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“They gave us the right to choose.” A qualitative study of preferences for differentiated service delivery location among recipients of antiretroviral therapy at Lighthouse Trust in Lilongwe Malawi
Some differentiated service delivery (DSD) models for antiretroviral therapy (ART) allow stable recipients of care (RoC) to receive multi-month ART drug refills and complete rapid reviews in community sites. As DSD options expand across sub-Saharan Africa, RoC’s preferences and perspectives on community-based DSD versus clinic-based care models warrants attention. Lighthouse Trust (LT) implements DSD services for the Ministry of Health in Lilongwe, Malawi, including a community-based ART service delivery model that complements it traditional, clinic-based care. In this qualitative study, we explore reasons why RoC enrolled in LT clinics and eligible for DSD chose clinic-based ART services or a Nurse-led Community-based ART Program (NCAP) that reaches clients in established community peer support groups. We conducted eight focus group discussions (FGDs) among LT RoC: four FGDs among NCAP groups and four clinic-based FGDs (2 per setting) to explore opinions, preferences, and perceptions about ART service delivery. FGDs were recorded in Chichewa, translated and transcribed into English for thematic analysis. Findings were discussed with LT and NCAP teams to ensure results resonated with their personal experiences. Sixty-three participants took part in FGDs. Many findings were similar across care model. Across both NCAP and clinic FGDs, RoC were pleased with the care quality and appreciated the convenience of integrating their appointment visits at their chosen care model into their daily lives. Across FGDs, RoC also appreciated the quality of care, the respectful provider-to-patient interactions, and the attention to privacy at community and clinic sites. RoC in both clinic and NCAP care models expressed satisfaction with their chosen care model and preferred that choice over alternative options and locations, some noting their willingness to travel far to access LT’s high quality of clinic-based care. Privacy protection was an important consideration for choosing care models. At LT clinics, RoC highlighted the importance of physical separation between LT’s HIV-specific service site and other care services. In NCAP, RoC expressed that their choice of care model was reinforced by the sense of mutual support they received through NCAP peer support. These findings suggest the importance of offering personal choice to RoC on care model and selection of DSD options to support their ongoing engagement in care.
Journal Article
CCDC65 Mutation Causes Primary Ciliary Dyskinesia with Normal Ultrastructure and Hyperkinetic Cilia
Primary ciliary dyskinesia (PCD) is a genetic disorder characterized by impaired ciliary function, leading to chronic sinopulmonary disease. The genetic causes of PCD are still evolving, while the diagnosis is often dependent on finding a ciliary ultrastructural abnormality and immotile cilia. Here we report a novel gene associated with PCD but without ciliary ultrastructural abnormalities evident by transmission electron microscopy, but with dyskinetic cilia beating.
Genetic linkage analysis was performed in a family with a PCD subject. Gene expression was studied in Chlamydomonas reinhardtii and human airway epithelial cells, using RNA assays and immunostaining. The phenotypic effects of candidate gene mutations were determined in primary culture human tracheobronchial epithelial cells transduced with gene targeted shRNA sequences. Video-microscopy was used to evaluate cilia motion.
A single novel mutation in CCDC65, which created a termination codon at position 293, was identified in a subject with typical clinical features of PCD. CCDC65, an orthologue of the Chlamydomonas nexin-dynein regulatory complex protein DRC2, was localized to the cilia of normal nasal epithelial cells but was absent in those from the proband. CCDC65 expression was up-regulated during ciliogenesis in cultured airway epithelial cells, as was DRC2 in C. reinhardtii following deflagellation. Nasal epithelial cells from the affected individual and CCDC65-specific shRNA transduced normal airway epithelial cells had stiff and dyskinetic cilia beating patterns compared to control cells. Moreover, Gas8, a nexin-dynein regulatory complex component previously identified to associate with CCDC65, was absent in airway cells from the PCD subject and CCDC65-silenced cells.
Mutation in CCDC65, a nexin-dynein regulatory complex member, resulted in a frameshift mutation and PCD. The affected individual had altered cilia beating patterns, and no detectable ultrastructural defects of the ciliary axoneme, emphasizing the role of the nexin-dynein regulatory complex and the limitations of certain methods for PCD diagnosis.
Journal Article
Mapping HIV prevalence in sub-Saharan Africa between 2000 and 2017
HIV/AIDS is a leading cause of disease burden in sub-Saharan Africa. Existing evidence has demonstrated that there is substantial local variation in the prevalence of HIV; however, subnational variation has not been investigated at a high spatial resolution across the continent. Here we explore within-country variation at a 5 × 5-km resolution in sub-Saharan Africa by estimating the prevalence of HIV among adults (aged 15–49 years) and the corresponding number of people living with HIV from 2000 to 2017. Our analysis reveals substantial within-country variation in the prevalence of HIV throughout sub-Saharan Africa and local differences in both the direction and rate of change in HIV prevalence between 2000 and 2017, highlighting the degree to which important local differences are masked when examining trends at the country level. These fine-scale estimates of HIV prevalence across space and time provide an important tool for precisely targeting the interventions that are necessary to bringing HIV infections under control in sub-Saharan Africa.
Fine-scale estimates of the prevalence of HIV in adults across sub-Saharan Africa reveal substantial within-country variation and local differences in both the direction and rate of change in the prevalence of HIV between 2000 and 2017.
Journal Article
Alcohol use and viral suppression in HIV-positive Kenyan female sex workers on antiretroviral therapy
Excessive alcohol intake has been associated with poor adherence to antiretroviral therapy (ART). The impact of alcohol on viral suppression is particularly important among groups at high risk of HIV transmission, such as female sex workers (FSWs). Few studies have directly evaluated the association between alcohol use and HIV viral load. We hypothesized that hazardous or harmful alcohol use is associated with detectable plasma viral load among HIV-positive FSWs.
A prospective cohort study was conducted among HIV-positive FSWs in Mombasa, Kenya. Hazardous or harmful alcohol use was assessed yearly and defined as an Alcohol Use Disorders Identification Test (AUDIT) score ≥7. Detectable viral load was assessed every six months and defined as ≥180 c/mL. Adherence measures were collected monthly and included late ART refill (>48 hours) and self-reported adherence, using both a validated self-rating scale of ability to take medication and visual analog scale (VAS) of ART use in the last month. Generalized estimating equations were used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CI).
This analysis included 366 participants followed monthly between October 2012 and March 2018. At baseline, AUDIT scores indicated hazardous alcohol use (AUDIT 7-15) in 14.3%, harmful alcohol use (AUDIT 16-19) in 1.4%, and alcohol dependency (AUDIT ≥20) in 1.4% of participants. After adjusting for potential confounders, a combined exposure including hazardous, harmful, and dependent alcohol use was not associated with detectable viral load (aRR 1.10, 95%CI 0.63-1.92) or late ART refill (aRR 1.13, 95%CI 0.82-1.56), but was associated with lower self-rated ability to take medication (aRR 2.38, 95%CI 1.42-3.99) and a lower rate of self-reported perfect ART adherence by VAS (aRR 2.62, 95%CI 1.84-3.71).
In this FSW cohort, while participants reporting hazardous, harmful, or dependent alcohol use were not more likely to have a detectable viral load, they were more likely to report lower ART adherence. These results suggest that interventions targeting alcohol use among this population of FSWs may not have a large impact on viral suppression.
Journal Article
Student Responses to a Tough Early Assessment : A Useful \Kick up the Bum\?
First year is a delicate time for students. Many have little idea what to expect of university, and their sense of identity as tertiary students is fragile. A diagnostic assessment early in first semester may reassure students that
they have chosen the right path. However, some academics, particularly in engineering, argue that this early assessment should be very demanding - so tough, in fact, that some students fail - in order to alert students to the hard work
required to pass the course. This study uses a mixed methods design (weekly surveys and in-depth interviews) to explore the effects of a purposefully tough early assessment on first year engineering students at an Australian university.
We find that, across the cohort, the high failure rate was not associated with a significant slump or spike in motivation. Although some students were initially dismayed by their results, most went on to address their study with
resilience, and appreciated the \"kick up the bum\", as they described it. [Author abstract]
Journal Article
Prevalence and predictors of unmet contraceptive need in HIV-positive female sex workers in Mombasa, Kenya
Female sex workers (FSWs) in sub-Saharan Africa are a key population for HIV prevention and treatment interventions, but less attention is given to their family planning needs. We evaluated the prevalence and predictors of unmet contraceptive need in HIV-positive FSWs.
This cross-sectional analysis used data from an existing longitudinal study of FSWs in Mombasa, Kenya. This analysis included women who were HIV positive, age ≥18 years, pre-menopausal, not currently pregnant or desiring pregnancy, and reported exchanging sex for cash or in-kind payment at the time of enrollment. Unmet contraceptive need was defined as non-use of modern non-barrier contraceptives and not currently trying to become pregnant. Poisson regression was used to identify factors independently associated with unmet contraceptive need.
Among 346 HIV-positive FSWs, 125 (36.1%) reported modern non-barrier contraceptive use, leaving 221 (63.9%, 95%CI 58.8-68.9%) with unmet contraceptive need. Condom use was the only form of contraception for 129 (37.3%) participants. In unadjusted analyses, unmet contraceptive need was associated with physical abuse in the past year by someone other than a regular partner (PR 1.2, 95%CI 1.0-1.5), desire for (more) children (PR 1.3, 95%CI 1.1-1.5), and having 2-3 previous pregnancies compared to 0-1 prior pregnancies (PR 0.8, 95%CI 0.6-0.9). In adjusted analyses, lower number of previous pregnancies and having desire for future children remained significantly associated with a higher prevalence of unmet contraceptive need.
Unmet need for modern non-barrier contraception was found in two-thirds of HIV-positive FSWs who reported that they were not currently trying to become pregnant, and was higher in women with the lowest number of prior pregnancies (0-1 prior pregnancies) and in those reporting desire for (more) children in the future. These findings highlight the need for concerted efforts to identify and eliminate barriers to contraceptive use in FSWs living with HIV.
Journal Article
Student Responses to a Tough Early Assessment: A Useful \Kick up the Bum\?
First year is a delicate time for students. Many have little idea what to expect of university, and their sense of identity as tertiary students is fragile. A diagnostic assessment early in first semester may reassure students that they have chosen the right path. However, some academics, particularly in engineering, argue that this early assessment should be very demanding - so tough, in fact, that some students fail - in order to alert students to the hard work required to pass the course. This study uses a mixed methods design (weekly surveys and in-depth interviews) to explore the effects of a purposefully tough early assessment on first year engineering students at an Australian university. We find that, across the cohort, the high failure rate was not associated with a significant slump or spike in motivation. Although some students were initially dismayed by their results, most went on to address their study with resilience, and appreciated the \"kick up the bum\", as they described it.
Journal Article
EMERGENCY REMOTE TEACHING IN INDONESIA: A MISSED OPPORTUNITY FOR GREATER LEARNER AUTONOMY
The sudden switch to learning from home during the COVID-19 pandemic impacted teachers across the world. In Indonesia, schools were closed from early March 2020 onwards. This paper presents the findings of a qualitative research project that investigated how Indonesian teachers of English responded to the challenges of Emergency Remote Teaching (ERT) and whether ERT would lead to greater learner autonomy. Ten teachers responded to an invitation to participate in focus groups and individual interviews on Zoom and to contribute examples of their lesson plans from the lockdown period. All teachers found that WhatsApp was the most efficient and effective platform for remote teaching, allowing synchronous and asynchronous sharing of audio, video and text-based materials. Despite the challenges of poor connectivity and lack of face-to-face contact, the teachers were able to continue involving their students actively in integrated, communicative tasks that pushed them to extend their communicative competence. Unexpectedly, however, the move to online teaching did not herald a shift towards greater learner autonomy. The data from this research shows that English language teaching in Indonesia is still firmly teacher-controlled despite the affordances of online learning.
Journal Article
Inconsistent Provider Testing Practices for Congenital Cytomegalovirus: Missed Diagnoses and Missed Opportunities
Newborn congenital cytomegalovirus (cCMV) screening programs have been found to increase the rates of early diagnosis and treatment. In North America, newborn cCMV screening programs have not been widely implemented, leaving healthcare providers to rely on clinical suspicion alone to prompt testing. This study sought to examine healthcare providers’ cCMV testing practices at a quaternary children’s hospital. A retrospective review of the electronic health record was completed for eligible infants over a six-year period. Bivariate calculations and analyses were performed. Between 2014 and 2019, a total of 40,091 infants were cared for at the study institution, of which 178 were tested for cCMV and 10 infants were diagnosed with cCMV. Isolated small-for-gestational age was the most common indication (53/178) to prompt testing. Overall, the cCMV testing rate was 4.5 tests per 1000 infants, with a resulting diagnostic prevalence of 0.2 cases per 1000 infants, which is 15-fold lower than the expected prevalence. Providers relying on clinical suspicion alone are infrequently testing infants for cCMV, resulting in missed diagnoses and missed opportunities for treatment. Systematic cCMV screening practices may improve diagnosis, treatment, and childhood outcomes.
Journal Article