惠康信托

This Viewpoint discusses the use of generative artificial intelligence to measure mental health.

BACKGROUND:HIV pre-exposure prophylaxis (PrEP) programmes in Africa reach young women at risk of sexually transmitted infections (STIs). We evaluated curable STI prevalence, incidence and risk factors among women initiating PrEP. METHODS:From August to December 2022, sexually active women aged 16-30 years from 15 South African sites, and one site each in Eswatini, Kenya, Malawi, Uganda and Zambia were enrolled into the INSIGHT cohort and offered oral emtricitabine/tenofovir PrEP with follow-up at 1, 3 and 6 months. At each visit, STI symptoms were assessed and treatment provided based on syndromic management or diagnostic testing. Diagnostic tests included nucleic acid amplification for Chlamydia trachomatis and Neisseria gonorrhoeae, the rapid OSOM for Trichomonas vaginalis at enrolment and month 6, and serological testing for syphilis at enrolment using rapid plasma reagin with confirmatory Treponema pallidum particle agglutination. Prevalence and incidence of each STI were calculated, and predictors assessed using multivariable regression. RESULTS:Of 3087 participants offered daily oral PrEP with a median age of 23 (IQR 21-27), 3011 had STI results and 30.9% had one or more STIs, with 15.7% reporting symptoms. The prevalence of C. trachomatis, N. gonorrhoeae, T. vaginalis and syphilis was 20.8%, 6.8%, 6.0% and 4.4%, respectively. The incidence of one or more STIs (C. trachomatis, N. gonorrhoeae or T. vaginalis) was 49.3/100 person-years (95% CI 45.3 to 53.4) with 12.7% reporting symptoms. The incidence of C. trachomatis was 30.6/100 person-years (95% CI 27.5 to 33.7), N. gonorrhoeae 10.8/100 person-years (95% CI 9.0 to 12.6) and T. vaginalis 11.5/100 person-years (95% CI 9.7 to 13.4). An incident STI diagnosis was associated with low alcohol use (adjusted incidence rate ratio (aIRR) 1.3; 95% CI 1.0 to 1.6) and moderate alcohol use (aIRR 1.4; 95% CI 1.1 to 1.8), and having an STI diagnosed at enrolment (aIRR 1.8; 95% CI 1.5 to 2.1). CONCLUSION:The high prevalence and incidence of STIs among African women initiating PrEP, most of whom did not report symptoms, highlights the need for aetiologic testing to detect STIs, guide treatment and reduce reproductive health sequelae and risk of transmission. TRIAL REGISTRATION NUMBER:clinicaltrials.gov NCT05746065.

Solid fuels are still used by over 3 billion people worldwide, including many residents of informal settlements. Most interventions designed to improve people's solid fuel-related health have failed or fallen short of their ambitions. Often, this is because implementers have not fully understood the contexts, cultures and behaviours of the places and people they are working within and with. To address this, our study used a food-energy nexus lens to explore people's experiences of the cooking journey, i.e., decision-making regarding which fuel to use, obtaining fuel and then cooking using that fuel. We videoed 'go along' interviews with residents of two African informal settlements during their cooking journeys. Interviews with 15 participants in Mukuru (Kenya) and 15 in Ndirande (Malawi) were analyzed using thematic analysis. Participants' decision-making regarding fuel use was complex, dynamic (considering short-to-long timescales) and context-specific. Participants were aware of some of the household air pollution (and other solid fuel-related) health risks, though there were some misconceptions. The use of waste materials in solid fuel cooking-particularly during ignition-was common. The 'cooking journey' framing in this study highlighted the range of risks and challenges experienced across the food-energy nexus beyond household air pollution, including terrain, the built environment and gender-based violence. Broader approaches to understanding the contexts, cultures and behaviours of fuel users in informal settlements, such as our 'cooking journey' approach, can support better intervention design, and therefore enable progress towards sustainable development goal 7-access to affordable, reliable, sustainable and modern energy for all.

BACKGROUND:WHO recommends fractional dose vaccination to address yellow fever vaccine shortages during outbreaks. In adults, a 500 IU dose has recently been shown to be non-inferior to the full standard dose, but the minimum effective dose for children is unknown. METHODS:We conducted a randomised, double-blind, non-inferiority trial at two centres in Kenya and Uganda, including infants aged 9-12 months with no previous yellow fever vaccination or infection. Participants were randomly assigned 1:1 in blocks of variable sizes of four, six, or eight to receive either the standard dose (>13 000 IU) or 500 IU of the Institut Pasteur de Dakar (Dakar, Senegal) 17D-204 yellow fever vaccine, co-administered with the measles-rubella vaccine. The primary outcome was seroconversion 28 days post-vaccination, defined as a four-fold or greater increase in antibody titre at day 28 from baseline (day 0), as measured by the 50% plaque reduction neutralisation test. Non-inferiority was shown if the lower bound of the 95% CI for the difference in seroconversion rates between doses exceeded -10 percentage points. Safety was assessed in the safety population, which included all participants who received a study vaccine dose. This study is registered with ClinicalTrials.gov (NCT04059471) and is complete. FINDINGS:Between Oct 7, 2021, and June 14, 2023, 420 infants were enrolled and randomly assigned (210 participants in each group). The seroconversion rate at day 28 was 99% (95% CI 96-100; 177 of 179 infants) for the standard dose and 93% (88-96; 166 of 179 infants) for the 500 IU dose in the per-protocol population. The difference in seroconversion rate was -6·15 percentage points (95% CI -10·27 to -2·02); therefore, non-inferiority was not met for the 500 IU dose. 12 serious adverse events were reported in the study (eight in the 500 IU dose group and four in the standard dose group), but all were considered unrelated to vaccination. INTERPRETATION:Compared with the standard yellow fever vaccine dose, a dose of 500 IU did not meet the non-inferiority criterion, suggesting that minimum dose requirements in adults are not generalisable to infants. Therefore, standard yellow fever doses should be used for infants in the routine WHO Expanded Programme on Immunization. FUNDING:European and Developing Countries Clinical Trials Partnership and the Wellcome Trust.

Background:It is unknown whether the choice of malaria treatment for uncomplicated malaria affects coronavirus disease 2019 (COVID-19) severity, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load, or duration of viral shedding. Several antimalarials exhibit antiviral activity against SARS-CoV-2 in vitro and have been suggested as potential therapeutic candidates for COVID-19, particularly pyronaridine-artesunate (PA), despite disappointing clinical results with chloroquine and hydroxychloroquine. Methods:We conducted an open-label randomised trial comparing standard 3-day treatment with PA and artemether-lumefantrine (AL) in newly diagnosed SARS-CoV-2 infected patients aged ≥6 months with rapid diagnostic test or microscopy-confirmed non-severe malaria in Kenya and Burkina Faso. SARS-CoV-2 was assessed by RT-PCR on days 3, 7, 14, and 28, and symptom resolution was assessed daily for 14 days using FLU-PRO Plus. The primary endpoint was the proportion of participants with SARS-CoV-2 clearance by day 7. Secondary endpoints included SARS-CoV-2 clearance by days 14, 21, and 28, time to SARS-CoV-2 clearance over 28 days, median viral load on day 7, and time to symptom resolution. Complete case analysis was conducted using log-binomial regression for binary outcomes, Cox-regression for time-to-event outcomes, and negative binomial regression for count outcomes, all adjusted for disease severity and viral load at enrolment. The trial is registered with ClinicalTrials.gov NCT04695197. Findings:From January 2021 to January 2022, 143 participants were randomised (PA = 69, AL = 74, intention-to-treat [ITT] population), including 117 with reverse transcription polymerase chain reaction (RT-PCR) confirmed (PA = 58, AL = 59, modified intention-to-treat [mITT] population) and 26 with rapid-antigen test confirmed SARS-CoV-2 infection. The median age was 19 years (interquartile range [IQR] 13-38), 66% were aged ≥15 years. Baseline characteristics were comparable. SARS-CoV-2 clearance by day 7 (primary endpoint) was 41% (22/54) with PA versus 58% (33/57) with AL (adjusted risk ratio [aRR] = 0.78, 95% confidence interval [CI] 0.45-1.35, p = 0.37); by day-14: PA = 80% (44/55) versus AL = 96% (55/57) (aRR = 0.86, 0.58-1.29, p = 0.47). Median (IQR) viral load on day 7 was higher with PA (855 [30-2883] versus AL:81 [12-209] copies/mL, p = 0.023). Time to SARS-CoV-2 clearance over 28 days was slower with PA (adjusted hazard ratio [aHR]: 0.55, 0.37-0.83, p = 0.004). Time to symptom clearance between treatments was similar (aHR = 1.01, 0.91-1.13, p = 0.79). Parasitological cure rates by day 42 were PA = 100% and AL = 99%. Five serious adverse events occurred (PA = 2, AL = 3) in three participants (PA = 1, AL = 2), including three hospitalisations (PA = 1, AL = 2), resulting in two deaths, both from respiratory failure (PA = 1, AL = 1). No serious adverse events (SAEs) were considered treatment-related. Interpretation:Pyronaridine-artesunate in COVID-19 patients co-infected with malaria was associated with slower viral clearance than standard treatment with artemether-lumefantrine but similar symptom resolution. Both treatments were highly effective as antimalarials and should continue to be considered first- or second-line treatment options for uncomplicated malaria in patients with mild to moderate COVID-19. Funding:Gates Foundation.