Katherine A. Muldoon

Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries

ObjectiveFew studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.MethodsWe used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization.ResultsSignificant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78-0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40-0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03-1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82-0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36-0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.77-0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02-4.00) were found to be a significant risk factor for MMR.ConclusionSeveral key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities.

High Prevalence and Partner Correlates of Physical and Sexual Violence by Intimate Partners among Street and Off-Street Sex Workers

Objectives Intimate partner violence (IPV) is associated with increased risk of HIV among women globally. There is limited evidence and understanding about IPV and potential HIV risk pathways among sex workers (SWs). This study aims to longitudinally evaluate prevalence and correlates of IPV among street and off-street SWs over two-years follow-up. Methods Longitudinal data were drawn from an open prospective cohort, AESHA (An Evaluation of Sex Workers Health Access) in Metro Vancouver, Canada (2010–2012). Prevalence of physical and sexual IPV was measured using the WHO standardized IPV scale (version 9.9). Bivariate and multivariable logistic regression using Generalized Estimating Equations (GEE) were used to examine interpersonal and structural correlates of IPV over two years. Results At baseline, 387 SWs had a male, intimate sexual partner and were eligible for this analysis. One-fifth (n = 83, 21.5%) experienced recent physical/sexual IPV at baseline and 26.2% over two-years follow-up. In multivariable GEE analysis, factors independently correlated with physical/sexual IPV in the last six months include: childhood (<18 years) sexual/physical abuse (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [CI]: 1.14–3.69), inconsistent condom use for vaginal and/or anal sex with intimate partner (AOR = 1.84, 95% CI: 1.07–3.16), <daily prescription opioid use (AOR = 1.72, 95% CI: 1.02–2.89), providing financial support to intimate partner (AOR = 1.65, 95% CI: 1.05–2.59), and sourcing drugs from intimate partner (AOR = 1.62, 95% CI: 1.02–2.26). Discussion Our results demonstrate that over one-fifth of SWs in Vancouver report physical/sexual IPV in the last six months. The socio-structural correlates of IPV uncovered here highlight potential HIV risk pathways through SWs’ intimate, non-commercial partner relationships. The high prevalence of IPV among SWs is a critical public health concern and underscores the need for integrated violence and HIV prevention and intervention strategies tailored to this key population.

Structural determinants of dual contraceptive use among female sex workers in Gulu, northern Uganda.

To describe the characteristics of female sex workers (FSWs) who do and do not use dual contraceptives (i.e. male condoms plus a non‐barrier method) in Gulu, northern Uganda.

Decisions, decisions: the importance of condom use decision making among HIV sero-discordant couples in a prospective cohort study in Uganda

Objectives We examined sexual decision making type among couples in HIV sero-discordant partnerships in Uganda, and investigated how sexual decision making type changed over time and its effect on condom use. Methods Data were drawn from a longitudinal cohort of HIV sero-discordant couples, recruited through the AIDS Support Organisation in Jinja, Uganda. Sexual decision making was measured using the Sexual Relationship Power Scale, and couples’ individual self-report answers were matched to assess agreement for decision making type and condom use. Generalised linear mixed effects modelling was used to assess statistically significant differences in time trend of sexual decision making type, and to investigate the independent association of decision making type on condom use status over time. Results Of the 533 couples included in this analysis, 345 (65%) reported using condoms at last sex at study enrolment. In the time trend analysis of decision making, the proportion of couples who decided together increased over time while the proportions of couples who reported that one partner decided or no one decided/did not use condoms, decreased over time (overall p<0.001). Compared with couples who decided together, those who disagreed (adjusted OR=0.42, 95% CI 0.28 to 0.64) and those where one partner decided (adjusted OR=0.20, 95% CI 0.12 to 0.34) had significantly lower odds of condom use at last sex, even after controlling for confounders. Conclusions Couples who disagreed on decision making, or agreed that one partner decides alone, had significantly lower odds of reporting condom use compared with couples who decided together. HIV counselling interventions that encourage joint sexual decision making may improve condom use within this population.

Universal vs Risk Factor Screening for Methicillin-Resistant Staphylococcus aureus in a Large Multicenter Tertiary Care Facility in Canada.

OBJECTIVE To assess the clinical effectiveness of a universal screening program compared with a risk factor-based program in reducing the rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) among admitted patients at the Ottawa Hospital. DESIGN Quasi-experimental study. SETTING Ottawa Hospital, a multicenter tertiary care facility with 3 main campuses, approximately 47,000 admissions per year, and 1,200 beds. METHODS From January 1, 2006 through December 31, 2007 (24 months), admitted patients underwent risk factor-based MRSA screening. From January 1, 2008 through August 31, 2009 (20 months), all patients admitted underwent universal MRSA screening. To measure the effectiveness of this intervention, segmented regression modeling was used to examine monthly nosocomial MRSA incidence rates per 100,000 patient-days before and during the intervention period. To assess secular trends, nosocomial Clostridium difficile infection, mupirocin prescriptions, and regional MRSA rates were investigated as controls. RESULTS The nosocomial MRSA incidence rate was 46.79 cases per 100,000 patient-days, with no significant differences before and after intervention. The MRSA detection rate per 1,000 admissions increased from 9.8 during risk factor-based screening to 26.2 during universal screening. A total of 644 new nosocomial MRSA cases were observed in 1,448,488 patient-days, 323 during risk factor-based screening and 321 during universal screening. Secular trends in C. difficile infection rates and mupirocin prescriptions remained stable after the intervention whereas population-level MRSA rates decreased. CONCLUSION At Ottawa Hospital, the introduction of universal MRSA admission screening did not significantly affect the rates of nosocomial MRSA compared with risk factor-based screening. Infect. Control Hosp. Epidemiol. 2015;37(1):41-48.

Lack of Effectiveness of Antiretroviral Therapy in Preventing HIV Infection in Serodiscordant Couples in Uganda: An Observational Study.

Background We examined the real-world effectiveness of ART as an HIV prevention tool among HIV serodiscordant couples in a programmatic setting in a low-income country. Methods We enrolled individuals from HIV serodiscordant couples aged ≥18 years of age in Jinja, Uganda from June 2009 – June 2011. In one group of couples the HIV positive partner was receiving ART as they met clinical eligibility criteria (a CD4 cell count ≤250 cells/ μL or WHO Stage III/IV disease). In the second group the infected partner was not yet ART-eligible. We measured HIV incidence by testing the uninfected partner every three months. We conducted genetic linkage studies to determine the source of new infections in seroconverting participants. Results A total of 586 couples were enrolled of which 249 (42%) of the HIV positive participants were receiving ART at enrollment, and an additional 99 (17%) initiated ART during the study. The median duration of follow-up was 1.5 years. We found 9 new infections among partners of participants who had been receiving ART for at least three months and 8 new infections in partners of participants who had not received ART or received it for less than three months, for incidence rates of 2.09 per 100 person-years (PYRs) and 2.30 per 100 PYRs, respectively. The incidence rate ratio for ART-use was 0.91 (95% confidence interval 0.31-2.70; p=0.999). The hazard ratio for HIV seroconversion associated with ART-use by the positive partner was 1.07 (95% CI 0.41-2.80). A total of 5/7 (71%) of the transmissions on ART and 6/7 (86%) of those not on ART were genetically linked. Conclusion Overall HIV incidence was low in comparison to previous studies of serodiscordant couples. However, ART-use was not associated with a reduced risk of HIV transmission in this study.

Gendered HIV risk patterns among polygynous sero-discordant couples in Uganda

Stable serodiscordant relationships and sexual concurrency are pathways that contribute to the HIV epidemic in sub-Saharan Africa. However whether polygyny imparts the same risks as informal concurrent relationships remains an open research question. Using data collected at enrolment from a cohort study of sero-discordant couples, this analysis investigates how polygynous relationships differ from those involving only a single female spouse and whether men involved in polygynous partnerships are more likely to report HIV-risk behaviour than those in single spouse partnerships. Of 444 enrolled couples, 111 (25%) were polygynous and 333 (75%) were single-spouse partnerships. We found that polygynous men were more likely to report controlling sexual decision-making and to report any unprotected sex with unknown sero-status partner. After controlling for potential confounders, polygynous men were still more likely to report unprotected sex with an unknown sero-status partner. In this sample of sero-discordant couples we found indication of excess HIV-risk behaviour among men involved in polygynous relationships.

Policing the epidemic: High burden of workplace violence among female sex workers in conflict-affected northern Uganda

ABSTRACT Sex workers in sub-Saharan Africa experience a high burden of HIV with a paucity of data on violence and links to HIV risk among sex workers, and even less within conflict-affected environments. Data are from a cross-sectional survey of female sex workers in Gulu, northern Uganda (n = 400). Logistic regression was used to determine the specific association between policing and recent physical/sexual violence from clients. A total of 196 (49.0%) sex workers experienced physical/sexual violence by a client. From those who experienced client violence the most common forms included physical assault (58.7%), rape (38.3%), and gang rape (15.8%) Police harassment was very common, a total of 149 (37.3%) reported rushing negotiations with clients because of police presence, a practice that was significantly associated with increased odds of client violence (adjusted odds ratio: 1.61, 95% confidence intervals: 1.03–2.52). Inconsistent condom use with clients, servicing clients in a bar, and working for a manager/pimp were also independently associated with recent client violence. Structural and community-led responses, including decriminalisation, and engagement with police and policy stakeholders, remain critical to addressing violence, both a human rights and public health imperative.

Cost Analysis of Universal Screening vs. Risk Factor-Based Screening for Methicillin-Resistant Staphylococcus aureus (MRSA)

Background The literature remains conflicted regarding the most effective way to screen for MRSA. This study was designed to assess costs associated with universal versus risk factor-based screening for the reduction of nosocomial MRSA transmission. Methods The study was conducted at The Ottawa Hospital, a large multi-centre tertiary care facility with approximately 47,000 admissions annually. From January 2006-December 2007, patients underwent risk factor-based screening for MRSA on admission. From January 2008 to August 2009 universal MRSA screening was implemented. A comparison of costs incurred during risk factor-based screening and universal screening was conducted. The model incorporated probabilities relating to the likelihood of being tested and the results of polymerase chain reaction (PCR) testing with associated effects in terms of MRSA bacteremia and true positive and negative test results. Inputted costs included laboratory testing, contact precautions and infection control, private room costs, housekeeping, and length of hospital stay. Deterministic sensitivity analyses were conducted. Results The risk factor-based MRSA screening program screened approximately 30% of admitted patients and cost the hospital over

Measuring Food and Nutrition Security: Tools and Considerations for Use Among People Living with HIV

780 000 annually. The universal screening program screened approximately 83% of admitted patients and cost over