Malika Sharma

Pre-exposure prophylaxis for sexually-acquired HIV risk management: a review

Despite significant efforts, the rate of new HIV infections worldwide remains unacceptably high, highlighting the need for new HIV prevention strategies. HIV pre-exposure prophylaxis (PrEP) is a new approach that involves the ongoing use of antiretroviral medications by HIV-negative individuals to reduce the risk of HIV infection. The use of daily tenofovir/emtricitabine as oral PrEP was found to be effective in multiple placebo-controlled clinical trials and approved by the United States Food and Drug Administration. In addition, the Centers for Disease Control and Prevention in the United States and the World Health Organization have both released guidelines recommending the offer of oral PrEP to high-risk populations. The scale-up of PrEP is underway, but several implementation questions remain unanswered. Demonstration projects and open-label extensions of placebo-controlled trials are ongoing and hope to contribute to our understanding of PrEP use and delivery outside the randomized controlled trial setting. Evidence is beginning to emerge from these open-label studies and will be critical for guiding PrEP scale-up. Outside of such studies, PrEP uptake has been slow and several client- and provider-related barriers are limiting uptake. Maximizing the public health impact of PrEP will require rollout to be combined with interventions to promote uptake, support adherence, and prevent increases in risk behavior. Additional PrEP strategies are currently under investigation in placebo-controlled clinical trials and may be available in the future.

Endogenous Klebsiella endophthalmitis in a Vietnamese immigrant

A previously healthy 54-year-old carpenter presented with a 13-day history of redness, tearing and pain in his left eye, which was associated with a progressive reduction in visual acuity. He had no fever or other systemic symptoms. He had no history of eye trauma or surgery, and he regularly used

An agent–vector–host–environment model for controlling small arms and light weapons

Armed violence is a significant public health problem. It results in fatal and non-fatal injuries and disrupts social and economic processes that are essential to the health of individuals and communities. We argue that an agent–vector–host–environment model can be helpful in understanding and describing the availability and misuse of small arms and light weapons. Moreover, such a model can assist in identifying potential control points and in developing mitigation strategies. These concepts have been developed from analogous vector control programs and are applied to controlling arms to reduce their misuse. So-called ‘de-normalization’ and ‘de-legitimization’ campaigns that focus on the vector – including the industry producing these commodities – can be based on the experience of public health in controlling tobacco use and exposure. This model can assist health professionals, civil society and governments in developing comprehensive strategies to limit the production, distribution and misuse of small arms and light weapons.

The perceived organizational impact of the gender gap across a Canadian department of medicine and proposed strategies to combat it: a qualitative study

BackgroundDespite the gender parity existing in medical schools for over three decades, women remain underrepresented in academic medical centers, particularly in senior ranks and in leadership roles. This has consequences for patient care, education, research, and workplace culture within healthcare organizations. This study was undertaken to explore the perspectives of faculty members at a single department of medicine on the impact of the existing gender gap on organizational effectiveness and workplace culture, and to identify systems-based strategies to mitigate the gap.MethodsThe study took place at a large university department of medicine in Toronto, Canada, with six affiliated hospitals. In this qualitative study, semi-structured individual interviews were conducted between May and September 2016 with full-time faculty members who held clinical and university-based appointments. Transcripts of the interviews were analyzed using thematic analysis. Three authors independently reviewed the transcripts to determine a preliminary list of codes and establish a coding framework. A modified audit consensus coding approach was applied; a single analyst reviewed all the transcripts and a second analyst audited 20% of the transcripts in each round of coding. Following each round, inter-rater reliability was determined, discrepancies were resolved through discussion, and modifications were made as needed to the coding framework. The analysis revealed faculty members’ perceptions of the gender gap, potential contributing factors, organizational impacts, and possible solutions to bridge the gap.ResultsOf the 43 full-time faculty members who participated in the survey (29 of whom self-identified as female), most participants were aware of the existing gender gap within academic medicine. Participants described social exclusion, reinforced stereotypes, and unprofessional behaviors as consequences of the gap on organizational effectiveness and culture. They suggested improvements in (1) the processes for recruitment, hiring, and promotion; (2) inclusiveness of the work environment; (3) structures for mentorship; and (4) ongoing monitoring of the gap.ConclusionThe existing gender gap in academic medicine may have negative consequences for organizational effectiveness and workplace culture but many systems-based strategies to mitigate the gap exist. Although these solutions warrant rigorous evaluation, they are feasible to institute within most healthcare organizations immediately.

Training tomorrow's physician‐advocates

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‘Can the patient speak?’: postcolonialism and patient involvement in undergraduate and postgraduate medical education

Patients are increasingly being engaged in providing feedback and consultation to health care institutions, and in the training of health care professionals. Such involvement has the potential to disrupt traditional doctor–patient power dynamics in significant ways that have not been theorised in the medical literature. Critical theories can help us understand how power flows when patients are engaged in the training of medical students.

The role of people living with HIV as patient instructors – reducing stigma and improving interest around HIV care among medical students*

ABSTRACT People living with HIV/AIDS (PHAs) are increasingly recognized as experts in HIV and their own health. We developed a simulated clinical encounter (SCE) in which medical students provided HIV pre- and post-test counselling and point-of-care HIV testing for PHAs as patient instructors (PHA-PIs) under clinical preceptor supervision. The study assessed the acceptability of this teaching tool with a focus on assessing impact on HIV-related stigma among medical students. University of Toronto pre-clerkship medical students participated in a series of SCEs facilitated by 16 PHA-PIs and 22 clinical preceptors. Pre- and post-SCE students completed the validated Health Care Provider HIV/AIDS Stigma Scale (HPASS). HPASS measures overall stigma, as well as three domains within HIV stigma: stereotyping, discrimination, and prejudice. Higher scores represented higher levels of stigma. An additional questionnaire measured comfort in providing HIV-related care. Mean scores and results of paired t-tests are presented. Post-SCE, students (n  = 62) demonstrated decreased overall stigma (68.74 vs. 61.81, p  < .001) as well as decreased stigma within each domain. Post-SCE, students (n  = 67) reported increased comfort in providing HIV-related care (10.24 vs. 18.06, p  < .001). Involving PHA-PIs reduced HIV-related stigma among medical students and increased comfort in providing HIV-related care.

Time to Viremia for Patients Taking their First Antiretroviral Regimen and the Subsequent Resistance Profiles

Background: The resistance profiles for patients on first-line antiretroviral therapy (ART) regimens after viremia have not been well studied in community clinic settings in the modern treatment era. Objective: To determine time to viremia and the ART resistance profiles of viremic patients. Methods: HIV-positive patients aged ≥16 years initiating a three-drug regimen were retrospectively identified from 01/01/06 to 12/31/12. The regimens were a backbone of two nucleoside reverse transcriptase inhibitors (NRTIs) and a third agent: a protease inhibitor (PI), non-nucleoside reverse transcriptase inhibitor (NNRTI), or an integrase inhibitor (II). Time to viremia was compared using a proportional hazards model, adjusting for demographic and clinical factors. Resistance profiles were described in those with baseline and follow-up genotypes. Results: For 653 patients, distribution of third-agent use and viremia was: 244 (37%) on PIs with 80 viremia, 364 (56%) on NNRTIs with 84 viremia, and 45 (7%) on II with 11 viremia. Only for NNRTIs, time to viremia was longer than PIs (p = 0.04) for patients with a CD4 count ≥200 cells/mm3. Of the 175 with viremia, 143 (82%) had baseline and 37 (21%) had follow-up genotype. Upon viremia, emerging ART resistance was rare. One new NNRTI (Y181C) mutation was identified and three patients taking PI-based regimens developed NRTI mutations (M184 V, M184I, and T215Y). Conclusions: Time to viremia for NNRTIs was longer than PIs. With viremia, ART resistance rarely developed without PI or II mutations, but with a few NRTI mutations in those taking PI-based regimens, and NNRTI mutations in those taking NNRTI-based regimens.

Missed opportunities: Peripartum hepatic failure in a Chinese immigrant

Hepatitis B surface antigen (HBsAg) positivity presents unique management challenges in pregnancy. We present the case of a 26-year-old HBsAg-positive woman who presented at 35 weeks gestational age with nausea, vomiting, and abdominal pain with markedly elevated liver enzymes. An elevated alpha feto-protein on antenatal screening had been misconstrued as fetal in origin. Magnetic resonance imaging and liver biopsy confirmed hepatocellular carcinoma. She died of fulminant hepatic failure two weeks after emergent delivery. This case highlights the importance of adequate evaluation and management of pregnant patients testing positive for HBsAg on routine antenatal testing.

HIV pre-exposure prophylaxis

Currently, PrEP refers to prophylactic daily oral use of tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), a formulation that is indicated in Canada for the treatment of HIV infection. Although licensed only in the United States for PrEP, this formulation is used off label in Canada for