Paul K. Drain

Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries.

BackgroundBoth religious practices and male circumcision (MC) have been associated with HIV and other sexually-transmitted infectious diseases. Most studies have been limited in size and have not adequately controlled for religion, so these relationships remain unclear.MethodsWe evaluated relationships between MC prevalence, Muslim and Christian religion, and 7 infectious diseases using country-specific data among 118 developing countries. We used multivariate linear regression to describe associations between MC and cervical cancer incidence, and between MC and HIV prevalence among countries with primarily sexual HIV transmission.ResultsFifty-three, 14, and 51 developing countries had a high (>80%), intermediate (20–80%), and low (<20%) MC prevalence, respectively. In univariate analyses, MC was associated with lower HIV prevalence and lower cervical cancer incidence, but not with HSV-2, syphilis, nor, as expected, with Hepatitis C, tuberculosis, or malaria. In multivariate analysis after stratifying the countries by religious groups, each categorical increase of MC prevalence was associated with a 3.65/100,000 women (95% CI 0.54-6.76, p = 0.02) decrease in annual cervical cancer incidence, and a 1.84-fold (95% CI 1.36-2.48, p < 0.001) decrease in the adult HIV prevalence among sub-Saharan African countries. In separate multivariate analyses among non-sub-Saharan African countries controlling for religion, higher MC prevalence was associated with a 8.94-fold (95% CI 4.30-18.60) decrease in the adult HIV prevalence among countries with primarily heterosexual HIV transmission, but not, as expected, among countries with primarily homosexual or injection drug use HIV transmission (p = 0.35).ConclusionMale circumcision was significantly associated with lower cervical cancer incidence and lower HIV prevalence in sub-Saharan Africa, independent of Muslim and Christian religion. As predicted, male circumcision was also strongly associated with lower HIV prevalence among countries with primarily heterosexual HIV transmission, but not among countries with primarily homosexual or injection drug use HIV transmission. These findings strengthen the reported biological link between MC and some sexually transmitted infectious diseases, including HIV and cervical cancer.

Correlates of national HIV seroprevalence: An ecologic analysis of 122 developing countries

Background:Ecologic analyses of social and developmental correlates of country-level HIV seroprevalence may suggest strategies for combating the HIV/AIDS epidemic. Methods:Regression analyses were performed for 81 variables obtained primarily from United Nation agencies for 122 developing countries. Variable measures were compared between highest and lowest tertiles of HIV seroprevalence. Results:Geography, religion, and income inequality were independently associated with HIV seroprevalence. Countries with earlier ages at first sex, higher teenage birth rates, and higher fertility rates had higher HIV seroprevalence. Countries with high HIV seroprevalence had fewer women using contraceptives, more persons with casual sex partners, and higher herpes simplex virus 2 seroprevalence. Male circumcision and Muslim religion were colinearly associated with lower HIV seroprevalence. Countries with high HIV seroprevalence had fewer doctors, more midwives, and less access to essential medications, but health spending differences were minor. Conclusions:Ecologic analyses support population-level behavioral approaches, such as delaying sexual debut and discouraging casual sex partners, and reinforce biologic measures, such as controlling sexually transmitted infections and promoting male circumcision, for HIV prevention. Fewer births attended by skilled personnel, but more midwives, in countries with the highest HIV seroprevalence suggest potential strategies for reducing mother-to-child transmission. Correlations with selected health indicators suggest additional obstacles for implementing HIV treatment programs.

C-reactive protein independently predicts Hiv-related outcomes among women and children in a resource-poor setting

Objective:To evaluate C-reactive protein (CRP) as a predictor of HIV-related outcomes among women and children in a resource-poor setting. Design:We measured serum CRP concentration among 606 HIV-infected women, all of whom were not taking highly-active antiretroviral therapy, 3 to 11 months after they gave birth, and assessed relationships of CRP to HIV-related endpoints, including maternal disease progression, mother-to-child transmission of HIV, and maternal and child mortality. Methods:We used Cox proportional hazards and regression models adjusted for age, sociodemographic characteristics, anthropometric measurements, hemoglobin, CD4 cell count, HIV viral load, and, for child outcomes, breastfeeding status. Results:Ninety-four women had a high CRP concentration (> 10 mg/l). During the follow-up, 56 women progressed to WHO stage 4 and 188 died, and a high maternal CRP concentration was associated with a 2.26-fold [95% confidence interval (CI), 1.64–3.12] greater risk of progression to stage 4 or death. Among children, 174 acquired HIV and 116 died by age 2 years, and a high maternal CRP concentration was associated with a 3.03-fold (95% CI, 1.85–4.96) greater risk of child mortality. In multivariate analyses among adults, a high maternal CRP concentration was associated with a 1.55-fold (95% CI, 1.08–2.23) greater risk of progression to stage 4 or death. A maternal CRP concentration was not significantly associated with mother-to-child transmission of HIV. Conclusions:A high maternal CRP concentration independently predicts HIV disease progression, maternal mortality, and child mortality in a resource-poor setting. C-reactive protein may be an important and inexpensive prognostic indicator for HIV-infected women and their children.

Low serum albumin and the acute phase response predict low serum selenium in HIV-1 infected women

BackgroundLow serum selenium has been associated with lower CD4 counts and greater mortality among HIV-1-seropositive individuals, but most studies have not controlled for serum albumin and the presence of an acute phase response.MethodsA cross-sectional study was conducted to evaluate relationships between serum selenium concentrations and CD4 count, plasma viral load, serum albumin, and acute phase response markers among 400 HIV-1-seropositive women.ResultsIn univariate analyses, lower CD4 count, higher plasma viral load, lower albumin, and the presence of an acute phase response were each significantly associated with lower serum selenium concentrations. In multivariate analyses including all four of these covariates, only albumin remained significantly associated with serum selenium. For each 0.1 g/dl increase in serum albumin, serum selenium increased by 0.8 μg/l (p < 0.001). Women with an acute phase response also had lower serum selenium (by 5.6 μg/l, p = 0.06).ConclusionSerum selenium was independently associated with serum albumin, but not with CD4 count or plasma viral load, in HIV-1-seropositive women. Our findings suggest that associations between lower serum selenium, lower CD4 count, and higher plasma viral load may be related to the frequent occurrence of low serum albumin and the acute phase response among individuals with more advanced HIV-1 infection.

Educational objectives for international medical electives: a literature review.

Purpose Although most medical schools and residency programs offer international medical electives (IMEs), little guidance on the educational objectives for these rotations exists; thus, the authors reviewed the literature to compile and categorize a comprehensive set of educational objectives for IMEs. Method In February and July 2012, the authors searched SciVerse Scopus online, which includes the Embase and MEDLINE databases, using specified terms. From the articles that met their inclusion criteria, they extracted the educational objectives of IMEs and sorted them into preelective, intraelective, and postelective objectives. Results The authors identified and reviewed 255 articles, 11 (4%) of which described 22 educational objectives. Among those 22 objectives, 5 (23%), 15 (68%), and 2 (9%) were, respectively, preelective, intraelective, and postelective objectives. Among preelective objectives, only cultural awareness appeared in more than 2 articles (3/11; 27%). Among intraelective objectives, the most commonly defined were enhancing clinical skills and understanding different health care systems (9/11; 82%). Learning to manage diseases rarely seen at home and increasing cultural awareness appeared in nearly half (5/11; 45%) of all articles. Among postelective objectives, reflecting on experiences through a written project was most common (9/11; 82%). Conclusions The authors identified 22 educational objectives for IMEs in the published literature, some of which were consistent across institutions. These consistencies, in conjunction with future research, can be used as a framework on which institutions can build their own IME curricula, ultimately helping to ensure that their medical trainees have a meaningful learning experience while abroad.

The Emergence of Undergraduate Majors in Global Health: Systematic Review of Programs and Recommendations for Future Directions

Global health education has been expanding rapidly and several universities have created an undergraduate major degree (bachelors degree) in global heath or global health studies. Because there are currently no national guidelines for undergraduate degrees in global health, each of these programs was developed along individual lines. To guide the development of future global health majors, we conducted a systematic review of undergraduate majors in global health. We identified eight programs and invited program directors or representatives to a symposium at the Consortium of Universities for Global Health 2016 conference to review their existing undergraduate major in global health and to discuss lessons learned and recommendations for other colleges and universities seeking to develop undergraduate degrees in global health. We noted significant diversity among the existing programs in terms of required courses, international field experiences, and thesis research projects. In this review, we describe these global health programs, their student characteristics, as well as the key educational competencies, program requirements, and core global health courses. Based on program reviews and discussions, we identify seven recommendations for the development and expansion of an undergraduate major in global health and discuss issues that have arisen in the curricular development of these programs that warrant further exploration. As the field of global health education continues to expand, following these students after graduation will be essential to ensure that the degree programs in global health both meet student needs and launch students on viable career pathways.

Point-of-care viral load testing and differentiated HIV care

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Experiential Bloom's Taxonomy learning framework for point-of-care diagnostics training of primary healthcare workers

The delivery of accessible, affordable and equitable primary healthcare (PHC) is a key focus in many resource-limited settings. One strategy that has been used to improve health access and healthcare equity in rural and resource-limited settings is the use of point-of-care (POC) diagnosticsin PHC clinics. POC testing is defined as: pathology testing performed in a clinical setting at the time of patient consultation, generating a result that is used to make an immediate informed clinical decision that contributes to an improved health outcome for the patient. Although itrelies on clinical, non-laboratory staff and frontline workers, such as nurses, to perform diagnostic testing, POC testing is seen as one of the ways to improve affordability, access and equity in rural areas. A primary advantage of POC diagnostics is that the completion of the test and treatment cycle in the same encounter is conducive to retention in care and patient outcomes.

Dolutegravir for first-line antiretroviral therapy in low-income and middle-income countries: uncertainties and opportunities for implementation and research

A new first-line antiretroviral therapy (ART) regimen containing dolutegravir is being rolled out in low-income and middle-income countries (LMICs). In studies from predominantly high-income settings, dolutegravir-based regimens had superior efficacy, tolerability, and durability compared with existing first-line regimens. However, several questions remain about the roll out of dolutegravir in LMICs, where most people with HIV are women of reproductive age, tuberculosis prevalence can be high, and access to viral load and HIV drug resistance testing is limited. Findings from cohort studies suggest that dolutegravir is safe when initiated in pregnancy, but more data are needed to determine the risk of adverse birth outcomes when dolutegravir-based regimens are initiated before conception. Increasing access to viral load testing to monitor the effectiveness of dolutegravir remains crucial, but the best strategy to manage patients with viraemia is unclear. Furthermore, evidence to support the effectiveness of dolutegravir when given with tuberculosis treatment is scarce, particularly in programmatic settings in LMICs. Lastly, whether nucleoside reverse transcriptase inhibitor resistance will affect the long-term efficacy of dolutegravir-based regimens in first-line, and potentially second-line, ART is unknown. Clinical trials, cohorts, and surveillance of HIV drug resistance will be necessary to answer these questions and to maximise the benefits of this new regimen.

Incipient and Subclinical Tuberculosis: a Clinical Review of Early Stages and Progression of Infection

SUMMARY Tuberculosis (TB) is the leading infectious cause of mortality worldwide, due in part to a limited understanding of its clinical pathogenic spectrum of infection and disease. Historically, scientific research, diagnostic testing, and drug treatment have focused on addressing one of two disease states: latent TB infection or active TB disease. Recent research has clearly demonstrated that human TB infection, from latent infection to active disease, exists within a continuous spectrum of metabolic bacterial activity and antagonistic immunological responses. This revised understanding leads us to propose two additional clinical states: incipient and subclinical TB. The recognition of incipient and subclinical TB, which helps divide latent and active TB along the clinical disease spectrum, provides opportunities for the development of diagnostic and therapeutic interventions to prevent progression to active TB disease and transmission of TB bacilli. In this report, we review the current understanding of the pathogenesis, immunology, clinical epidemiology, diagnosis, treatment, and prevention of both incipient and subclinical TB, two emerging clinical states of an ancient bacterium.