High HIV Detection in a Tertiary Facility in Liberia: Implications and Opportunities.

Background: HIV/AIDS remains one of the world's most significant public health challenges; sub-Saharan Africa accounts for 71% of the global burden of HIV. Testing for HIV is pivotal to achieving UNAIDS 95-95-95 target towards bringing an end to the epidemic. Objective: The study assessed five-year HIV testing data from the largest tertiary hospital in Monrovia, Liberia and highlights risk groups that would benefit from targeted testing and prevention interventions. Methods: This was a single-center academic hospital-based retrospective analysis of HIV testing data from January 2014 to December 2018 obtained from all testing sites at John F. Kennedy Medical Center in Monrovia, Liberia. Pooled HIV testing data during the study period were analyzed using descriptive statistics and stratified by age, gender and pregnancy status. Annual diagnoses rates were reported as proportion of individuals tested within a specified category (age [<15 years, age 15-24 years and >=25 years], gender, and pregnancy status) that had a positive HIV test. Five-year trends were analyzed. Results: Over the study period, 41,343 non-pregnant individuals were screened for HIV. In addition, the antenatal clinic performed 24,913 tests. Of non-pregnant individuals tested, 4,066 (10%) were diagnosed with HIV ranging from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15-24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018 respectively. Annually, 2-3% of all pregnant women tested were diagnosed with HIV. While HIV detection rates decreased over time overall, children less than 15 years of age showed an annual increase from 6.7% in 2014 to 12.3% in 2018. Conclusion: A large five-year dataset from the largest tertiary facility in Liberia shows broad HIV detection rates that are much higher than national prevalence estimates. Ramping up HIV testing and prevention interventions including pre-exposure prophylaxis are sorely needed.

Role of nebulized epinephrine in moderate bronchiolitis: a quasi-randomized trial.

BACKGROUND/AIMS: Bronchiolitis is the most common lower respiratory illness that characteristically affects the children below 2 years of age accounting about 2-3% of patients admitted to hospital each year [1-4]. We compared the effect of racemic epinephrine (RE) and 3% hypertonic saline (HS) nebulization on the length of stay (LOS) in the hospital. METHODS: We looked at the infants with moderate bronchiolitis, from October 2013 to March 2014. Out of eighty cases, 16 in HS and 18 in RE groups were enrolled. At the time of admission, 0.2 ml of RE added to 1.8 ml of distilled water was nebulized to RE group, as compared with 2 ml of 3% HS in nebulized form. RE was re-administered if needed on 6 h in comparison with 3% HS at the frequency of 1 to 4 h. RESULTS: One infant from RE group and three infants from HS group were excluded due to progression towards severe bronchiolitis. The LOS in RE group ranged between 18 and 160 h (mean 45 h), while in HS group, LOS was 18.50-206 h (mean 74.3 h). The LOS was significantly short in RE group (p value 0.015) which was statistically significant. CONCLUSION: Racemic epinephrine nebulization as first-line medication may significantly reduce the length of hospital stay in infants with moderate bronchiolitis in comparison with nebulized HS.

Substantial gap in primary care: older adults with HIV presenting late to care.

BACKGROUND: Late diagnosis of human immunodeficiency virus (HIV) is associated with increased morbidity and mortality, and represents a serious public health concern. METHODS: A retrospective medical record review was conducted on 188 patients with newly diagnosed HIV at a large academic center's HIV clinic from 1/2010 to 12/2019. Patient demographic data, HIV staging, and response to combination antiretroviral therapy (cART) as measured by HIV viral suppression at 12 weeks (HIV RNA < 50 copies) were collected. Bivariate analyses were applied to compare patients ≥50 years old to those < 50 years old. RESULTS: Over two-thirds of the older patients with a new diagnosis of HIV presented with a CD4 count < 200, or an AIDS-defining illness. Though not statistically significant, this same group also had a delay to viral suppression with only 59% achieving viral suppression after 12-weeks of cART initiation. CONCLUSIONS: This study suggests that older patients are presenting to care with advanced stages of HIV, and may also have a delay in achieving viral suppression after cART initiation. Future studies should aim to target HIV testing and treatment strategies for this at-risk older adult group.

Dolutegravir And Lamivudine Combination For The Treatment Of HIV-1 Infection.

There have been remarkable advances in drug development for the treatment of HIV-1 infection. From the co-formulation of combination antiretroviral therapy (cART) into single-tablet regimens to the development of long-acting antiretroviral (ARV) drug formulations, the treatment of HIV has and will become much more tolerable and less complicated for patients. In addition, and appropriately, there is a focus on reducing short- and long-term toxicities of treatment while maintaining robust efficacy. One of such approaches includes 2-drug regimen constructs that contain and retain effective ARV compounds while excluding components that have relatively unfavorable toxicity profiles. The first-ever 2-drug regimen approved for the treatment of HIV-1 infection for treatment-naive people living with HIV (PLWH), consisting of the integrase inhibitor dolutegravir (DTG) and the nucleoside reverse transcriptase inhibitor (NRTI) lamivudine (3TC), is reviewed in this paper. The chemical composition and properties, pharmacokinetic and pharmacodynamics profile, and clinical trial data on efficacy and safety of DTG/3TC are presented. An expert opinion aims to highlight important considerations for the use of DTG/3TC in the context of existing and emerging ARV options.

Sexual Violence against Men Who Have Sex with Men and Transgender Women in Mongolia: A Mixed-Methods Study of Scope and Consequences.

The role of sexual violence in health and human rights-related outcomes, including HIV, is receiving increasing attention globally, yet the prevalence, patterns, and correlates of sexual violence have been little-studied among men who have sex with men (MSM) and transgender women in low and middle income countries. A mixed-methods study with quantitative and qualitative phases was conducted among MSM and transgender women in Ulaanbaatar, Mongolia. Methods included respondent-driven sampling (RDS) with structured socio-behavioral surveys (N = 313) as well as qualitative methods including 30 in-depth interviews and 2 focus group discussions. Forced sex in the last three years was reported by 14.7% of respondents (RDS-weighted estimate, 95%CI: 9.4-20.1; crude estimate 16.1%, 49/307) in the quantitative phase. A descriptive typology of common scenarios was constructed based on the specific incidents of sexual violence shared by respondents in the qualitative phase (37 incidents across 28 interviews and 2 focus groups). Eight major types of sexual violence were identified, most frequent of which were bias-motivated street violence and alcohol-involved party-related violence. Many vulnerabilities to and consequences of sexual violence described during the qualitative phase were also independently associated with forced sex, including alcohol use at least once per week (AOR = 3.39, 95% CI:1.69-6.81), and having received payment for sex (AOR = 2.77, 95% CI:1.14-6.75). Building on the promising strategies used in other settings to prevent and respond to sexual violence, similar strengthening of legal and social sector responses may provide much needed support to survivors and prevent future sexual violence.

Inappropriate use of proton pump inhibitors among medical inpatients: a questionnaire-based observational study.

OBJECTIVES: To evaluate the appropriateness of proton pump inhibitor (PPI) prescribing by conducting an audit of medical inpatients against recommended guidelines. DESIGN: Questionnaire-based study. All medical wards were audited and different information was documented by patients' medical records review (both hospital visit notes and general practitioner's letters) and short interview, where we asked them to name the clinical reason for using PPI. SETTING: This study was carried out in the setting of a regional hospital (537-bed, secondary care referral centre) in Ireland. PARTICIPANTS: The study participants were all consecutive medical patients admitted to the medical wards at Waterford Regional Hospital, Waterford. MAIN OUTCOME MEASURES: The appropriateness of PPI usage in our regional hospital by assessing the level of its prescribing against published guidelines (NICE, 2000). RESULTS: During the audit period, 205 consecutive medical inpatients were assessed. Seventy-nine percent (162 out of 205) of the studied patients were found to be using PPI. For 45% (n = 73) of patients, there was no documentation of valid indication for being on PPI. Overall, 64% of patients were prescribed PPI by hospital doctors, either during their current or previous admissions. We noted that 31% (n = 51) of patients were taking PPI for ≥2 years and another 25% of patients were using PPI for about one year. Only 12% (n = 20) of patients had undergone endoscopy procedures. CONCLUSION: Inappropriate use of PPI remains common in hospital practice. The risks of using long-term PPI must be weighed against the benefits.

Comparison of 21-gauge and 22-gauge aspiration needle in endobronchial ultrasound-guided transbronchial needle aspiration: results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit. METHODS: We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge. RESULTS: A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P < .001). CONCLUSIONS: There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.

A cross-sectional evaluation of correlates of HIV testing practices among men who have sex with men (MSM) in Mongolia.

This study analyzed patterns and associations of HIV testing including sexual practices, HIV related knowledge, and human rights contexts among MSM in Mongolia. 313 participants were accrued using respondent-driven sampling and administered a structured questionnaire. Descriptive statistics are presented with crude and adjusted-point estimates with confidence intervals (95 % CI); and logistic regression models were used to identify factors associated with HIV testing in the last 12 months. RDS-adjustment demonstrated that 48.9 % (95 % CI = 36.7-58.3) of MSM had an HIV test in the past 12 months. Logistic regression revealed that experience of a human rights violation, enacted (OR = 0.50, 95 % CI = 0.26-0.97) or perceived (OR = 0.56, 95 % CI = 0.26-0.97), was inversely associated with a recent HIV test. Higher level of education (OR = 1.84, 95 % CI = 1.14-2.99), knowledge that anal sex is highest risk for HIV infection (OR = 4.54, 95 % CI = 2.41-8.56), and having 5 or more male sexual partners (OR = 1.82, 95 % CI = 1.00-3.30), were positively associated with a recent HIV test. MSM in Mongolia are at high risk for HIV infection and coverage of HIV testing is suboptimal. Understanding the variable sexual risk practices and barriers to HIV testing are vital to designing effective and relevant HIV-status dependent HIV intervention services.

Perceptions and attitudes of hospital staff toward paging system and the use of mobile phones.

OBJECTIVES: Our objective was to document the pattern of mobile phone usage by medical staff in a hospital setting, and to explore any perceived benefits (such as improved communications) associated with mobile phones. METHODS: This cross-sectional survey was conducted in Waterford Regional Hospital, Ireland, where bleep is the official system of communication. All non-consultant hospital doctors, of medical disciplines only, were asked to participate. The questionnaire was designed to explore the pattern and different aspects of mobile phone usage. RESULTS: At the time of study, there were sixty medical junior doctors, and the response rate was 100 percent. All participants used mobile phones while at work, and also for hospital-related work. For 98.3 percent the mobile phone was their main mode of communication while in the hospital. Sixty-two percent (n = 37) made 6-10 calls daily purely for work-related business, and this comprised of ≥ 80 percent of their daily usage of mobile phones. For 98 percent of participants, most phone calls were work-related. Regarding reasons for using mobile phones, all reported that using mobile phone is quicker for communication. CONCLUSIONS: Mobile phone usage is very common among the medical personnel, and this is regarded as a more efficient means of communication for mobile staff than the hospital paging system.