproductive, drug use, and other social contexts of women who inject drugs. The process by which intimate partners influenced women's initiation of drug use, transition to injecting practices, and maintenance of injecting drug use were identified using thematic analysis. Results Boyfriends and intimate either facilitated or restrained women's drug-injecting. On the one hand, young women's entry into drug use was prompted by relationship problems, or a need to acquiesce with their drug-using boyfriends. Once women started injecting, intimate partners facilitated ongoing drug-injecting by financing the acquisition of drugs, peddling drugs to their women, or sharing their drugs with their women. The social capital that peddlers held insulated women from police arrests, and encouraged women to seek and sustain intimate relations with well-connected peddlers. Men's influences over women were driven by an underlying patriarchal drug acquisition and economic power. On the other hand, boyfriends and intimate partners who were non-injectors or non-drug users sought to moderate women's injecting drug use by encouraging them to inject less, to smoke or snort instead of injecting, or to enroll into rehabilitation. These moderating influences were most prominent when couples were pregnant. Despite men being a source of practical and emotional support, women were frequently unable limit or alter their injecting drug use, due to its addictive nature. Men's disagreement with women's ongoing injecting strained relationships, and occasionally led to separation. Conclusions Some boyfriends facilitated women's injecting drug use, while others moderated it, supporting assertions that intimate relationships can both be a site of injecting risks or protection. At the micro-level, these findings highlight an opportunity for couple-based interventions, leveraging on non-drug injecting males as a resource to support women adopt safer injecting practices. At a macro level, incorporating livelihood interventions into harm reduction programs is required in order to mitigate economic-based influence of male intimate partners on women's injecting drug use. At both levels, gender transformative approaches are essential. To gain a comprehensive understanding of women's injecting drug use, future studies drug use should explore women's contexts beyond micro influences and consider their wider macro-structural determinants

The Impact of Professional Midwives and Mentoring on the Quality and Availability of Maternity Care in Government Sub-district Hospitals in Bangladesh: A Mixed-Methods Observational Study.

Background: This study compared government sub-district hospitals in Bangladesh without globally standard midwives, with those with recently introduced midwives, both with and without facility mentoring, to see if the introduction of midwives was associated with improved quality and availability of maternity care. In addition, it analysed the experiences of the newly deployed midwives and the maternity staff and managers that they joined. Methods: This was a mixed-methods observational study. The six busiest hospitals from three pre-existing groups of government sub-district hospitals were studied; those with no midwives, those with midwives, and those with midwives and mentoring. For the quantitative component, observations of facility readiness (n=18), and eight quality maternity care practices (n=641) were carried out using two separate tools. Willing maternity staff (n=237) also completed a survey on their knowledge, perceptions, and use of the maternity care interventions. Descriptive statistics and logistic regression were used to identify differences between the hospital types. The qualitative component comprised six focus groups and 18 interviews involving midwives, other maternity staff, and managers from the 3 hospital types. Data were analysed using an inductive cyclical process of immersion and iteration to draw out themes. The quantitative and qualitative methods complemented each other and were used synergistically to identify the study’s insights. Results: Quantitative analysis found that, of the eight quality practices, hospitals with midwives but no mentors were significantly more likely than hospitals without midwives to use three: upright labour (94% vs. 63%; OR=22.57, p=0.001), delayed cord clamping (88% vs. 11%; OR=140.67, p<0.001), skin-to-skin (94% vs. 13%; OR=91.21, p<0.001). Hospitals with mentors were significantly more likely to use five: ANC card (84% vs. 52%; OR=3.29, p=0.002), partograph (97% vs. 14%; OR=309.42, p=0.002), upright positioning for labour (95% vs. 63%; OR=1850, p<0.001), delayed cord clamping (98% vs. 11%; OR=3400, p=0.003), and skin-to-skin contact following birth (93% vs. 13%; OR=70.89, p<0.001). Qualitative analysis identified overall acceptance of midwives and the transition to improved quality care; this was stronger with facility mentoring. The most resistance to quality care was expressed in facilities without midwives. In facilities with midwives and mentoring, midwives felt proud, and maternity staff conveyed the greatest acceptance of midwives. Conclusion: Facilities with professional midwives had better availability and quality of maternity care across multiple components of the health system. Care quality further improved with facility mentors who created enabling environments, and facilitated supportive relationships between existing maternity staff and managers and the newly deployed midwives

Comparative evaluation of [(99m)tc]tilmanocept for sentinel lymph node mapping in breast cancer patients: results of two phase 3 trials.

BackgroundSentinel lymph node (SLN) surgery is used worldwide for staging breast cancer patients and helps limit axillary lymph node dissection. [(99m)Tc]Tilmanocept is a novel receptor-targeted radiopharmaceutical evaluated in 2 open-label, nonrandomized, within-patient, phase 3 trials designed to assess the lymphatic mapping performance.MethodsA total of 13 centers contributed 148 patients with breast cancer. Each patient received [(99m)Tc]tilmanocept and vital blue dye (VBD). Lymph nodes identified intraoperatively as radioactive and/or blue stained were excised and histologically examined. The primary endpoint, concordance (lower boundary set point at 90 %), was the proportion of nodes detected by VBD and [(99m)Tc]tilmanocept.ResultsA total of 13 centers contributed 148 patients who were injected with both agents. Intraoperatively, 207 of 209 nodes detected by VBD were also detected by [(99m)Tc]tilmanocept for a concordance rate of 99.04 % (p &lt; 0.0001). [(99m)Tc]tilmanocept detected a total of 320 nodes, of which 207 (64.7 %) were detected by VBD. [(99m)Tc]Tilmanocept detected at least 1 SLN in more patients (146) than did VBD (131, p &lt; 0.0001). In 129 of 131 patients with ≥1 blue node, all blue nodes were radioactive. Of 33 pathology-positive nodes (18.2 % patient pathology rate), [(99m)Tc]tilmanocept detected 31 of 33, whereas VBD detected only 25 of 33 (p = 0.0312). No pathology-positive SLNs were detected exclusively by VBD. No serious adverse events were attributed to [(99m)Tc]tilmanocept.Conclusion[(99m)Tc]Tilmanocept demonstrated success in detecting a SLN while meeting the primary endpoint. Interestingly, [(99m)Tc]tilmanocept was additionally noted to identify more SLNs in more patients. This localization represented a higher number of metastatic breast cancer lymph nodes than that of VBD

Community and Ecosystem-level Changes in a Species-rich Tallgrass Prairie Restoration

Changes in the plant community and ecosystem properties that follow the conversion of agriculture to restored tallgrass prairies are poorly understood. Beginning in 1995, we established a species-rich, restored prairie chronosequence where -3 ha of agricultural land have been converted to tallgrass prairie each year. Our goals were to examine differences in ecosystem properties between these restored prairies and adjacent agricultural fields and to determine changes in, and potential interactions between, the plant community and ecosystem properties that occur over time in the restored prairies. During the summers of 2000-2002, we examined species cover, soil C and N, potential net C and N mineralization, litter mass, soil texture, and bulk density across the 6- to 8-year-old prairie chronosequence and adjacent agricultural fields in southern Minnesota. We also established experimentally fertilized, watered, and control plots in the prairie chronosequence to examine the degree of nitrogen limitation on aboveground and belowground net primary production (ANPP and BNPP). Large shifts in functional diversity occurred within three growing seasons. First-year prairies were dominated by annuals and biennials. By the second growing season, perennial native composites had become dominant, followed by a significant shift to warm-season C4 grasses in prairies ?3 yr old. Ecosystem properties that changed with the rise of C4 grasses included increased BNPP, litter mass, and C mineralization rates and decreased N mineralization rates. ANPP increased significantly with N fertilization but did not vary between young and old prairies with dramatically different plant community composition. Total soil C and N were not significantly different between prairie and agricultural soils in the depths examined (0-10, 10-20, 20-35, 35-50, 50-65 cm). We compared the results from our species-rich prairie restoration to published data on ecosystem function in other restored grasslands, such as Conservation Reserve Program (CRP) and old-field successional sites. Results suggest that rapid changes in functional diversity can have large impacts on ecosystem-level properties, causing community- and system-level dynamics in species-rich prairie restorations to converge with those from low-diversity managed grasslands

Assessing the Feasibility of a Peer Education Project to Improve Mental Health Literacy in Adolescents in the UK

Many mental health problems begin in adolescence and occur on a spectrum of severity: early recognition and intervention is important. This study is a quantitative feasibility study of the Mental Health Foundation's Peer Education Project (PEP). Attrition, psychometric properties of questionnaires, indications of improvement on a range of outcomes, and sample size required for a powered trial of effectiveness were assessed. 203 students completed the survey both pre and post-intervention. It was found that existing previously-validated measures had good psychometric properties, with two new questionnaires demonstrating reasonable reliability (self-help confidence alpha = 0.78, mental health knowledge alpha = 0.59). There were indications of improvement in help-seeking intentions, the number of sources likely to seek help from, and mental health knowledge from pre- to post-intervention. A future trial of PEP with a sample of approximately 36 schools, researcher-led data collections, and help-seeking intentions or sources as a primary outcome appears to be feasible