Corrigendum: The evolution of HIV self-testing and the introduction of digital interventions to improve HIV self-testing.

[This corrects the article DOI: 10.3389/frph.2023.1121478.].

The evolution of HIV self-testing and the introduction of digital interventions to improve HIV self-testing.

HIV self-testing (HIVST) complements traditional HIV testing programmes by removing barriers and increasing access to testing for key populations, and digital interventions have been developed for HIVST to improve the testing and linkage to care experience for users. The first HIVST kit was proposed in 1986, but it took 10 years for the home sample collection (HSC) HIVST to become available and another 16 years for rapid diagnostic test HIVST to be approved by the Federal Drug Administration. Since then, studies have shown high usability and performance of HIVST, which led the World Health Organization formally recommending HIVST in 2016, and currently almost 100 countries have incorporated HIVST into their national testing strategy. Despite the popularity, HIVST present challenges around pre-and post-test counselling, as well as the ability to report results and link users to care, and digital interventions for HIVST have been introduced to address these challenges. The first digital intervention for HIVST was introduced in 2014 and showed that digital interventions could be used to distribute HIVST kits, report results and link users to care. Since then, dozens of studies have been conducted, which have validated and expanded on these early findings, but many were pilot studies with small sample sizes and lacked the standardization of indicators required to aggregate data across platforms to prove impact at scale. For digital interventions for HIVST to be championed for scale-up, they must continue to show measurable impact at larger scales, while still maintaining and standardizing data security and integrity.

Ribosomal S6 Kinase Regulates the Timing and Entrainment of the Mammalian Circadian Clock Located in the Suprachiasmatic Nucleus.

Previous work in the suprachiasmatic nucleus (SCN), the locus of the principal circadian clock, has shown that the activation state of the ERK/MAPK effector p90 ribosomal S6 kinase (RSK) is responsive to photic stimulation and is modulated across the circadian cycle. These data raise the prospect that RSK signaling contributes to both SCN clock timing and entrainment. Here, we found marked expression of the three main RSK isoforms (RSK1/2/3) within the SCN of C57/Bl6 mice. Further, using a combination of immunolabeling and proximity ligation assays, we show that photic stimulation led to the dissociation of RSK from ERK and the translocation of RSK from the cytoplasm to the nucleus. To test for RSK functionality following light treatment, animals received an intraventricular infusion of the selective RSK inhibitor, SL0101, 30 min prior to light (100 lux) exposure during the early circadian night (circadian time 15). Notably, the disruption of RSK signaling led to a significant reduction (∼45 min) in the phase delaying effects of light, relative to vehicle-infused mice. To test the potential contribution of RSK signaling to SCN pacemaker activity, slice cultures from a per1-Venus circadian reporter mouse line were chronically treated with SL0101. Suppression of RSK signaling led to a significant lengthening of the circadian period (∼40 min), relative to vehicle-treated slices. Together, these data reveal that RSK functions as a signaling intermediate that regulates light-evoked clock entrainment and the inherent time keeping properties of the SCN.

Digitally supported HIV self-testing increases facility-based HIV testing capacity in Ekurhuleni, South Africa.

Background: HIV testing is the first step for linkage to HIV prevention or treatment services. Facility-based HIV testing is the most utilised method, but faces challenges such as limited work space and human resources. Digitally supported HIV self-testing (HIVST) provided in clinics shifts testing to the client, potentially empowering the client, and addresses such constraints. Objectives: The study primary objective was to determine the feasibility of integrating digitally supported HIVST into the clinic. Secondary objectives were to describe HIV testing volume, populations reached, and antiretroviral treatment (ART) initiation. Method: We conducted an analysis of prospectively collected data during implementation of digitally supported HIVST in two healthcare facilities based in South Africa from June 2019 to September 2019. We described implementation and client characteristics using HIVST and compared testing before and during implementation. Results: During the 4-month implementation period there were 35 248 client visits. A total of 6997 (19.9%) of these visits involved HIV testing. Of those testing, 2278 (32.5%) used HIVST. Of the 2267 analysed, 264 (11.6%) were positive: 182 (12%) women and 82 (11%) men. Of those, 230 (95.4%) were confirmed HIV positive and 150 (65%) initiated ART within 14 days. During a four-month pre-implementation period, 14.5% of the clients tested for HIV. Compared to the pre-implementation period, we observed a 25% increase in HIV testing. Conclusion: Digitally supported HIVST increased the number of clients completing HIV testing in the health facility, without a need to significantly increase staff or space. Facility-based digitally assisted HIVST has the potential to increase HIV testing in high HIV prevalence clinic populations.

Evaluating the Implementation of the GREAT4Diabetes WhatsApp Chatbot to Educate People With Type 2 Diabetes During the COVID-19 Pandemic: Convergent Mixed Methods Study.

BACKGROUND: In South Africa, diabetes is a leading cause of morbidity and mortality, which was exacerbated during the COVID-19 pandemic. Most education and counseling activities were stopped during the lockdown, and the GREAT4Diabetes WhatsApp Chatbot was innovated to fill this gap. OBJECTIVE: This study aimed to evaluate the implementation of the chatbot in Cape Town, South Africa, between May and October 2021. METHODS: Convergent mixed methods were used to evaluate the implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, cost, coverage, effects, and sustainability. Quantitative data were derived from the chatbot and analyzed using the SPSS. Qualitative data were collected from key informants and analyzed using the framework method assisted by Atlas-ti. The chatbot provided users with 16 voice messages and graphics in English, Afrikaans, or Xhosa. Messages focused on COVID-19 infection and self-management of type 2 diabetes. RESULTS: The chatbot was adopted by the Metro Health Services to assist people with diabetes who had restricted health care during the lockdown and were at a higher risk of hospitalization and death from COVID-19 infection. The chatbot was disseminated via health care workers in primary care facilities and local nonprofit organizations and via local media and television. Two technical glitches interrupted the dissemination but did not substantially affect user behavior. Minor changes were made to the chatbot to improve its utility. Many patients had access to smartphones and were able to use the chatbot via WhatsApp. Overall, 8158 people connected with the chatbot and 4577 (56.1%) proceeded to listen to the messages, with 12.56% (575/4577) of them listening to all 16 messages, mostly within 32 days. The incremental setup costs were ZAR 255,000 (US $16,876) and operational costs over 6 months were ZAR 462,473 (US $30,607). More than 90% of the users who listened to each message found them useful. Of the 533 who completed the whole program, 351 (71.1%) said they changed their self-management a lot and 87.6% (369/421) were more confident. Most users changed their lifestyles in terms of diet (315/414, 76.1%) and physical activity (222/414, 53.6%). Health care workers also saw benefits to patients and recommended that the service continues. Sustainability of the chatbot will depend on the future policy of the provincial Department of Health toward mobile health and the willingness to contract with Aviro Health. There is the potential to go to scale and include other languages and chronic conditions. CONCLUSIONS: The chatbot shows great potential to complement traditional health care approaches for people with diabetes and assist with more comprehensive patient education. Further research is needed to fully explore the patient's experience of the chatbot and evaluate its effectiveness in our context.

Influence of shift work on cardiovascular disease risk in Southern African long-distance truck drivers: a cross-sectional study.

OBJECTIVES: Cardiovascular disease (CVD) is a major problem globally. Truck drivers have an increased risk of CVD due to a sedentary lifestyle, irregular working hours and behavioural choices. We aimed to get insight into the contribution of night shift work to CVD risk in long-distance truck drivers in South Africa. DESIGN: A cross-sectional study. SETTING: Enrolment took place at three South African truck stop locations in two provinces; Bloemfontein (Free State), Pomona Road (Gauteng) and Soweto (Gauteng). PARTICIPANTS: 607 males aged ≥18 years with full-time employment as a long-distance truck driver were included. The criteria for inclusion were willingness and being able to provide informed consent and to complete the study procedures. PRIMARY AND SECONDARY OUTCOME MEASURES: Information was collected on sociodemographics, occupational and health characteristics. Physical measurements, an ECG and carotid intima-media thickness (CIMT) measurements were taken. A night shift was defined as working at least 3 hours between 22:00 and 6:00 hours once a week. CVD risk was defined with the Framingham Risk Score (FRS), the Atherosclerotic Cardiovascular Disease (ASCVD) risk algorithm, left ventricular hypertrophy (LVH) and CIMT. RESULTS: In total, 607 truck drivers were included of which 305 (50.2%) worked in day shifts only and 302 (49.8%) worked day and night shifts. There was a high prevalence of CVD risk factors in both groups as 33% were hypertensive, 28% obese and 37% had abnormal lipid levels. Working day and night shifts compared with working only day shifts did not result in differences in FRS, ASCVD risk or LVH. No difference was found in CIMT measurements, except for the maximum bulb thickness which was higher in day shift workers. CONCLUSIONS: CVD risk factors are considerably present in male truck drivers in South Africa. CVD risk does not differ between dayshift and day-night shift workers in this cross-sectional analysis.

Changes in Perceptions and Use of Mobile Technology and Health Communication in South Africa During the COVID-19 Lockdown: Cross-sectional Survey Study.

BACKGROUND: In late March 2020, South Africa implemented a 5-stage COVID-19 Risk Adjusted Strategy, which included a lockdown that required all residents to remain home to prevent the spread of COVID-19. Due to this lockdown, individuals have been forced to find and use alternatives for accomplishing tasks including shopping, socializing, working, and finding information, and many have turned to the internet and their mobile devices. OBJECTIVE: This study aimed to describe how South Africans consume and internalize information surrounding the COVID-19 outbreak in order to determine whether the COVID-19 lockdown and social isolation have influenced technology behavior, particularly in terms of health communication and information. METHODS: From June 24 to August 24, 2020, people in South Africa were invited to complete a survey through the Upinion mobile app, an online data collection resource. The survey collected information on demographics, and technology use during the lockdown, and COVID-19 knowledge. RESULTS: There were 405 participants, of which 296 (73.06%) were female. A total of 320 (79.01%) participants had a tertiary school education, 242 (59.75%) were single, and 173 (42.72%) had full-time employment. The lockdown forced 363 (89.63%) participants to use more technology, especially for work (n=140, 24.05%) and social media/communication (n=133, 22.85%). Security or privacy issues (n=46, 38.98%) and unfamiliarity with technology (n=32, 27.12%) were identified as the most common issues faced by the 127 (31.36%) participants who were unsure about using technology prior to the lockdown. Almost all participants (n=392, 96.79%) stated that they would continue using technology after the lockdown. Multimedia (n=215, 53.09%), mobile phone content (n=99, 24.44%), and health organizations and professionals (n=91, 22.47%) were the main sources of COVID-19 information. Most participants (n=282, 69.63%) felt that they had enough information. Two-thirds (n=275, 67.90%) of participants stated that they had used their mobile phones for health information before the lockdown, with web searches (n=109, 26.91%), social media (n=58, 14.32%), and government and institutional websites (n=52; 12.84%) serving as their main sources of information. Overall, the mean COVID-19 knowledge score was 8.8 (out of 10), and 335 (82.72%) had adequate knowledge (scored ≥8). Males were less likely to identify the correct transmission routes, and single participants were less likely to identify the signs and symptoms of the coronavirus. Tertiary school graduates were 4 times more likely to correctly identify the routes and 2 times more likely to identify how to stop the spread of the virus. People aged 43-56 years were 4 times more likely to identify how the coronavirus can be prevented, and participants ≥57 years were 2.6 times more likely to obtain a knowledge score of 10 when compared to those under 29 years of age. CONCLUSIONS: This study has shown that the COVID-19 lockdown has forced people to increase technology use, and people plan to continue using technology after the lockdown is lifted. Increased technology use was seen across a variety of fields; however, barriers including privacy, unfamiliarity, and data costs were identified. This population showed high COVID-19 knowledge, although the use of web searches and social media, instead of government and institutional websites, increases the potential for health misinformation to be spread.

A Lay-User Assessment of Hepatitis C Virus Self-Testing Device Usability and Interpretation in Johannesburg, South Africa.

Only 20% of people with hepatitis C virus (HCV) know their status. In low-income countries diagnosis is under 10%. Self-testing for HCV antibodies (HCVST) could expand the coverage of HCV testing services. Currently, there are no stringent regulatory authority (SRA) approved HCVSTs, therefore lay-user usability of three prototype kits was assessed. This was a cross-sectional observational study conducted with 171 (CareStart n = 60, Bioline n = 52, First Response n = 59) participants. Participants were given one of the three HCVST kits with only instructions for use (IFU) and asked to perform the test in front of a professional trained in rapid diagnostic tests (RDT). Usability indices were calculated based on the correctness of performing each step of the product-specific process followed by contrived results interpretation and a post-test interview. The usability index was 93.9% for CareStart, 90.7% for Bioline and 94.9% for First Response. Most errors were on incorrect handwashing, sample collection and transfer to the test device. An average of 93.1% of contrived results were correctly interpreted, with most errors related to interpreting invalid results. Most participants (n = 167) stated they would visit a clinic after a positive result. With negative results, nearly half (28/60 (46.7%)) stated they should condomize, while just over two-thirds of participants that used Bioline (35/52 (67.3%)) and First Response (38/59 (64.4%)) said they should re-test. Most participants (n = 162) found the devices easy to use. Participants liked that self-testing was fast, private and convenient, however there were some confusion with IFU steps and pictures, finger-pricking with the lancet, collecting blood after the finger-prick, and transferring the sample/buffer. Prototype HCVST kits exhibit high usability and result interpretation by lay-users, and should be considered for SRA approval.

Uptake of the Ithaka mobile application in Johannesburg, South Africa, for human immunodeficiency virus self-testing result reporting.

BACKGROUND: Human immunodeficiency virus self-testing (HIVST) can reduce facility-based HIV testing barriers; however, no proven applications exist with widespread uptake for self-reporting or linkage to care. Mobile health (mHealth) applications (apps) have shown high usability and feasibility scores, so Ithaka was developed for South Africans to self-report HIVST results outside clinical settings. OBJECTIVES: This study investigated the use of Ithaka as a support tool for HIVST users, specifically the ability to self-report results. METHOD: This cross-sectional study was conducted from November 2018 to June 2019. At existing HIVST distribution sites, individuals were given HIVST kits and then invited to use Ithaka. Participants could test at home and report their results through the app anytime. Ithaka tracked when people logged-on, registered, received counselling and reported results. Post-study surveys on user experience were also conducted. RESULTS: Of 751 participants, 531 (70.7%) logged onto the app, 412 (54.9%) registered, 295 (39.3%) received counselling and 168 (22.4%) self-reported results. Participants strongly agreed that Ithaka was useful and that it was easy to upload results. Forty-one participants completed a post-test survey, and 39/41 (95.1%) completed the app journey. Most participants (36/41;87.8%) had no challenges, although 2/41 (4.9%) cited perceived data costs, 2/41 (4.9%) difficulty uploading results and 1/41 (2.4%) language, as challenges. CONCLUSION: Despite the small sample size, this study has shown that HIVST participants under pragmatic conditions were willing and able to self-report results via the app, whilst also identifying areas of improvement for scaling up.

International citizen project to assess early stage adherence to public health measures for COVID-19 in South Africa.

INTRODUCTION: With over 500 000 infections and nearly 12 000 deaths, South Africa (SA) is the African epicenter of the current Coronavirus (COVID-19) pandemic. SA has implemented a 5-stage Risk-Adjusted Strategy which includes a phased national lockdown, requiring social distancing, frequent hand washing and wearing face masks. Strict adherence to this strategy is crucial to reducing COVID-19 transmission, flattening the curve, and preventing resurgence. As part of the 22-country International Citizens Project COVID-19 (ICPcovid), this study aimed to describe the SA adherence to the Risk-Adjusted Strategy and identify determinants of adherence. METHOD: During 24 April-15 May 2020, people were electronically invited, through social media platforms and a text blast, to complete an online survey, accessible via www.icpcovid.com. The survey investigated COVID-19 testing and preventative adherence measures, then used logistic regression analysis to identify predictors of adherence. RESULTS: There were 951 participants, with 731(76.9%) 25 to 54 years. Most (672;70.7%) were female, and 705(74.1%) had a university degree. Since the epidemic started, 529(55.6%) and 436(45.9%) participants stated they were eating healthier and taking more vitamins, respectively. Only 82(8.6%) had been COVID-19 tested, and 1(1.2%) tested positive. In public, 905(95.2%) socially distanced, however 99(10.4%) participants had recently attended meetings with over ten people. Regular hand washing was practiced by 907(95.4%) participants, 774(81.4%) wore face masks and 854(89.8%) stayed home when they experienced flu-like symptoms. The odds of adhering to the guidelines were lower among men versus women (AOR 0.72, 95% confidence interval [CI] = 0.528, 0.971) and those who had flu-like symptoms (AOR 0.42, 95% CI = 0.277, 0.628). In contrast, increased odds were reported for those who reported increased vitamin intake (AOR 1.37, 95% CI = 1.044,1.798), and were either cohabiting or married (AOR 1.39, 95% CI = 1.042,1.847). CONCLUSION: Despite high reported adherence, face mask use and symptomatic individuals not self-isolating, were areas for improvement. However, these factors cannot solely account for SA's increasing COVID-19 cases. Larger general population studies are needed to identify other adherence predictors for a strengthened SA COVID-19 response. While the government must continue to educate the entire population on preventative measures, provide personal protective equipment and stress the importance of adherence, there also needs to be implementation of prioritised prevention strategies for men and single individuals to address their demonstrated lower adherence.

Evaluation of a mobile application to support HIV self-testing in Johannesburg, South Africa.

BACKGROUND: Human immunodeficiency virus self-testing (HIVST) reduces barriers associated with facility-based testing; however, no formal mechanism exists for users to self-report results or link to care. The AspectTM HIVST mobile application (app) was developed for use in South Africa. OBJECTIVES: This study evaluated the acceptability and feasibility of the AspectTM HIVST app for individuals from the inner city of Johannesburg. METHOD: This cross-sectional pilot, with a convenience sample of 300 adults, was conducted in July 2018. Participants were provided an OraQuick HIVST kit and a smartphone preloaded with the app, then asked to follow the in-app instructions for use (IFU) to complete the HIVST and upload results. Trained healthcare workers (HCWs) observed and recorded any deviations from the IFU, and conducted a post-test survey to assess acceptability. Feasibility was evaluated by the number of participants who agreed to participate, completed the self-test, and uploaded all information onto the app correctly. RESULTS: Most participants (98.7%) found the app easy to use. To reduce difficulties related to the IFU (26; 8.7%), participants suggested multimedia supplements (4; 1.3%), additional languages (4; 1.3%) and simplified instructions (5; 1.7%). All individuals approached, agreed to participate, 267 (89.0%) correctly completed all steps and 210 (78.7%) successfully captured all information on the app. Most errors (26; 8.7%) were testing errors and 1 (0.3%) was from the app sequence. Twelve (4.5%) errors were with test strip imaging and 72 (27.0%) discordances were with demographic information. CONCLUSION: Despite some challenges with IFU interpretation and data capture via the app, this pilot showed that the AspectTM HIVST app is an acceptable way to upload mobile HIVST results and demographic information to a central database.

Usability assessment of seven HIV self-test devices conducted with lay-users in Johannesburg, South Africa.

INTRODUCTION: The first 90 of the 90-90-90 initiative introduced by the World Health Organization(WHO) in 2015 requires 90% of people with HIV be aware of their status by 2020. In South Africa, conventional facility-based testing had reached 84.9% in 2018; innovative new methods, like HIV self-testing(HIVST) may close the testing gap. This study aimed to determine the usability of seven HIVST kits among untrained South Africans. METHODS: This cross-sectional study of 1400 adults in Johannesburg evaluated the usability of five blood fingerstick and two oral fluid HIVSTs, using WHO prequalification criteria, from June 2016 to June 2018. Participants were handed one kit, with no further information about the device or test procedure, and asked to perform the test in front of an observer. The observer used product-specific semi-structured questionnaires organized into a composite usability index(UI) using a HIVST process checklist, a contrived results interpretation and a post-test interview that expanded on participant experiences with the device and instructions-of-use(IFU). Participants were not tested themselves, but provided with contrived results to interpret. RESULTS: The average UI was 92.8%(84.2%-97.6%); the major difficulty was obtaining and transferring the specimen. Participants correctly interpreted 96.1% of the non-reactive/negative, 97.0% of the reactive/positive, 98.0% of the invalid and 79.9% of the weak positive results. Almost all participants(97.0%) stated they would visit a clinic or seek treatment for positive results; with negative results, half(50.6%) stated they should re-test in the next three months while one-third(36.1%) said they should condomize. Nearly all found the devices easy to use(96.6%), the IFUSs easy to understand(97.9%) and felt confident using the test unassisted(95.9%) but suggested improvements to packaging/IFUs to further increase usability; 19.9% preferred clinic-based testing to HIVST. CONCLUSION: The UI and interpretation of results was high and in-line with previous usability studies, suggesting that these kits are appropriate for use in the general, untrained and unsupervised public.

Cross-sectional study of the health of southern African truck drivers.

OBJECTIVES: Lifestyle and working conditions of truck drivers predisposes them to risk-factors associated with communicable and non-communicable diseases, but little is known about the health status of African truck driver. This study aims to assess a cross-section of truckers in South Africa to describe their health information. SETTING: The study took place across three truck-stop rest areas in the South African provinces of Free State and Gauteng. PARTICIPANTS: Eligibility criteria included being males aged 18 years and older, full-time employment as a long-distance truck driver. A total of 614 male truck drivers participated; 384 (63%) were Zimbabwean and 325 (55%) completed high-school. PRIMARY AND SECONDARY OUTCOME MEASURES: The trucker survey explored demographics; working conditions; sexual, eating and sleeping behaviours; mental health status, medical history and cardiac risk-factors. Medical assessments included physical measurements, glucose and lipid measurements, ECG, carotid intima-media thickness (CIMT) and cardiac ultrasound. RESULTS: In the previous month, 554 (91%) participants were sexually active; 522 (86%) had sex with a regular partner; 174 (27%) with a casual partner; 87 (14%) with a sex worker. Average time driving was 10 hours/day, 20 days/month, 302 (50%) never worked night shifts and 74 (12%) worked nights approximately four times per week. 112 (18%) experienced daytime sleepiness and 59 (10%) were ever hospitalised from an accident. Forty-seven (8%, 95% CI 5.3 to 9.5) were HIV-positive, with half taking antiretrovirals. Forty-eight (8%) truckers had some moderate depression, while 21 (4%) suffered from post-traumatic stress disorder. Reported tuberculosis, myocardial infarction, and diabetes were <3%. Prominent cardiac risk-factors included smoking (n=63, 11%), consuming alcohol (>15 drinks/week) (n=54, 9%), overweight/obesity (n=417, 69%), and hypertension (n=220, 36%,95% CI 32.1 to 39.7). ECG results showed 23 (4.9%) and 29 (5.3%) drivers had left ventricular hypertrophy using the Cornell criterion and product, respectively. CIMT measurements indicated nine (4.2%) drivers had a carotid atherosclerotic plaque. CONCLUSION: This first holistic assessment of health among southern African male truck drivers demonstrates substantial addressable cardiovascular risk factors, mental health issues and sexual risk behaviours.

Acceptability of Mobile Health Interventions to Increase Diabetic Risk Factor Awareness Among the Commuter Population in Johannesburg: Descriptive Cross-Sectional Study.

BACKGROUND: Developing countries are experiencing a shift from infectious diseases such as HIV and tuberculosis to noncommunicable diseases (NCDs) such as diabetes. Diabetes accounts for more disability-adjusted life years than any other NCD in South Africa, and research has identified a number of preventable risk factors; however, there is not enough evidence from lower resource settings as to how best to disseminate this information to the population. Today, 90% of the world's population lives in mobile phone coverage areas, and this provides a unique opportunity to reach large populations with health information. OBJECTIVE: This study aimed to investigate how potential mobile health (mHealth) platforms should be paired with diabetes risk factor education so that at-risk communities are empowered with information to prevent and manage diabetes. METHODS: A Likert-style survey was distributed to commuters in the City of Johannesburg in July 2018 that explored participants' background characteristics as well as their knowledge and awareness surrounding diabetic risk factors (such as exercise, smoking, and hypertension) and their comfort level with various information delivery methods (such as WhatsApp, short message service, and email). The grouped variables from diabetic risk factors and information delivery methods were described with mean Likert scores and then investigated for relationships with Spearman Rho correlation coefficients. RESULTS: Background characteristics revealed that the self-reported prevalence of diabetes was twice as high in this studied commuter population than the national average. WhatsApp was the most favorable mHealth information delivery method and had a moderate correlation coefficient with diet and nutrition (0.338; P<.001) as well as a weaker correlation with physical activity (0.243; P<.001). Although not as robust as the WhatsApp correlations, each of the other information delivery methods also showed weaker, yet statistically significant, relationships with one or more of the risk factors. CONCLUSIONS: The elevated self-reported diabetes prevalence reinforces the need for diabetes risk factor education in the studied commuter population of Johannesburg. The most feasible mHealth intervention for diabetic risk factor education should focus on WhatsApp messaging while also offering content across other mHealth and traditional platforms to remove barriers to access and enhance the user experience. The content should emphasize diet and nutrition as well as physical activity while also incorporating information on secondary risk factors.

Improving Linkage to and Retention in Care in Newly Diagnosed HIV-Positive Patients Using Smartphones in South Africa: Randomized Controlled Trial.

BACKGROUND: South Africa provides free antiretroviral therapy for almost 5 million people living with HIV, but only 71% of the eligible people are on treatment, representing a shortfall in the care cascade, especially among men and youth. Many developing countries have expanded access to smartphones; success in health apps raises the possibility of improving this cascade. OBJECTIVE: SmartLink is a health app for Android smartphones providing HIV-related laboratory results, information, support, and appointment reminders to engage and link patients to care. This study aimed to evaluate the ability of SmartLink to improve linkage to care for HIV-positive smartphone owners. METHODS: This study was a multisite randomized controlled trial in Johannesburg. The intervention arm received the app (along with referral to a treatment site) and the control arm received the standard of care (referral alone). Linkage to care was confirmed by an HIV-related blood test reported on the National Health Laboratory Service database between 2 weeks and 8 months after initiation. RESULTS: A total of 345 participants were recruited into the study; 64.9% (224/345) of the participants were female and 44.1% (152/345) were aged less than 30 years. In addition, 46.7% (161/345) were employed full time, 95.9% (331/345) had at least secondary school education, and 35.9% (124/345) were from Zimbabwe. Linkage to care between 2 weeks and 8 months was 48.6% (88/181) in the intervention arm versus 45.1% (74/164) in the control (P=.52) and increased to 64.1% (116/181) and 61.0% (100/164) (P=.55), respectively, after the initial 8-month period. Moreover, youth aged 18 to 30-years showed a statistically significant 20% increase in linkage to care for the intervention group. CONCLUSIONS: Youth aged less than 30 years have been historically difficult to reach with traditional interventions, and the SmartLink app provides a proof of concept that this population reacts to mobile health interventions that engage patients in HIV care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW).

The MomConnect Nurses and Midwives Support Platform (NurseConnect): A Qualitative Process Evaluation.

BACKGROUND: Over the past decade, mobile health has steadily increased in low-income and middle-income countries. However, few platforms have been able to sustainably scale up like the MomConnect program in South Africa. NurseConnect was created as a capacity building component of MomConnect, aimed at supporting nurses and midwives in maternal and child health. The National Department of Health has committed to expanding NurseConnect to all nurses across the country, and an evaluation of the current user experience was conducted to inform a successful scale up. OBJECTIVE: This study aims to evaluate the perception and use of NurseConnect by nurses and midwives to produce feedback that can be used to optimize the user experience as the platform continues to scale up. METHODS: We conducted focus group discussions and in-depth interviews with 110 nurses and midwives from 18 randomly selected health care facilities across South Africa. Questions focused on mobile phone use, access to medical information and their experience with NurseConnect registration, as well as the content and different platforms. RESULTS: All participants had mobile phones and communication through calls and messaging was the main use in both personal and work settings. Of 110 participants, 108 (98.2%) had data-enabled phones, and the internet, Google, and apps (South African National Department of Health Guidelines, iTriage, Drugs.com) were commonly used, especially to find information in the work setting. Of 110 participants, 62 (56.4%) were registered NurseConnect users and liked the message content, especially listeriosis and motivational messages, which created behavioral change in some instances. The mobisite and helpdesk, however, were underutilized because of a lack of information surrounding these platforms. Some participants did not trust medical information from websites and had more confidence in apps, while others associated a "helpdesk" with a call-in service, not a messaging one. Many of the unregistered participants had not heard of NurseConnect, and some cited data and time constraints as barriers to both registration and uptake. CONCLUSIONS: Mobile and smartphone penetration was very high, and participants often used their phone to find medical information. The NurseConnect messages were well-liked by all registered participants; however, the mobisite and helpdesk were underutilized owing to a lack of information and training around these platforms. Enhanced marketing and training initiatives that optimize existing social networks, as well as the provision of data and Wi-Fi, should be explored to ensure that registration improves, and that users are active across all platforms.

Clinical decisions for anterior restorations: the concept of restorative volume.

UNLABELLED: The choice of the most appropriate restoration for anterior teeth is often a difficult decision. Numerous clinical and technical factors play an important role in selecting the treatment option that best suits the patient and the restorative team. Experienced clinicians have developed decision processes that are often more complex than may seem. Less experienced professionals may find difficulties making treatment decisions because of the widely varied restorative materials available and often numerous similar products offered by different manufacturers. The authors reviewed available evidence and integrated their clinical experience to select relevant factors that could provide a logical and practical guideline for restorative decisions in anterior teeth. The presented concept of restorative volume is based on structural, optical, and periodontal factors. Each of these factors will influence the short- and long-term behavior of restorations in terms of esthetics, biology, and function. Despite the marked evolution of esthetic restorative techniques and materials, significant limitations still exist, which should be addressed by researchers. The presented guidelines must be regarded as a mere orientation for risk analysis. A comprehensive individual approach should always be the core of restorative esthetic treatments. CLINICAL SIGNIFICANCE: The complex decision process for anterior esthetic restorations can be clarified by a systematized examination of structural, optical, and periodontal factors. The basis for the proposed thought process is the concept of restorative volume that is a contemporary interpretation of restoration categories and their application.

Co-existence of crowns and veneers in the anterior dentition: case report.

Crowns and veneers provide distinct treatment strategies with different outcomes in terms of tissue conservation, periodontal distress and esthetic result. It is not always clear where a crown or veneer is indicated, but in the last two decades, adhesive technology, conservative approaches and esthetic demands have increased clinical indications for porcelain veneers in restorative dentistry. A combination of veneers and crowns may be required, especially in the anterior region. It may be desirable to reinforce some teeth and preserve tissue on others. Problems can arise with the esthetic integration of both types of restoration, owing to their inherent mechanical and optical properties. Several clinical and laboratory techniques can be applied for a successful combination. In this article the authors describe the procedures and difficulties in treating a case with such needs.

Induction of neutralizing antibody responses to hepatitis C virus with synthetic peptide constructs incorporating both antibody and T-helper epitopes.

We describe a peptide-based strategy for hepatitis C virus (HCV) vaccine design that exploits synthetic peptides representing antibody epitopes of the hypervariable region 1 (HVR1) of the E2 glycoprotein and also less variable regions immediately downstream of HVR1. These epitopes were linked to a T-helper (T(h)) epitope (KLIPNASLIENCTKAEL) derived from the Morbillivirus canine distemper virus. Antibody titres induced by the two vaccine candidates T(h)-A (E2 amino acid 384-414) and T(h)-B (E2 amino acid 390-414) were significantly higher than those produced against vaccines lacking the T(h) epitope (P<0.05). Mice inoculated with the vaccine candidates T(h)-C (E2 amino acids 412-423) and T(h)-F (E2 amino acids 436-447) emulsified in complete Freund's adjuvant each elicited antibody titres that were significantly higher than those elicited by T(h)-E (E2 amino acids 396-407) and T(h)-D (E2 amino acids 432-443) (P<0.01). Antisera obtained from mice inoculated with the epitope vaccines T(h)-A, T(h)-B, T(h)-D and T(h)-E bound to E2 expressed at the surface of 293T cells that had been transfected with E1E2. Furthermore, IgG from the sera of mice inoculated with four of the vaccine candidates, T(h)-A, T(h)-C, T(h)-D and T(h)-E, inhibited the entry of HCV/human immunodeficiency virus pseudoparticles (HCVpps) into Huh-7 cells. These results demonstrate the potential of synthetic peptide-based constructs in the delivery of potential neutralizing epitopes that are present within the viral envelope of HCV.