BACKGROUND:Inflammation in and around the brain in patients with meningitis can lead to confusion, cognitive dysfunction, and behavioral changes associated with mental health disorders. Stigma associated with HIV or mental illness can complicate meningitis, leading to misdiagnosis or delays in diagnosis and care. The frequency of misdiagnosis and/or co-occurrence of meningitis and mental illness among people living with HIV (PLWH) remains uncertain. We explored the experiences of meningitis patients and the barriers and facilitators to care related to HIV stigma and mental illness. METHODS:We conducted a convergent mixed-methods study to evaluate experiences of patients who were hospitalized with HIV-associated meningitis from February 2017 to May 2022 at Lira Regional Referral Hospital in Uganda. Experiences among patients who survived and family members of patients who died were explored. Surveys were conducted to obtain demographic information, investigate stigma, and assess symptoms of mental illness. Semi-structured interviews probed the overall experience of patients with HIV and meningitis regarding social support, mental health, and stigma. RESULTS:Twenty-four patients with HIV-associated meningitis and 20 family members of deceased meningitis patients were enrolled. Family members reported that 80% of deceased patients experienced stigma, whereas 29.2% of surviving patients reported experiencing stigma. Combined responses from surviving patients and family members identified 31.8% of patients with mental illness symptoms described as overthinking, depression, and/or anxiety, while 60.8% experienced HIV-related stigma. Among participants who died, family members reported mental illness symptoms in 40%, compared to self-reports of 25% in survivors. Barriers to HIV care included (a) lack of HIV education, (b) mental illness symptoms, (c) lack of social support, and (d) stigma or shame. While common facilitators were (a) access to HIV clinics and ART medication, (b) having a life purpose, and (c) social support. CONCLUSION:Stigma and symptoms of mental illness were common among patients with HIV and meningitis, which likely affected antiretroviral therapy (ART) adherence and HIV care. Recommendations include (1) adding mental health screening during hospital admission for all meningitis patients, especially among PLWH, for early evaluation and treatment and (2) increasing community awareness to dispel misconceptions and reduce HIV-related stigma.

Background: Cryptococcal meningitis (CM) is one of the deadliest opportunistic infections related to HIV/AIDS. A research gap exists surrounding the barriers to CM diagnosis, treatment delivery, and care from the healthcare provider's perspective. Objectives: The purpose of this study was to elucidate provider's behaviors, to identify barriers and facilitators to diagnose and treat CM, and to assess their knowledge of CM, cryptococcal screening, and treatment. Design, setting, and participants: A convergent mixed-methods study among twenty healthcare providers who provided CM patient referrals to Lira Regional Referral Hospital in Lira, Uganda. Methods: Surveys and interviews were conducted to obtain information from healthcare providers who referred CM patients to Lira Regional Referral Hospital from 2017 to 2019. Questions related to provider education, knowledge, barriers to CM care, and patient education were inquired to understand the providers' perspectives. Results: Nurses had the least amount of CM knowledge with half knowing the cause of CM. Approximately half the participants knew about CM transmission, but only 15 % knew the duration of CM maintenance therapy. Most participants (74 %) last had education regarding CM during didactic training. In addition, 25 % disclosed they never educate patients due to time constraints (30 %) and lack of knowledge (30 %). Nurses (75 %) were least likely to provide patient education. Most participants acknowledged their lack of CM knowledge and attributed it to a lack of education and perceived inexperience with CM. Conclusions: Providers' gaps in knowledge due to the lack of education and experience contributes to decreased patient education, and the lack of access to appropriate supplies affects their provision for CM diagnosis, treatment, and care. These results can guide evidence-based interventions to improve health providers' knowledge. Recommendations for standardized CM education should be developed for both providers and patients in collaboration with professional boards and the Uganda Ministry of Health.

Patient satisfaction is an important component of health and healthcare utilization, which measures the perceived needs and expectations for healthcare services. Patient satisfaction surveys are effective in improving health outcomes by informing health facilities on service and provider gaps and guiding the development of effective action plans and policies for quality improvement within a healthcare organization. Although patient satisfaction and patient flow analyses have been conducted in Zimbabwe, the combination of these two quality improvement measures in the context of Human Immunodeficiency Virus (HIV) clinics has not previously been evaluated. This study assessed and evaluated patient flow and patient satisfaction to enhance care quality and improve HIV service delivery to optimize patient health. We collected time and motion data from HIV patients who attended three purposively selected City of Harare Polyclinics in Harare, Zimbabwe. All patients who sought care at the clinic were given time and motion forms to track their movement and the time spent at each service area. After services were completed, patients were invited to participate in a satisfaction survey regarding their services and care. The average waiting time from clinic arrival to see the provider was 2 hr and 14 min. The areas with the longest waiting time and bottlenecks occurred at registration (49 min) and the HIV clinic waiting area (44 min). Despite these extended times, the overall patient satisfaction for HIV services was high at 72%, with over half (59%) reporting that there was nothing they did not like about their services. Patients were most satisfied with services provided (34%), timely service (27%), and antiretroviral medications (19%). The areas of least satisfaction were related to time delays (24%) and cashier delays (6%). Despite prolonged waiting times, patients' overall satisfaction with their clinic experience remains high. Perceptions of satisfaction are influenced by experience, culture, and context. However, there are still several areas of recommendations to improve service, care, and quality. Specifically, reducing or eliminating service fees, increasing clinic hour times, and having available medication were most cited. Support from the Zimbabwe Ministry of Health and Child Care, City of Harare, and other decision-makers is needed to improve patient satisfaction and address patients' recommendations within the City of Harare Polyclinic organization in accordance with the 2016-20 National Health Strategies for Zimbabwe.

In rural areas of sub-Saharan Africa, infrastructure and resources for treatment of cryptococcal meningitis (CM) are often lacking. We introduced a CM diagnosis and treatment program (CM-DTP) at Lira Regional Referral Hospital (LRRH) in rural Uganda to determine if implementing high-quality standard of care protocols would improve outcomes. Information extracted from hospital charts and clinical record forms at LRRH were used to compare diagnoses, treatments, and outcomes for all patients diagnosed with meningitis (n = 281) over a two-year period after initiation of the CM-DTP in February of 2017 to all patients diagnosed with meningitis (n = 215) in the two preceding years. After implementation of the CM-DTP, we observed increased confirmed diagnoses of CM from 22.2% (48 of 215) to 35.2% (99 of 281), (p = 0.002) among all patients diagnosed with meningitis. Among all patients treated for CM, the proportion who received standard of care treatment with amphotericin B plus fluconazole increased from 63 of 127 (49.6%) to 109 of 146 (74.7%), (p <0.001) and mortality improved from 66 of 127 (52.0%) to 57 of 146 (39.0%), (p = 0.04) after implementation of the CM-DTP. Implementation of the CM-DTP was associated with increased number of lumbar punctures and decreased use of antibiotics in patients with CM, as well as decreased mortality among patients with meningitis from all causes. Improved diagnosis, treatment, and mortality were observed following implementation of the CM-DTP. Our results demonstrate that quality treatment of CM in rural Uganda is feasible.

Background: Cryptococcal meningitis (CM) remains a major cause of mortality for HIV-infected persons in sub-Saharan Africa, despite widespread access to antiretroviral therapy. Delays in CM diagnosis and treatment contribute to high mortality, with patients often arriving “too late” for treatment to be effective. Little is known about patient-related delays and their experiences with CM. Objectives: This study seeks to identify the factors related to delays in diagnosis and care among patients with cryptococcal meningitis. Methods: A convergent mixed-methods approach was used to understand delays related to diagnosis and treatment of CM among patients admitted to Lira Regional Referral Hospital in rural northern Uganda. We collected data from February to March 2020 using surveys followed by semi-structured interviews from 20 CM patients who survived hospitalization and 20 family members of deceased patients during February 2017–November 2019. Interviews were audio-recorded, transcribed, and thematically coded for analysis. Findings: Delays to CM care were related to 1) self-medication, 2) lack of CM education, 3) seeking treatment multiple times at health centers with 4) missed/misdiagnosis, and 5) cultural factors. Among patients who died, 70% sought care ≥3 times, while those who survived, 35% of sought care ≥3 times before CM diagnosis. Only 10% of patients and 40% of family members knew what caused CM, indicating a lack of knowledge. Conclusions: Patients sought medical care for CM symptoms, but several factors contributed to CM diagnosis and care delays. Many of these factors relate to a lack of CM education and knowledge among patients and providers. A CM awareness campaign for the general public, targeted education for HIV patients, and continuing medical education for healthcare providers can decrease delays and improve outcomes.

ObjectiveTo conduct a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe.IntroductionInfectious disease outbreaks, such as the Ebola outbreak in West Africa, highlight the need for surveillance systems to quickly detect outbreaks and provide data to prevent future pandemics.1–3 The World Health Organization (WHO) developed the Joint External Evaluation (JEE) tool to conduct country-level assessments of surveillance capacity.4 However, considering that outbreaks begin and are first detected at the local level, national-level evaluations may fail to identify capacity improvements for outbreak detection. The gaps in local surveillance system processes illuminate a need for investment in on-the-ground surveillance improvements that may be lower cost than traditional surveillance improvement initiatives, such as enhanced training or strengthening data transfer mechanisms before building new laboratory facilities.5 To explore this premise, we developed a methodology for assessing surveillance systems with special attention to the local level and applied this methodology to the malaria outbreak surveillance system in Mashonaland East, Zimbabwe.MethodsIn a collaboration between the Zimbabwe Field Epidemiology Training Program and the University of Washington, an interview guide was developed based on the Centers for Disease Control and Prevention’s (CDC) Updated Guidelines for Surveillance Evaluations and WHO’s JEE tool.4,6 The guide was tailored in country with input from key stakeholders from the Ministry of Health and Child Care and National Malaria Control Program. Interview guides included questions focused on outbreak detection, response, and control procedures, and surveillance system attributes (preparedness, data quality, timeliness, stability) and functionality (usefulness). The team utilized the tool to evaluate surveillance capacity in eleven clinics across two malaria-burdened districts of Mashonaland East, Mudzi and Goromonzi. Twenty-one interviews were conducted with key informants from the provincial (n=2), district (n=7), and clinic (n=12) levels. Main themes present in interviews were captured using standard qualitative data analysis methods.ResultsThe majority of key informants interviewed were nurses, nurse aids, or nurse officers (57%, 12/21). This evaluation identified clinic-level surveillance system barriers that may be driving malaria outbreak detection and response challenges. Clinics reported little opportunity for cross-training of staff, with 81% (17/21) mentioning that additional staff training support was needed. Only one clinic (10%, 1/11) had malaria emergency preparedness and response guidelines present, a resource recommended by the National Malaria Control Program for all clinics encountering malaria cases. A third of interviewees (33%, 7/21) reported having a standard protocol for validating malaria case data and 29% (6/21) reported challenges with data quality and validation, such as a duplication of case counts. While the surveillance system at all levels detects malaria outbreaks, clinics experience barriers to timely and reliable reporting of cases and outbreaks to the district level. Stability of resources, including transportation and staff capacity, presented barriers, with half (48%, 10/21) of interviewees reporting that their clinics were under-staffed. Additionally, the assessment revealed that the electronic case reporting system (a WHO-developed SMS application, Frontline) that is used to report malaria cases to the district was not functioning in either district, which was unknown at the provincial and national levels. To detect malaria outbreaks, clinics and districts use graphs showing weekly malaria case counts against threshold limit values (TLVs) based on historic five-year malaria case count averages; however, because TLVs are based on 5-year historic data, they are only relevant for clinics that have been in existence for at least five years. Only 30% (3/10) of interviewees asked about outbreak detection graphs reported that TLV graphs were up-to-date.ConclusionsThis surveillance assessment revealed several barriers to system performance at the clinic-level, including challenges with staff cross-training, data quality of malaria case counts, timeliness of updating outbreak detection graphs, stability of transportation, prevention, treatment, and human resources, and usefulness of TLVs for outbreak detection among new clinics. Strengthening these system barriers may improve staff readiness to detect and respond to malaria outbreaks, resulting in timelier outbreak response and decreased malaria mortality. This evaluation has some limitations. We interviewed key informants from a non-random sample covering 30% of all clinics in Mudzi and Goromonzi districts; thus, barriers identified may not be representative of all clinics in these districts. Secondly, evaluators did not interview individuals who may have been involved in outbreak detection and response but were not present at the clinic when interviews were conducted. Lastly, many of the evaluation indicators were based on self-reported information from key informants. Despite these limitations, convenience sampling is common to public health practice, and we reached a saturation of key informant themes with the 21 key informants included in this evaluation.7 By designing evaluation tools that focus on local-level knowledge and priorities, our assessment approach provides a framework for identifying and addressing gaps that may be overlooked when utilizing multi-national tools that evaluate surveillance capacity and improvement priorities at the national level.References1. World Health Organzation. International Health Regulations - Third Edition. Vol Third. Geneva, Switzerland; 2005. doi:10.1017/CBO9781107415324.004.2. Global Health Security Agenda. Implementing the Global Health Security Agenda: Progress and Impact from U.S. Government Investments.; 2018. https://www.ghsagenda.org/docs/default-source/default-document-library/global-health-security-agenda-2017-progress-and-impact-from-u-s-investments.pdf?sfvrsn=4.3. McNamara LA, Schafer IJ, Nolen LD, et al. Ebola Surveillance — Guinea, Liberia, and Sierra Leone. MMWR Suppl. 2016;65(3):35-43. doi:10.15585/mmwr.su6503a6.4. World Health Organization (WHO). Joint External Evaluation Tool: International Health Regulations (2005). Geneva; 2016. http://apps.who.int/iris/bitstream/10665/204368/1/9789241510172_eng.pdf.5. Groseclose SL, Buckeridge DL. Public Health Surveillance Systems: Recent Advances in Their Use and Evaluation. Annu Rev Public Health. 2017;38(1):57-79. doi:10.1146/annurev-publhealth-031816-044348.6. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MWWR. 2001;50(No. RR-13).7. Dworkin SL. Sample size policy for qualitative studies using in-depth interviews. Arch Sex Behav. 2012;41(6):1319-1320. doi:10.1007/s10508-012-0016-6.

National-level evaluations may fail to identify capacity improvements for detecting and responding to outbreaks which begin and are first detected at the local level. In response to this issue, we conducted a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. We visited eleven clinics in Mudzi and Goromonzi districts. Twenty-one interviews were conducted with key informants from the provincial (n = 2), district (n = 7), and clinic (n = 12) levels. Interviews focused on surveillance system activities, preparedness, data quality, timeliness, stability, and usefulness. Main themes were captured utilising standard qualitative data analysis techniques. While the surveillance system detects malaria outbreaks at all levels, we identified several gaps. Clinics experience barriers to timely and reliable reporting of outbreaks to the district level and staff cross-training. Stability of resources, including transportation (33% of informants, n = 7) and staff capacity (48% of informants, n = 10), presented barriers. Strengthening these surveillance barriers may improve staff readiness to detect malaria outbreaks, resulting in timelier outbreak response and a reduction in malaria outbreaks, cases, and deaths. By focusing at the local level, our assessment approach provides a framework for identifying and addressing gaps that may be overlooked when utilising tools that evaluate surveillance capacity at the national level.

Male circumcision (MC) significantly reduces HIV acquisition among men, leading WHO/UNAIDS to recommend high HIV and low MC prevalence countries circumcise 80% of adolescents and men age 15–49. Despite significant investment to increase MC capacity only 27% of the goal has been achieved in Zimbabwe. To increase adoption, research to create evidence-based messages is greatly needed. The Integrated Behavioral Model (IBM) was used to investigate factors affecting MC motivation among adolescents. Based on qualitative elicitation study results a survey was designed and administered to a representative sample of 802 adolescent boys aged 13–17 in two urban and two rural areas in Zimbabwe. Multiple regression analysis found all six IBM constructs (2 attitude, 2 social influence, 2 personal agency) significantly explained MC intention (R2 = 0.55). Stepwise regression analysis of beliefs underlying each IBM belief-based construct found 9 behavioral, 6 injunctive norm, 2 descriptive norm, 5 efficacy, and 8 control beliefs significantly explained MC intention. A final stepwise regression of all the significant IBM construct beliefs identified 12 key beliefs best explaining intention. Similar analyses were carried out with subgroups of adolescents by urban–rural and age. Different sets of behavioral, normative, efficacy, and control beliefs were significant for each sub-group. This study demonstrates the application of theory-driven research to identify evidence-based targets for the design of effective MC messages for interventions to increase adolescents’ motivation. Incorporating these findings into communication campaigns is likely to improve demand for MC.

Slow adult male circumcision uptake is one factor leading some to recommend increased priority for infant male circumcision (IMC) in sub-Saharan African countries. This research, guided by the integrated behavioral model (IBM), was carried out to identify key beliefs that best explain Zimbabwean parents' motivation to have their infant sons circumcised. A quantitative survey, designed from qualitative elicitation study results, was administered to independent representative samples of 800 expectant mothers and 795 expectant fathers in two urban and two rural areas in Zimbabwe. Multiple regression analyses found IMC motivation among fathers was explained by instrumental attitude, descriptive norm and self-efficacy; while motivation among mothers was explained by instrumental attitude, injunctive norm, descriptive norm, self-efficacy, and perceived control. Regression analyses of beliefs underlying IBM constructs found some overlap but many differences in key beliefs explaining IMC motivation among mothers and fathers. We found differences in key beliefs among urban and rural parents. Urban fathers' IMC motivation was explained best by behavioral beliefs, while rural fathers' motivation was explained by both behavioral and efficacy beliefs. Urban mothers' IMC motivation was explained primarily by behavioral and normative beliefs, while rural mothers' motivation was explained mostly by behavioral beliefs. The key beliefs we identified should serve as targets for developing messages to improve demand and maximize parent uptake as IMC programs are rolled out. These targets need to be different among urban and rural expectant mothers and fathers.

BACKGROUND:The World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS promote MC (male circumcision) as a key HIV prevention strategy where HIV prevalence and incidence are high and MC prevalence is low. In Zimbabwe, to achieve the 1.26 million circumcisions needed to be performed by 2015 to achieve optimal MC coverage, a new approach was needed. The primary objective of the current trial was to assess the performance (safety, procedure time, and cost) of the PrePex device compared to forceps-guided surgical circumcision.METHODS AND FINDINGS:This Phase II, randomized, open-label trial in Zimbabwe involved healthy, non-circumcised adult male volunteers who were randomly assigned to the PrePex device (n = 160) or surgical arm (n = 80). Three doctors and 4 nurses, all certified on both circumcision methods, performed the procedures. The PrePex device procedure involves a plastic ring with a rubber O-ring that necrotizes the foreskin to facilitate easy and minimally invasive removal. Total procedure time was the primary endpoint. Adverse event (AE) data were also gathered for 90 days post-procedure. All 80 participants in the surgical arm and 158 participants in the PrePex arm achieved complete circumcision. The total procedure time for the PrePex device was approximately one-third of the total surgical procedure (4.8 minutes, Standard Deviation [SD]: 1.2 versus 14.6 minutes; SD: 4.2; p<0.00001). There were 2 AEs for 2 participants (rate of 1.3%, 95% Confidence Interval: 0.0025-4.53%), which were resolved with simple intervention. The AEs were device related, including 1 case of pain leading to device removal and 1 case of removal of the device.CONCLUSIONS:The trial supports previous studies' conclusions that the PrePex procedure is safe, quick, easy to apply, and effective in terms of procedure time as an alternative to traditional surgical circumcision. The PrePex device has great potential for use in overburdened health systems and in resource-limited settings and is recommended for use in rapid scale-up of adult MC in Zimbabwe.TRIAL REGISTRATION:ClinicalTrials.gov NCT01956370.

Male circumcision (MC), an effective HIV prevention tool, has been added to Zimbabwe's Ministry of Health and Child Care HIV/AIDS Prevention Program. A Phase I safety trial of a nonsurgical male circumcision device was conducted and extensive psychosocial variables were assessed. Fifty-three men (18 and older) were recruited for the device procedure; 13 follow-up clinical visits were completed. Interviews conducted three times (before the procedure, at 2 weeks and 90 days post-procedure) assessed: Satisfaction; expectations; actual experience; activities of daily living; sexual behavior; and HIV risk perception. Using the Integrated Behavioral Model, attitudes towards MC, sex, and condoms, and sources of social influence and support were also assessed. Men (mean age 32.5, range 18-50; mean years of education = 13.6; 55% employed) were satisfied with device circumcision results. Men understand that MC is only partially protective against HIV acquisition. Most (94.7%) agreed that they will continue to use condoms to protect themselves from HIV. Pain ratings were surprisingly negative for a procedure billed as painless. Men talked to many social networks members about their MC experience; post-procedure (mean of 14 individuals). Minimal impact on activities of daily living and absenteeism indicate possible cost savings of device circumcisions. Spontaneous erections occurred frequently post-procedure. The results had important implications for changes in the pre-procedure clinical counseling protocol. Clear-cut counseling to manage pain and erection expectations should result in improved psychosocial outcomes in future roll-out of device circumcisions. Men's expectations must be managed through evidence-based counseling, as they share their experiences broadly among their social networks.

This paper explores the roles of acute infection and concurrent partnerships in HIV transmission dynamics among young adults in Zimbabwe using realistic representations of the partnership network and all published estimates of stage-specific infectivity. We use dynamic exponential random graph models to estimate partnership network parameters from an empirical study of sexual behavior and drive a stochastic simulation of HIV transmission through this dynamic network. Our simulated networks match observed frequencies and durations of short- and long-term partnerships, with concurrency patterns specific to gender and partnership type. Our findings suggest that, at current behavior levels, the epidemic cannot be sustained in this population without both concurrency and acute infection; removing either brings transmission below the threshold for persistence. With both present, we estimate 20–25% of transmissions stem from acute-stage infections, 30–50% from chronic-stage, and 30–45% from AIDS-stage. The impact of acute infection is strongly moderated by concurrency. Reducing this impact by reducing concurrency could potentially end the current HIV epidemic in Zimbabwe.

Background: Understanding what factors contribute to alcohol abuse in resource-poor countries is important given its adverse health consequences. Past research shows that social peers influence substance abuse, suggesting that the social environment may be an effective target for reducing alcohol abuse across a population. This study investigates the determinants of alcohol use and abuse in rural Zimbabwe and tests a Community Popular Opinion Leader (CPOL) community-based intervention partly directed at reducing alcohol abuse.Methods: Tests were conducted on the impact of the CPOL intervention on alcohol use patterns across communities in rural Zimbabwe over three waves from 2003 to 2007, including community- and individual-level tests using data based on in-person interviews of adult men and women (ages 18-30: N=5543). Data were analyzed using paired-sample t-tests, as well as logistic and ordinary least-squares regression with random effects.Results: Higher drinking (any use, more frequent use, greater quantity, and/or frequent drunkenness) was generally associated with being male, older, not married, more highly educated, of Shona ethnicity, away from home frequently, employed, having no religious affiliation, or living in areas with a higher crude death rate or lower population density. Over the study period, significant declines in alcohol use and abuse were found in intervention and control sites at relatively equal levels.Conclusions: Although no support was found for the effectiveness of the CPOL study in reducing alcohol abuse. Zimbabwe is similar to other countries in the impact of socio-demographic and cultural factors on alcohol use and abuse. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

OBJECTIVE:To determine whether community populations in community popular opinion leader intervention venues showed greater reductions in sexual risk practices and lower HIV/sexually transmitted disease (STD) incidence than those in comparison venues.METHODS:A 5-country group-randomized trial, conducted from 2002 to 2007, enrolled cohorts from 20 to 40 venues in each country. Venues, matched within country on sexual risk and other factors, were randomly assigned within matched pairs to the community popular opinion leader intervention or an AIDS education comparison. All participants had access to condoms and were assessed with repeated in-depth sexual behavior interviews, STD/HIV testing and treatment, and HIV/STD risk-reduction counseling. Sexual behavior change and HIV/STD incidence were measured over 2 years.RESULTS:Both intervention and comparison conditions showed declines of approximately 33% in risk behavior prevalence and had comparable diseases incidence within and across countries.CONCLUSIONS:The community-level intervention did not produce greater behavioral risk and disease incidence reduction than the comparison condition, perhaps due to the intensive prevention services received by all participants during the assessment. Repeated detailed self-review of risk behavior practices coupled with HIV/STD testing, treatment, HIV risk-reduction counseling, and condom access can themselves substantially change behavior and disease acquisition.

Objective. To determine whether patient race, ethnicity, or insurance status was associated with access to cervical cancer screening with liquid-based cytology (LBC) and with human papillomavirus (HPV) DNA testing and with access to on-site colposcopy at the provider's principal practice site.Materials and Methods. We conducted a nationally representative survey of clinicians in specialties that provide cervical cancer screening. Adjusted odds ratios (OR) were estimated for the associations between race, ethnicity, and insurance status of patients and provider use of LBC, HPV DNA testing, and on-site colposcopy.Results. Providers who cared for >= 20% Hispanic patients were less likely to use LBC (OR 0.60, 95% CI = 0.42-0.84). Providers who cared for >= 25% black women (OR 0.71, 95% CI = 0.51-0.98) and providers who cared for <75% privately insured patients (OR 0.66, 95% Cl = 0.46-0.95) were less likely to use HPV DNA testing. Providers who cared for <75% privately insured patients were less likely to have on-site colposcopy (OR 0.57, 95% CI = 0.37-0.89), but those who cared for >= 20% Medicaid patients were more likely to have on-site colposcopy (OR 1,86, 95% CI = 1.26-2.73).Conclusions. Given the high rates of cervical cancer in minority women, access to cervical cancer screening and diagnostic follow-up must be ensured. It may also be beneficial to ensure affordable access to technologies such HPV DNA testing that increases the sensitivity of disease detection and to on-site colposcopy that facilitates follow-up of abnormal cytology.

Background: Because high-risk HPV is highly prevalent in the general population, usually transient, and rarely causes clinical symptoms, and because diagnostic and treatment options for HPV in men are lacking, partner notification is not useful for preventing transmission or protecting the health of male partners.Methods: We conducted a nationally representative survey of clinicians in 7 specialties that perform cervical cancer screening, Providers were asked whether they recommend that women with an abnormal Pap or positive HPV test inform sex partners of the infection or refer partners to a clinician.Results: A large proportion of providers in all 7 specialties encourage women with either an abnormal Pap or a positive HPV test to tell their sex partners to see a clinician, ranging from 48% to 73% across specialties. Providers who perform reflex HPV testing were more likely to recommend that patients with an ASCUS Pap inform their partners of test results if an HPV test was positive than if it was negative (66%-83% vs. 29%-50%): providers who perform adjunct HPV testing were more likely to recommend that patients with a normal Pap inform their partners if an HPV test was positive than if it was negative (72%-92% vs. 30%-52%).Conclusions: Most providers advise patients with cervical cancer screening tests suggestive of HPV infection to notify their sex partners and to refer them to a clinician. Guidelines are needed for providers to clarify any rationale for clinical evaluation of male partners, including that informing partners has a limited role in the control of HPV transmission or in preventing adverse health outcomes in the male partner.

Objective: To describe current practices of primary care (PC) clinicians for STD/HIV control services: risk assessment, prevention counseling, and offering tests.Study Design: We identified clinical strategies through qualitative interviews. We then surveyed by mail a random sample of Washington State family physicians, general internists, obstetrician-gynecologists, nurse practitioners, and certified nurse midwives. We identified characteristics of clinicians and their practices associated with each strategy and universal provision of each service.Results: We report on 519 clinicians (80% adjusted response rate). Clinicians provided services to selected patients they considered high risk. Universal practices were less common: risk assessment (56%), prevention counseling (60%), STD tests (30%), and HIV tests (19%). Universal services were more common among nurses, those recently trained, and those seeing more STD patients.Conclusion: Different types of PC clinicians use widely differing clinical strategies and many use selective rather than universal approaches to STD/HIV control services. Further research is needed to develop tailored interventions to improve provision of these services.

Objective: To determine the feasibility interviewing (ACASI) for data collection responses to questions eliciting sensitive ACASI versus computer-assisted persona countries. of using audio computer-assisted self-in developing countries, and to compare information about sexual behavior using I interviewing (CAPI) in five developing Design: A feasibility study determined whether ACASI could be used in populations in developing countries. A follow-up, randomized crossover study compared responses to questions eliciting sensitive information about sexual behavior using ACASI versus CAP[. Methods: The NIMH Collaborative HIV/STD Prevention Trial conducted a feasibility study of ACASI in convenience samples in China, India, Peru, and Russia, then a randomized crossover ACASI versus CAN study among volunteers in these countries plus Zimbabwe. Results: Approximately equal numbers of men and women completed the feasibility study; the results suggested a high comfort level among participants. Married respondents in China and India appeared to give unreliable responses on sexual activity. In the crossover study, the pattern of responses to sensitive questions showed few differences. In China, higher rates of sexual risk were reported on CAPI. In Peru and Russia, differences by mode were found in the number of partners in the past year. Conclusion: Despite variable computer experience and literacy, feasibility study participants reported ease in completing ACASI, and preferred a computer to an interviewer for answering sensitive questions, or had no preference. In the crossover study, most participants gave similar responses on both modes of survey administration. ACASI appears to be feasible in these settings, although low literacy may pose problems if participants cannot clarify questions. (C) 2007 Lippincott Williams & Wilkins.

Objective: To describe the community popular opinion leader (C-POL) intervention employed in the NIMH Collaborative HIV/STD Prevention Trial, including its theoretical, conceptual, and empirical basis, intervention procedures and methods, core elements, and how its content was culturally tailored to address the needs of varied populations. Design: The programme is designed to identify, recruit, train, and intensively engage C-POLs of a target population to convey HIV risk reduction messages to people in their communities, with the intention of reducing high-risk behavior at a population level. Methods: Based on the diffusion of innovation theory, the intervention identified, trained, and engaged C-POL within a high-risk community population to advocate, recommend, and endorse the importance of safer behavior to other members of the same population. Nine core elements of the intervention are discussed. Data collected during rapid ethnography were used to adapt the content of the intervention for food market owners and workers in China, male patrons of wine shops and at-risk women congregating nearby in India, young people in social gathering venues in Peruvian barrios, dormitory students in Russia, and people congregating in commercial areas of growth points in Zimbabwe. Results: The C-POL intervention model taps into community strengths, altruism, and people's desire to do something to help fight against AIDS. With few exceptions, C-POLs participated enthusiastically in the training sessions and reported having conversations in the community. Conclusion: Rapid ethnography can be used to tailor an intervention to diverse settings while maintaining fidelity to the core elements of the intervention. (C) 2007 Lippincott Williams & Wilkins.