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Background Injection drug use (IDU) is a growing public health threat in Virginia, though there is limited knowledge of related morbidity. The purpose of this study was to describe the temporal, geographic and clinical trends and characteristics of infective endocarditis associated with IDU (IDU-IE) and to identify opportunities for better-quality care of people who inject drugs (PWID). Methods We reviewed charts for all admissions coded for both IE and drug use disorders at the University of Virginia Medical Center (UVA) from January 2000 to July 2016. A random sample of 30 admissions coded for IE per year were reviewed to evaluate temporal trends in the proportion of IDU associated IE cases. Results There were a total of 76 patients with IDU-IE during the study period, 7.54-fold increase (prevalence ratio: 8.54, 95% CI 3.70–19.72) from 2000 to 2016. The proportion of IE that was IDU-associated increased by nearly 10% each year (prevalence ratio of IDU per year: 1.09, 95% CI: 1.05–1.14). Patients with IDU-IE had longer hospital stays [median days (interquartile range); IDU-IE, 17 (10–29); non-IDU-IE, 10 (6–18); p -value = 0.001] with almost twice the cost of admission as those without IDU [median (interquartile range); IDU-IE, $47,899 ($24,578-78,144); non-IDU-IE, $26,460 ($10,220-60,059); p -value = 0.001]. In 52% of cases there was no documentation of any discussion regarding addiction treatment. Conclusion IDU-IE is a severe infection that leads to significant morbidity and healthcare related costs. IDU-IE rates are increasing and will likely continue to do so without targeted interventions to help PWID. The diagnosis and treatment of IDU-IE provides an opportunity for the delivery of addiction treatment, counseling, and harm reduction strategies.

The World Health Organization (WHO) recognizes point-of-use water treatment (PoUWT) technologies as effective means to improve water quality. This paper investigates long-term performance and social acceptance of a novel PoUWT technology, a silver-infused ceramic tablet, in Limpopo Province, South Africa. When placed in a water storage container, the silver-embedded ceramic tablet releases silver ions into water, thereby disinfecting microbial pathogens and leaving the water safe for human consumption. As a result of its simplicity and efficiency, the silver-embedded ceramic tablet can serve as a stand-alone PoUWT method and as a secondary PoUWT to improve exisitng PoUWT methods, such as ceramic water filters. In this paper, three PoUWT interventions were conducted to evaluate the silver-embedded ceramic tablet: (1) the silver-embedded ceramic tablet as a stand-alone PoUWT method, (2) ceramic water filters stand-alone, and (3) a filter-tablet combination. The filter-tablet combination evaluates the silver-embedded ceramic tablet as a secondary PoUWT method when placed in the lower reservoir of the ceramic water filter system to provide residual disinfection post-filtration. Samples were collected from 79 households over one year and analyzed for turbidity, total silver levels and coliform bacteria. Results show that the silver-embedded ceramic tablet effectively reduced total coliform bacteria (TC) and E. coli when used as a stand-alone PoUWT method and when used in combination with ceramic water filters. The silver-embedded ceramic tablet's performance as a stand-alone PoUWT method was comparable to current inexpensive, single-use PoUWT methods, demonstrating 100% and 75% median reduction in E. coli and TC, respectively, after two months of use. Overall, the the filter-tablet combination performed the best of the three interventions, providing a 100% average percent reduction in E. coli over one year. User surveys were also conducted and indicated that the silver-embedded ceramic tablet was simple to use and culturally appropriate. Also, silver levels in all treated water samples remained below 20 μg/L, significantly lower than the drinking water standard of 100 μg/L, making it safe for consumption. Long-term data demonstrates that the silver-embedded ceramic tablet has beneficial effects even after one year of use. This study demonstrates that the silver-embedded ceramic tablet can effectively improve water quality when used alone, or with ceramic water filters, to reduce rates of recontamination. Therefore, the tablet has the potential to provide a low-cost means to purify water in resource-limited settings.

PositiveLinks (PL) is a smartphone-based platform designed in partnership with people living with HIV (PLWH) to improve engagement in care. PL provides daily medication reminders, check-ins about mood and stress, educational resources, a community message board, and an ability to message providers. The objective of this study was to evaluate the impact of up to 24 months of PL use on HIV viral suppression and engagement in care and to examine whether greater PL use was associated with improved outcomes. This study occurred between September 2013 and March 2017 at a university-based Ryan White HIV clinic. We assessed engagement in care and viral suppression from study baseline to the 6-, 12-, 18- and 24-month follow-up time periods and compared trends among high vs. low PL users. We compared time to viral suppression, proportion of days virally suppressed, and time to engagement in care in patients with high vs. low PL use. 127 patients enrolled in PL. Engagement in care and viral suppression improved significantly after 6 months of PL use and remained significantly improved after 24 months. Patients with high PL use were 2.09 (95% CI 0.64-6.88) times more likely to achieve viral suppression and 1.52 (95% CI 0.89-2.57) times more likely to become engaged in care compared to those with low PL use. Mobile technology, such as PL, can improve engagement in care and clinical outcomes for PLWH. This study demonstrates long-term acceptability of PL over two years and provides evidence for long-term improvement in engagement in care and viral suppression associated with PL use.

Background Malaria remains a global health concern and is endemic in Limpopo, Mpumalanga and KwaZulu Natal Provinces of South Africa, which aims to eliminate malaria by 2025. Community engagement plays a significant role in improving the acceptability and effectiveness of programmes aimed at reducing malaria transmission. The success of such intervention efforts depends on the knowledge, attitudes and practices (KAP) of the community, and understanding the KAP of community residents may support malaria control efforts in the locality. In this context, a cross-sectional household survey to assess community KAP on malaria transmission and prevention in the Ha-Lambani village, Vhembe District, Limpopo Province was conducted. Methods Data were collected between November 2018 and May 2019 by questionnaire of 261 consenting adults (213 females and 48 males, aged between 18 and 95 years) selected from different households. Also, a focus group discussion among 13 randomly selected participants was conducted. Pearson’s Chi Square test was used to determine statistical differences by village. Results Study participants (100%, 261/261) were aware of the presence of malaria in their community and 95% associated it with mosquito bites. The local health clinic was the most prominent source of malaria information (85%). Only 22% correctly identified headache, chills and fever as the three most common symptoms of malaria. The majority of participants (98%) knew that effective medication for malaria is available and had a positive treatment-seeking behaviour. Knowledge of malaria prevention measures was high (82%); contrarily, 97% of respondents did not sleep under a bed net the previous night. The focus group data concurred with these results and also revealed that poor bed net use resulted from lack of access to bed nets because community residents could not afford them. Conclusions The study demonstrates that participants have appropriate knowledge about malaria transmission and a positive treatment-seeking behaviour. However, economic barriers are responsible for the inadequate use of bed nets. Therefore, distribution of bed nets to the community should be considered to improve practice of malaria prevention measures. Furthermore, knowledge of signs and symptoms and appropriate malaria treatment was limited, and initiatives to improve awareness on these topics should be continued.

Consumption of microbial-contaminated water can result in diarrheal illnesses and enteropathy with the heaviest impact upon children below the age of five. We aimed to provide a comprehensive analysis of water quality in a low-resource setting in Limpopo province, South Africa. Surveys were conducted in 405 households in rural communities of Limpopo province to determine their water-use practices, perceptions of water quality, and household water-treatment methods. Drinking water samples were tested from households for microbiological contamination. Water from potential natural sources were tested for physicochemical and microbiological quality in the dry and wet seasons. Most households had their primary water source piped into their yard or used an intermittent public tap. Approximately one third of caregivers perceived that they could get sick from drinking water. All natural water sources tested positive for fecal contamination at some point during each season. The treated municipal supply never tested positive for fecal contamination; however, the treated system does not reach all residents in the valley; furthermore, frequent shutdowns of the treatment systems and intermittent distribution make the treated water unreliable. The increased water quantity in the wet season correlates with increased treated water from municipal taps and a decrease in the average contaminant levels in household water. This research suggests that wet season increases in water quantity result in more treated water in the region and that is reflected in residents’ water-use practices.

Background Campylobacter spp. are one of the most frequent causes of diarrhoeal disease in humans throughout the world. This study aimed at determining the prevalence and the genotypic distribution of Campylobacter spp. and their association with diarrhoea and child growth in children of less than the age of two in the Limpopo Province of South Africa . Methods A total of 4280 diarrheal and non-diarrheal stool samples were collected on a monthly basis from children recruited at birth and followed up to 24 months. All stool samples were screened for the presence Campylobacter antigen using ELISA technique after which CAH 16S primer was used on the positive samples to confirm the presence of Campylobacter . Subsequently, the PCR positive samples were further characterised using species specific primers for Campylobacter jejuni and Campylobacter coli. Results Campylobacter antigen was detected in 564/4280 (13.2%). Campylobacter was more commonly found in diarrheal stools (20.4%) compared to non-diarrheal stools (12.4%) with a statistically significant difference (χ 2  = 7.345; p  = 0.006). Throughout the year there were two main peaks of Campylobacter infection one in December- January and the second peak in June. The prevalence of Campylobacter increased with the age of the children up to 11 months after which the prevalence decreased. Out of 564 positive ELISA samples, 257 (45.6%) were confirmed to have 16S rRNA gene for Campylobacter spp . Furthermore, C. jejuni was found to be more prevalent (232/257) than C. coli (25/257) with a prevalence of 90.3% and 9.7%, respectively . Both C. jejuni and C. coli were significantly associated with diarrhea with statistical values of (χ 2  = 22.224; p  < 0.001) and (χ 2  = 81.682; p  < 0.001) respectively. Sequences generated from the analysis of hip gene confirmed the PCR positives samples were C. jejuni positive. Conclusions This study has delineated a high prevalence of Campylobacter spp . in the study cohort. Moreover, C. jejuni was found to be more prevalent than C. coli both of which were associated with diarrhea. These findings are of clinical and epidemiological significance.

Background Morbidity and mortality related to opioid use disorder (OUD) in the U.S. is at an all-time high. Innovative approaches are needed to address gaps in retention in treatment with medications for opioid use disorder (MOUD). Mobile health (mHealth) approaches have shown improvement in engagement in care and associated clinical outcomes for a variety of chronic diseases, but mHealth tools designed specifically to support patients treated with MOUD are limited. Methods Following user-centered development and testing phases, a multi-feature smartphone application called HOPE (Heal. Overcome. Persist. Endure) was piloted in a small cohort of patients receiving MOUD and at high risk of disengagement in care at an office-based opioid treatment (OBOT) clinic in Central Virginia. Outcomes were tracked over a six-month period following patient enrollment. They included retention in care at the OBOT clinic, usage of various features of the application, and self-rated measures of mental health, substance use, treatment and recovery. Results Of the 25 participants in the HOPE pilot study, a majority were retained in care at 6 months (56%). Uptake of bi-directional features including messaging with providers and daily check-ins of mood, stress and medication adherence peaked at one month, and usage persisted through the sixth month. Patients who reported that distance to clinic was a problem at baseline had higher loss to follow up compared to those without distance as a reported barrier (67% vs 23%, p = 0.03). Patients lost to in-person clinic follow up continued to engage with one or more app features, indicating that mHealth approaches may bridge barriers to clinic visit attendance. Participants surveyed at baseline and 6 months (N = 16) scored higher on scales related to overall self-control and self-efficacy related to drug abstinence. Conclusions A pilot study of a novel multi-feature smartphone application to support OUD treatment showed acceptable retention in care and patient usage at 6 months. Further study within a larger population is needed to characterize ‘real world’ uptake and association with outcomes related to retention in care, relapse prevention, and opioid-associated mortality.

Background Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States. Methods We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care. Results Over half of previously referred patients ( N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one’s own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care. Conclusions Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.

Background Recovery after surgery intersects physical, psychological, and social domains. In this study we aim to assess the feasibility and usability of a mobile health application called PositiveTrends to track recovery in these domains amongst participants undergoing hip, knee arthroplasty or spine surgery. Our secondary aim was to generate procedure-specific, recovery trajectories within the pain and medication, psycho-social and patient-reported outcomes domain. Methods Prospective, observational study in participants greater than eighteen years of age. Data was collected prior to and up to one hundred and eighty days after completion of surgery within the three domains using PositiveTrends. Feasibility was assessed using participant response rates from the PositiveTrends app. Usability was assessed quantitatively using the System Usability Scale. Heat maps and effect plots were used to visualize multi-domain recovery trajectories. Generalized linear mixed effects models were used to estimate the change in the outcomes over time. Results Forty-two participants were enrolled over a four-month recruitment period. Proportion of app responses was highest for participants who underwent spine surgery (median = 78, range = 36–100), followed by those who underwent knee arthroplasty (median = 72, range = 12–100), and hip arthroplasty (median = 62, range = 12–98). System Usability Scale mean score was 82 ± 16 at 180 days postoperatively. Function improved by 8 and 6.4 points per month after hip and knee arthroplasty, respectively. In spine participants, the Oswestry Disability Index decreased by 1.4 points per month. Mood improved in all three cohorts, however stress levels remained elevated in spine participants. Pain decreased by 0.16 (95% Confidence Interval: 0.13–0.20, p  < 0.001), 0.25 (95% CI: 0.21–0.28, p  < 0.001) and 0.14 (95% CI: 0.12–0.15, p  < 0.001) points per month in hip, knee, and spine cohorts respectively. There was a 10.9-to-40.3-fold increase in the probability of using no medication for each month postoperatively. Conclusions In this study, we demonstrate the feasibility and usability of PositiveTrends, which can map and track multi-domain recovery trajectories after major arthroplasty or spine surgery.

ObjectivesWe developed and tested a mobile health-based programme to enhance integration of HIV and tuberculosis (TB) care and to promote a patient-centred approach in a region of high coinfection burden. Phases of programme development included planning, stakeholder interviews and platform re-build, testing and iteration.SettingIn Irkutsk, Siberia, HIV/TB coinfection prevalence is high relative to the rest of the Russian Federation.ParticipantsPilot testing occurred for a cohort of 60 people with HIV and TB.ResultsKey steps emerged to ensure the mobile health-based programme could be operational and adequately adapted for the context, including platform language adaptation, optimisation of server management, iteration of platform features, and organisational practice integration. Pilot testing of the platform rebuild yielded favourable patient perceptions of usability and acceptability at 6 months (n=47 surveyed), with 18 of 20 items showing scores above 4 (on a scale from 1 to 5) on average. Development of this mobile health-based programme for integrated care of infections highlighted the importance of several considerations for tailoring these interventions contextually, including language adaptation and technological capacity, but also, importantly, contextualised patient preferences related to privacy and communication with peers and/or providers, existing regional capacity for care coordination of different comorbidities, and infection severity and treatment requirements.ConclusionsOur experience demonstrated that integration of care for TB and HIV can be well served by using multimodal mobile health-based programmes, which can enhance communication and streamline workflow between providers across multiple collaborating institutions and improve continuity between inpatient and outpatient care settings. Further study of programme impact on contextual disease-related stigma and social isolation as well as evaluation of implementation on a broader scale for HIV care is currently under way.Trial registration numberNCT03819374.