Implementing a pilot study of COVID-19 self-testing in high-risk populations and remote locations: results and lessons learnt.

BACKGROUND: Rapid antigen-detection tests for SARS-CoV-2 self-testing represent a useful tool for pandemic control and expanding access to community-level case screening. COVID-19 self-tests have been extensively used in high-income countries since 2021; however, their introduction and programmatic implementation in low- and middle-income countries was delayed. We aimed to identify and continuously improve a weekly COVID-19 self-testing model among staff at healthcare facilities and schools. METHODS: This mixed-methods, observational prospective study was conducted in 5 healthcare centres and 24 schools in Georgia, between June and December 2022. The study comprised the integration of COVID-19 self-testing into the national mandatory testing programme for high-risk groups, with primary distribution of self-tests among staff performed weekly, plus secondary distribution to their household members. These use cases were selected because NCDC was seeking to strengthen their already strong weekly testing programme, by investigating self-testing to ease the burden of testing in the healthcare system. Online surveys and semi-structured interviews were used for data collection. RESULTS: In total, 2156 participants were enrolled (1963 female, 72%). At baseline and mid- and end-points, 88%, 97% and 99%, respectively, of participants agreed/strongly agreed they would self-test. Similarly, the majority were willing to report their self-testing results (88%, 98% and 96% at baseline and mid- and end-points, respectively). Weekly reporting of test results to the national COVID-19 database was high during all the implementation. There were 622 COVID-19 positive results reported, and linked to care, from 601 individuals (282 participants and 319 household members). Findings from qualitative interviews showed great satisfaction with self-testing for its convenience, ease of use, trust in the results, no need to travel for diagnostics, and increased perception of safety. CONCLUSIONS: Our findings contribute to the evidence-base regarding self-testing strategies conducted via workplaces and secondary distribution to households. Willingness to perform a COVID-19 self-test increased after implementation. This pilot enhanced pandemic preparedness through expansion of the national self-testing reporting system, development of communications materials, changes in the national legal framework and coordination mechanisms, and improved perceptions around self-care in the community. The lessons learnt can inform operational aspects of the introduction and scale-up of self-care strategies.

Social Network Strategy improves access to HIV testing and harm reduction programs for PWID and their partners in Kazakhstan.

INTRODUCTION: The region of Eastern Europe and Сentral Asia has a growing HIV epidemic. Kazakhstan is a country in Central Asia with an estimated 33,000 people living with HIV. The new HIV infections have increased by 29% since 2010. Evidence suggests that HIV testing strategies focused on social networks are effective methods to identify more people with undiagnosed HIV. We conducted a study to describe the optimized HIV case finding (OCF) intervention for people who inject drugs (PWID) and their partners in Kazakhstan. METHODOLOGY: The OCF is based on recruitment of the extended risk social networks of HIV-positive PWID, using a two-step recruitment algorithm. RESULTS: There were 5,983 PWIDs and their partners tested for HIV, of those 149 (2.5%) received HIV-positive test results and the majority 145 (97%) were newly identified HIV-positive. The characteristics which had a statistically significant positive association with HIV-positive test results included: age group 15-19 (OR 4.12, 95% CI 1.44-11.7); age group 20-24 (OR 1.97, 95% CI 1.03-3.8); age group 50+ (OR 2.45, 95% CI 1.48-4.1); male sex (OR 1.78; 95% CI 1.2-2.6), participants who have previously received harm reduction services (OR 1.48; 95% CI 1.0-2.2); partners from "other groups" (OR 2.31, 95% CI 1.3-4.2). CONCLUSIONS: Low-threshold HIV testing and harm reduction services, like OCF using directly assisted self-testing and social network strategies are essential in reaching key populations with HIV prevention, increasing access to HIV testing and care.

People Who Inject Drugs and have tuberculosis: Opioid Substitution Therapy improves treatment outcomes in Ukraine.

INTRODUCTION: Opioid substitution therapy (OST) is one of the pillars of harm reduction strategies for People Who Inject Drugs (PWID). It should be an integral part of tuberculosis (TB) care to increase the uptake, compliance and effectiveness of treatment and also curtail risk behaviors. We aimed to compare TB treatment outcomes in relation to OST among PWID in six regions of Ukraine. METHODOLOGY: A retrospective cohort study using routine programmatic data from centers offering integrated TB and OST (December 2016 - May 2020). OST involved use of methadone or buprenorphine. TB treatment outcomes were standardized. RESULTS: Of 228 PWID (85% male) diagnosed with TB, 104 (46%) had drug-sensitive and 124 (64%) drug-resistant TB. The majority had pulmonary TB (95%), 64 (28%) were HCV-positive and 179 (78%) were HIV-positive, 91% of the latter were also on antiretroviral therapy. There were 114 (50%) PWID with TB on OST. For drug-sensitive TB (n=104), treatment success was significantly higher (61%) in those on adjunctive OST than those not on OST (42%, P<0.001). Similarly, for drug-resistant TB (n=124) treatment success was also significantly higher when individuals were on OST (43%) compared to when not on OST (26%, P<0.001). CONCLUSIONS: This operational research study shows that OST is associated with significantly improved treatment success in PWID and can contribute to achieving Universal Health Coverage and the WHO Flagship Initiative "Find.Treat.All. #End TB". We advocate for the scale-up of this intervention in Ukraine.

Breaking the paradigm: Optimized Case Finding multiplies tuberculosis detection among key populations in Ukraine.

INTRODUCTION: In 2018, there were 3 million "missed" tuberculosis (TB) cases globally, much of which was disproportionally concentrated among key populations. To enhance TB case-finding, an Optimized Case Finding (OCF) strategy involving all contacts within the social network of an index TB case was introduced in five regions of Ukraine. We assessed TB detection and linkage to TB treatment using OCF in key populations. METHODOLOGY: A cohort study using routine program data (July 2018 - March 2020). OCF empowers the index TB case to identify and refer up to eight close contacts within his/her social network for TB investigations. RESULTS: Of 726 index TB cases in key populations, 6,998 close contacts were referred for TB investigations and 275 were diagnosed with TB (183 drug-sensitive and 92 drug-resistant TB). The TB case detection rate was 3,930/100,000 and the Numbers Needed to Investigate to detect one TB case was 25. TB was most frequent among people who inject drugs and homeless groups. Compared to TB detection using routine household case finding within the general population (1,090/100,000), OCF was 3.6-fold more effective and when compared to passive case finding in the general population (60/100,000), OCF was 66 times more effective. 99% (273) of TB patients were linked to care and initiated TB treatment. CONCLUSIONS: The OCF strategy among key populations is very effective in identifying TB cases and involving them for treatment through the recruitment of the contacts from the risk social networks. We advocate to scale-up this case finding strategy in Ukraine and beyond.

Adverse Drug Reactions among Children with Tuberculosis in Tashkent, Uzbekistan, 2019.

The treatment of childhood tuberculosis can be challenging due to the lack of pediatric drug formulations and monitoring of drug-toxicity in routine settings. There are no published studies from Uzbekistan on the adverse drug reactions (ADR) associated with anti-tuberculosis treatment in children. In this study, we aimed to investigate the ADR associated with anti-tuberculosis treatment in children. This was a cohort study using secondary program data of children treated at the city and regional tuberculosis clinics in Tashkent, Uzbekistan. Of the 302 patients evaluated, 135 (44.7%) reported ADR. New tuberculosis was registered in 277 (92%) patients and 262 (87%) had extrapulmonary tuberculosis. Factors associated with ADR included treatment at a regional hospital (adjusted odds ratio, aOR = 1.75; p = 0.026), female sex (aOR = 2.2; p = 0.004), and treatment with second-line drugs (aOR = 8.82; p < 0.001). The most common ADRs were gastrointestinal disorders (28.5%) followed by hepatitis (8.9%) and dermatologic reactions (8.6%). Most of the ADRs were mild (55.6%) or moderate (43.7%), only one child had severe ADR. Patients with the identified risk factors should be closely monitored during the treatment. We also recommend expansion of ADR surveillance throughout the country for more representative data in the future.

Characteristics, utilisation and influence of viewpoint articles from the Structured Operational Research and Training Initiative (SORT IT) - 2009-2020.

Background: The Structured Operational Research and Training Initiative (SORT IT) teaches the practical skills of conducting and publishing operational research (OR) to influence health policy and/or practice. In addition to original research articles, viewpoint articles are also produced and published as secondary outputs of SORT IT courses. We assessed the characteristics, use and influence of viewpoint articles derived from all SORT IT courses. Methods: This was a cross-sectional study involving all published viewpoint articles derived from the SORT IT courses held from August 2009 - March 2020. Characteristics of these papers were sourced from the papers themselves and from SORT-IT members involved in writing the papers. Data on use were sourced from the metrics provided on the online publishing platforms and from Google Scholar. Influence on policy and practice was self-assessed by the authors of the papers and was performed only for papers deemed to be 'calls for action'. Results: A total of 41 viewpoint papers were published. Of these, 15 (37%) were 'calls for action'. In total, 31 (76%) were published in open-access journals and the remaining 10 in delayed access journals. In 12 (29%) of the papers, first authors were from low and middle-income countries (LMICs). Female authors (54%) were included in 22, but only four (10%) and two (5%) of first and last authors respectively, were female. Only seven (17%) papers had available data regarding online views and downloads. The median citation score for the papers was four (IQR 1-9). Of the 15 'call for action' papers, six influenced OR capacity building, two influenced policy and practice, and three influenced both OR capacity building within SORT IT and policy and practice. Conclusion: Viewpoint articles generated during SORT IT courses appear to complement original OR studies and are valued contributors to the dissemination of OR practices in LMICs.

Treatment Compliance of Multidrug Resistant Tuberculosis in Uzbekistan: Does Practice Follow Policy?

Compliance with treatment guidelines is essential to achieve successful outcomes in tuberculosis patients. Thus, we assessed if multidrug-resistant tuberculosis treatment practices from 2012-2018 in Uzbekistan were compliant with national guidelines in terms of regimens prescribed, weight-based drug dosages used, and documentation of treatment changes (such as prolongation of intensive phase, change of drugs, and their reasons) in the treatment card and Consilium form. A total of 1481 patients were included. Of them, only 25% received standardized regimens as per guidelines and the remaining received individualized regimens. There was an increasing trend in using standardized regimens from 2% in 2012 to 44% in 2018. Compliance to recommended weight-based drug dosages was observed in 85% of the patients during the intensive phase and 84% in the continuation phase-ranged 71-91% over the years. Prolongation of the intensive phase was done in 42% of patients. The treatment was changed in 44% of patients during the intensive phase and 34% of patients during the continuation phase. The documentation of treatment changes was suboptimal (42-75%) during the initial years (2012-2014); however, it improved significantly during later years (86-100%). Future research should explore reasons for non-compliance so that the quality of patient care can be improved.

Incidence rate and time to serious adverse events among rifampicin resistant tuberculosis patients in Georgia treated with new and repurposed anti-tuberculosis drugs, 2016-2018.

Considering the complexity of second-line anti-tuberculosis (TB) treatment regimens, the management of drug-resistant TB (DR-TB) in Georgia remains a major challenge. Since the introduction of new and repurposed anti-TB medications, the implementation of active TB Drug Safety Monitoring (aDSM) was a critical program component to help establish safety and manage all treatment related Serious Adverse Events (SAEs). In our study, we aimed to describe the occurrence, characteristics and timing of SAE among patients with Rifampicin Resistant and Multi-Drug Resistant TB (RR/MDR-TB) receiving new and/or repurposed anti-TB medications (bedaquiline, delamanid, linezolid, clofazimine, imipenem) during the period of 2016-2018 in Georgia and identify predictors of SAE. The data were obtained from the medical charts, electronic database and standardized aDSM reports During 2016-2018 period in total 970 people with RR/MDR-TB were notified in Georgia and 388 of them received new and/or repurposed TB drugs as part of their treatment regimen and all were included into the study. The results showed a total of 73 SAEs registered among 49 (12.6%) patients receiving new and/or repurposed drugs. The overall SAE incidence rate per 100 person-months was 1.16. The severity of the majority of the SAEs (46.6%) was grade III and 21.9% were grade IV. The most common SAE reported was hepatotoxicity, with an incidence of 0.26 per 100 person-month (n=16, 21.9%) followed by cardiotoxicity with an incidence of 0.16 per 100 person-month (n=10, 13.7%). Median time to SAE occurrence was 183 days (IQR 84 - 334) after treatment initiation. Resistance profile was the only predictor associated with occurrence of a SAEs. There was increased hazard of SAEs among patients with XDR-TB (adjusted HR=2.18, 95% CI: 1.12-4.23). Our findings on SAEs among patients treated with new or repurposed anti-TB drugs are echoing the findings available in the literature. They highlight the need for close monitoring of patients and underlines the importance of the aDSM during the whole treatment. Safety profile of the medications and combinations used are yet to be established and larger datasets comprised of patients receiving same treatment regimens need to be utilized.

Effectiveness and safety of fully oral modified shorter treatment regimen for multidrug-resistant tuberculosis in Georgia, 2019-2020.

Tuberculosis treatment is challenging, especially among people with drug-resistant forms of tuberculosis. The introduction of fully oral modified short treatment regimen has a great potential to shorten duration of treatment, improve safety and ultimately increase treatment success rate. In 2019 Georgia has piloted the modified fully oral shorter treatment regimen in a routine programmatic condition. Our study aimed to evaluate effectiveness and safety of the modified shorter treatment regimen in Georgia among the first 25 consecutively enrolled patients with rifampicin-resistant tuberculosis with proven sensitivity to fluoroquinolone and without prior exposure to second-line tuberculosis drugs. Regimen consisted of 9-month daily administration of bedaquilline, linezolid, levofloxacin, clofazimine and cycloserine. Study patients were enrolled between March-August 2019. We used a national electronic surveillance system, medical records and active TB drug-safety monitoring and management database to extract study related data. The mean age of the study participants was 48 years, 68% were male, 8% were HIV positive, 16% had diabetes and 12% tested positive for hepatitis C infection. The median time to culture conversion among 16 patients who were culture positive at treatment initiation was 1.0 (95% CI: 1.0-2.0) month. Of those, by the end of treatment 15 patients converted to negative. Out of the 25 patients in the study cohort 22 (88%) had successful treatment outcome, one patient (4%) died and two (8%) were lost to follow up. The regimen was largely well tolerated. Three patients (12%) experienced serious adverse events, of which in two cases were possibly related to TB drugs in the regimen. Seven patients developed adverse events of interest in eight instances, including musculoskeletal (twice), psychiatric, gastrointestinal disorders, hepatotoxicity, peripheral neuropathy, cardiotoxicity and myelosuppression (once each). In four patients (16%) the duration of the treatment was extended beyond nine months due to insufficient radiological improvements. Our findings demonstrate that good treatment outcomes are achievable in people with fluoroquinolone-sensitive tuberculosis within routine programmatic conditions using fully oral modified short treatment regimen. The extensive use of fully oral modified shorter treatment regimen in Georgia and other high priority countries in the World Health Organization European Region is warranted.

The reporting of the mode of transmission among HIV-positive men who have sex with men in Lviv oblast, Ukraine, 2014-2018.

INTRODUCTION: Men who have sex with men (MSM) are one of the key populations driving HIV/AIDS epidemic globally. To date, MSM is the only population in Ukraine where the prevalence and incidence of HIV is increasing. As HIV-positive MSM might feel uncomfortable to report homosexual intercourses as a possible mode of transmission (MoT) of HIV, they prefer being registered as patients with heterosexual or non-defined MoT. This study aimed to calculate the proportion of misclassified MoT among HIV-positive MSM registered in Lviv oblast, Ukraine, during 2014-2018. METHODOLOGY: Cross-sectional study with 127 HIV-positive MSM patients from Lviv region for the period of 2014-2018. RESULTS: Out of 127 HIV-positive MSM included in the study, 110 (86.6%) were from urban areas. In addition, 52 patients (40.9%) were diagnosed with stage 1 HIV, 16 (12.6%) - stage 2, 19 (15%) - stage 3, and 36 (28.3%) - stage 4. CD4 count < 200 cells/µL was found in 35 (27.6%) patients. Mean time from registration to antiretroviral therapy initiation was 80 days. During the first visit to medical doctor out of those 48 patients who had previously reported "other modes" of HIV transmission, 33 patients (68.7%) disclosed homosexual MoT of HIV. The remaining 15 (31.3%) patients disclosed their homosexual MoT of HIV later - during their regular follow-up visits to the doctor. CONCLUSION: Special measures are needed to improve the reporting of homosexual MoT which can potentially strengthen the HIV care among MSM.

Quality, Equity and Utility of Observational Studies during 10 Years of Implementing the Structured Operational Research and Training Initiative in 72 Countries.

Introduction: Observational studies are often inadequately reported, making it difficult to assess their validity and generalizability and judge whether they can be included in systematic reviews. We assessed the publication characteristics and quality of reporting of observational studies generated by the Structured Operational Research and Training Initiative (SORT IT). Methods: A cross-sectional analysis of original publications from SORT IT courses. SORT IT is a global partnership-based initiative aimed at building sustainable capacity for conducting operational research according to country priorities and using the generated evidence for informed decision-making to improve public health. Reporting quality was independently assessed using an adapted version of 'Strengthening the Reporting of Observational Studies in Epidemiology' (STROBE) checklist. Results: In 392 publications, involving 72 countries, 50 journals, 28 publishers and 24 disease domains, low- and middle-income countries (LMICs) first authorship was seen in 370 (94%) and LMIC last authorship in 214 (55%). Publications involved LMIC-LMIC collaboration in 90% and high-income-country-LMIC collaboration in 87%. The majority (89%) of publications were in immediate open access journals. A total of 346 (88.3%) publications achieved a STROBE reporting quality score of >85% (excellent), 41 (10.4%) achieved a score of 76-85% (good) and 5 (1.3%) a score of 65-75% (fair). Conclusion: The majority of publications from SORT IT adhere to STROBE guidelines, while also ensuring LMIC equity and collaborative partnerships. SORT IT is, thus, playing an important role in ensuring high-quality reporting of evidence for informed decision-making in public health.

People with high HIV viral load within risk networks: who are these people and who refers them best?

Introduction: Viral load is one of the most important determinants for HIV transmission. Identification of people with high viral load (PHVL) can be effective in limiting onward HIV transmission. In order to improve the identification of these individuals within risk networks, we determined a) the number of PHVL recruited through risk networks b) their socio-demographic, behavioural and clinical characteristics and c) the characteristics of individuals who referred these PHVL to the study. Methodology: From November 2013 to March 2016, in Odessa, Ukraine, Transmission Reduction Intervention Project (TRIP) was implemented to identify people recently infected with HIV within the risk networks of "seeds" and "venues" where they engaged in risk behaviour. Results: TRIP identified 53 PHVL, of whom 32 (60%) injected drugs; 42 (79%) were unaware of their HIV status; 25 (47%) had more than one sex partner, and only 14 (26%) were using condoms. There were 164 people who referred individuals into the study; 33 of them (20%) referred PHVL. In terms of referrers, those with lower than secondary level of education, not living with a sex partner, and reporting regular condom use were significantly more likely (p < 0.05) to refer PHVL. Most PHVL (38, 72%) and their referrers (27, 82%) were found through venues. Conclusions: In Odessa city, PHVL are at high risk of transmitting HIV as the majority inject drugs, do not know their HIV status, and have unprotected sex and/or multiple partners. Targeting these individuals for HIV prevention, harm reduction and initiation of antiretroviral treatment (ART) is urgent.

Shifting from an inpatient to outpatient centered model through transforming the TB financing in ex-Soviet countries.

INTRODUCTION: In former Soviet Union countries, tuberculosis (TB) financing largely relies on a hospital-centered model. The World Health Organization favors transformation to ambulatory treatment since it is cheaper and patient-centered. We explored policy and decision maker's perspectives on: a) enabling factors for transformation in Armenia and b) challenges and ways forward in doing so in Ukraine and Tajikistan. METHODOLOGY: Qualitative study of key informants from government, donors and the national TB program. RESULTS: 52 informants with a mean service record of 20 years were involved. Key enablers in Armenia included collaborative partnership and political will, carefully selecting an adapted financing scheme that avoided financial penalization of hospitals and health workers, and use of operational research. The operational challenges in Ukraine and Tajikistan hovered around the lack of technical capacity and guidance on "how to implement" alternative financing. Shortcomings in strategic planning, uncertainty/fear that existing hospital funding would be cut and reluctance to change were highlighted. Suggested ways forwards to change the current paradigm included country-level technical assistance, capacity building, regional exchanges and operational research. CONCLUSIONS: the perspectives of "those who decide" on transforming TB financing have been highlighted. Taking these perspectives on-board is vital for achieving the end-TB goals.

Mind the gap: Improving the performance of the reference laboratory to end-tuberculosis in Armenia.

INTRODUCTION: A one of the step towards achieving TB related targets is to ensure early and quality diagnosis of TB in national laboratories. WHO recommends that all national reference laboratories in TB burden countries strive to reach accreditation by 2025, based on ISO15189:2012 quality management system standard. To identify gaps, progress and evaluated the evolution in implementation QMS we performed a formal assessment of the national TB reference laboratory of Armenia, as well as estimates the specific quality indicators of NRL activity. METHODOLOGY: This is retrospective study cross-sectional study using laboratory data from the National TB Reference Laboratory in Armenia. Quality Management System assessments was conducted twice a year, using TB SLMTA assessment checklist. The sputum rejection and culture rates for quality indicators are calculated and assessed monthly. RESULTS: Compared to the baseline in 2016, there was a quality improvement reflecting the progress from zero to a "one star" in 2018. Areas that reached half of the target score included document and records, management review and responsibilities, evaluation and audits. Sections as "client management and customer service" and "evaluation and audits" stagnated in terms of progress. In terms of NRL performace, all indicators improved except for culture positivity in smear negative tuberculosis. CONCLUSION: Although a quality management system was introduced in the NRL there is now an urgent need to develop and implement an adapted roadmap for Armenia. This will be vital to hasten the much-needed pace towards accreditation.

Free hospitalization for acute respiratory infections in children: what effect and how much does it cost for Armenia?

INTRODUCTION: The "Child Certificate" program, launched in Armenia in 2011, made hospitalization for children less than seven years free in order to improve access to hospitalization, reduce out-of-pocket expenses and ensure Universal Health Coverage. We aimed to estimate trends in the number of outpatient and hospitalized acute respiratory infection (ARI) cases and related under-five mortality. METHODOLOGY: Cross-sectional study using data from national databases before (2008-2011) and after (2012-2017) Program implementation. The diagnosis of ARI was based on the International Classification of Disease (ICD-10). RESULTS: The average hospitalization per 1000 children under 14 and infants increased by 85% and 75% respectively, compared with the period before the introduction of the Program, while the frequency of outpatient visits remained unchanged. The ARI-related mortality in children less than five years and in infants decreased by 11% and 19%, respectively. Financial allocations for ARI-associated hospitalizations amounted to 2.1 billion Armenian drams in 2011 and increased to 3.3 billion drams in 2016 (an increase of 57%). For pneumonia, this increase was 108% (from 0.35 to 0.72 billion). CONCLUSIONS: The introduction of free hospitalization for ARI led to an increase in the hospitalization rates. There was a favorable decline in under-five mortality and an exponential increase in financial allocations. The reasons for hospitalization should be investigated to ensure rational hospitalization with parallel improvement of primary care to reduce delayed presentations. It is necessary to find ways addressing the growing financial allocations for ARI-associated hospitalization.

When will the coughing stop? Characteristics of children with pertussis (whooping cough) in Armenia (2014-2018).

INTRODUCTION: Despite the reported cases of whooping cough in Armenia, there has been no formal evaluation of "who these cases are and their load on hospital wards". In a tertiary reference hospital, we determined the trend in hospitalized pertussis cases stratified by vaccination status and risk factors associated with apnea and hospital stay. METHODOLOGY: Retrospective cohort study of children (< 18 years) with confirmed pertussis hospitalized at the Republican Infectious Diseases Hospital between 2014 and 2018. Multivariate logistic regression was used to identify risk factors. RESULTS: The majority (62%) of 116 children (44% female, mean age 21 months) were from regions outside the capital city of Yerevan. Standardized pertussis admissions increased by almost fivefold, from 2.2/1,000 in 2014 to 10.6/1,000 in 2018. The cumulative average percentage (2014-2018) of children not vaccinated against pertussis was 33%, while 29% were completely vaccinated. Twenty-five children (21%) had apnea, two of whom died. Younger age (Odds Ratio (OR) = 1.04; P = 0.05), not having been vaccinated (OR = 3.57; P = 0.01) and having comorbidities (OR = 4.1; P = 0.09) were associated with apnea. After adjusting for age, the longer hospital stay (>8 days) was significantly associated with non-vaccination (OR = 5.0, P = 0.002). CONCLUSIONS: There is a progressive increase in rate of hospital admissions for pertussis meriting closer vigilance on a national scale. Unvaccinated children of younger age are predisposed to apnea and longer hospitalization and would benefit from early referral to specialized infectious units. This may improve clinical outcomes and reduce hospital burden.

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background: Sierra Leone was severely affected by the 2014/2015 Ebola outbreak and is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods: This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,200 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results: Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period.  During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period (P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions: Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

Linking intravenous drug users to treatment through non-governmental organizations in Ukraine: how well is it working?

INTRODUCTION: Alliance for Public Health, the International Charitable Foundation, coordinates HIV prevention in Non-Governmental Organizations (NGO) working with people who inject drugs (PWID) in Ukraine. We aimed to describe the performance of the differential model of linking PWID to HIV care and treatment (Community Initiated Treatment Intervention - CITI). METHODOLOGY: A retrospective cohort study using routine program data was conducted among 8,927 PWID who were tested positive for the first time during January 2016 - June 2017. Study outcomes were enrollment into CITI and initiating antiretroviral treatment (ART). Factors associated with outcomes were estimated by logistic regressions with random effects. RESULTS: Among the study participants, 54% enrolled into CITI and 23% initiated ART. CITI enrolment was associated with being married (adjusted odds ratio (AOR) = 1.17; 95%: 1.02-1.34); less than weekly compared to daily (AOR = 1.31; 95%: 1.13-1.52); less than 5 years of drug use compared to > 14 years (AOR = 1.73; 95%: 1.40-2.13), and having no criminal records (AOR = 1.30; 95%: 1.12-1.50). Factors of non-ART initiation were male gender (AOR = 1.33; 95%: 1.16-1.53); being single (AOR = 1.48; 95%: 1.21-1.82); drug use duration > 14 years compared to < 5 years (AOR = 1.38; 95%: 1.03-1.85), unemployment (AOR = 1.45; 95%: 1.15-1.83) and history of incarceration (AOR = 1.21; 95%: 1.003-1.45). CONCLUSION: Mobilizing the NGO community and PWID to engage in outreach HIV testing activity and harm reduction for key populations has succeeded in opening the gateway to prevention, care and ART for thousands of PWID in Ukraine.

Anxiety, depression, and quality of life among HIV positive injection drug users in Ukraine, 2017.

INTRODUCTION: People who inject drugs (PWID) are one of the key populations most vulnerable to HIV infection, with 28 times higher prevalence compared to the rest of the population. PWID are known to have many physical, psychological and lifestyle challenges that can influence access to care. Depression is common among PWID living with HIV. It has major effect on health-related quality of life (HRQoL) and is influencing adherence to antiretroviral therapy. This study was conducted to explore how anxiety and depression affect HRQoL among HIV-positive PWID in Ukraine. It will provide knowledge for the further policy development. METHODOLOGY: A descriptive cross-sectional study using data from interviewer- administrated questionnaires was performed. The questionnaire was based on the Hospital Anxiety and Depression Scale. The questionnaire on HRQoL was based on the SF-36. RESULTS: Among the 90 HIV positive PWID 74% (67) and 61% (55) had anxiety and depression scores higher than 7 respectively, indicating that most patients had mental health problems. Average scores for general health (40), role limitations due to physical (44) and emotional health (34), vitality (41) and mental health (45) had mean scores less than 50 along with total physical (43) and mental health scores (35). Having an HIV positive partner or partner with unknown HIV status increases anxiety in HIV positive PWID. CONCLUSION: There are increased depressive and anxiety symptoms and poorer QoL among HIV-positive PWID in Ukraine. Strategies focusing on psychosocial support addressing QoL as part of HIV care could improve health outcomes for these comorbid and debilitating conditions.

Engaging people who inject drugs and their peers in HIV testing and harm reduction in Ukraine: do they make a difference?

INTRODUCTION: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction services. We assessed the effectiveness of including PWID and their peers in HIV-testing by comparing for a period before (2013-2014) and after their introduction (2015-2017), the a) numbers HIV tested b) number enrolled in harm reduction and c) frequency of HIV-testing. METHODOLOGY: An analysis of programme data involved PWID aged ≥ 14 years (1st January 2013-31st December 2017) in Ukraine. Between 2013-2014, HIV-testing (VCT) was done by trained health workers. From 2015, this was Directly Assisted HIV Self-testing (DAST) done by social workers and peers. Optimized HIV case finding (OCF) was introduced (in 2016) as an overlapping strategy with DAST. RESULTS: A total of 844,837 HIV tests were done with 23,427 (2.8%) HIV-positive results. With VCT, there were 164,417 HIV tests compared to 639,685 after engagement of PWID and their peers (>3-fold increase). The highest HIV positive yield (20%) was when OCF was included. With increasing HIV-testing caseload, a progressive decrease in enrollment in harm reduction was seen (85% in 2014 to 47% in 2017, X2 for trend P < 0.001). OCF resulted in enrollment into harm reduction of 2722 HIV-positives, which was 35% higher than through DAST alone (7,5%). HIV re-testing almost doubled with DAST. CONCLUSION: Active engagement of PWID and their peers in HIV-testing increased uptake of HIV-testing. Including OCF has a synergistic effect in HIV-positive yield. Strategies are urgently needed to ensure that individuals who are HIV tested are enrolled in harm reduction.