HIV-related stigmas contribute to HIV disparities, which faith-based organizations could address, but few studies have measured faith-based HIV intervention effects on HIV-related stigmas. Taking It to the Pews (TIPS) is a multilevel, religiously tailored HIV prevention intervention developed and implemented with faith leaders. Over 12 months, trained church health liaisons implemented the TIPS Toolkit (e.g., HIV sermon guides and responsive readings, testimonials) with the primary aim of increasing HIV testing. A cluster randomized controlled trial with 14 predominantly African American churches in Kansas City, MO, compared TIPS to a non-tailored, multilevel HIV education intervention; both intervention and comparison groups offered church-based HIV testing events with the local health department. We examined whether TIPS affected HIV stigma among congregants and community members, specifically, HIV discomfort (5-item scale), anticipated HIV stigma (4-item scale), and overall HIV stigma (11-item scale), while controlling for known correlates of HIV stigma. We recruited 1491 church and community members at 14 churches. Compared to standard HIV education, TIPS did not decrease HIV discomfort or overall HIV stigma and did increase anticipated HIV stigma. A secondary analysis found that among intervention participants, intervention exposure was associated lower stigma and higher HIV knowledge, with HIV testing events and information from health professionals or HIV + people being particularly influential. Direct contact with health professionals and HIV + people can help reduce stigma among church-affiliated populations, but broader exposure and strategies are needed for congregation-level stigma. Stigma reduction and HIV testing may have synergistic effects in faith-based settings.

Increasing access to COVID-19 testing in influential, accessible community settings is needed to address COVID-19 disparities among African Americans. We describe COVID-19 testing intervention approaches conducted in Kansas City, Missouri, African American churches via a faith-health-academic partnership. Trained faith leaders promoted COVID-19 testing with church and community members by implementing multilevel interventions using a tailored toolkit and standard education information. The local health department conducted more than 300 COVID-19 tests during or after Sunday church services and outreach ministry activities. (Am J Public Health. 2022;112(S9):S887-S891. https://doi.org/10.2105/AJPH.2022.306981).

Background: Clinical electives, provide opportunities to inform future career paths. The primary purpose of this study was to examine whether the clinical electives were being used as intended i.e. to help with specialization choice and to determine the factors that influence trainee decisions for specialty training at The University of the West Indies. Methods: A cross-sectional study was conducted between July 2019 and March 2020, using a self-administered questionnaire. Results: 193 participants completed the questionnaire, aged 20 to 35 years, 133 (68.9%) were females. The most common electives completed were internal medicine specialties (80, 41.5%), followed by surgical specialties (53. 27.5%). Only 64(33.2%) participants reported electives used to gain experience for future career; other reasons included filling knowledge gaps (101, 52.3%), having to repeat failed clerkships (19, 9.8%). Future career preferences were the specialties of surgery (75, 40.8%), internal medicine (41, 22.3%), anaesthetics (20,10.4%) and obstetrics & gynaecology (18, 9.3%). Males showed a preference for surgical specialties (p=0.002). The use of the elective for determining career path showed significant correlation with future specialty choice (Likelihood ratio chi-square test (32) = 98.37, p<0.001). Career motivation factors correlating significantly with future specialty choices were intellectual challenge (p=0.025), income (p=0.010), prestige(p=0.015) and working hours(p=0.012). Conclusions: There was use of clinical elective rotations as intended by senior medical students and junior doctors. Surgical specialties were the top selections especially for males. Career counseling was needed to guide beneficial use of the clinical electives and to encourage the alignment of specialty choice with trainee motivations.

Background The World Health Organization (WHO) defines HIV self-testing (HIVST) as “a process in which a person collects his or her own specimen (oral fluid or blood) and then performs an HIV test and interprets the result”.1 Previous studies on the use of HIVST have shown this is a viable and influential new technology to increase HIV screening and diagnosis by double in several populations.2-5 The WHO/ Pan American Health Organization (PAHO) 1, International Association of Providers of AIDS Care (IAPAC) 6, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF)7 and PEPFAR8 all recommend implementation of HIVST. Both assisted and unassisted HIVST methodologies have been proven to be effective techniques of capturing HIV diagnoses. 9 In this meta-analysis, assisted and unassisted HIV screening technologies have been equally effective in detecting HIV diagnoses (Cohen’s κ: directly assisted 0·98, 95% CI 0·96–0·99 and unassisted 0·97, 0·96–0·98; I²=34·5%, 0–97·8). The specific HIVST kit to be used in this study is the OraQuick® kit. OraQuick® is the only HIVST kit recommended by the WHO 10 OraQuick® has been previously used in Jamaica for community-based assisted HIV self-testing. The documented Sensitivity and Specificity of OraQuick® reported by the US Food and Drug Administration (FDA) is 91.7% and 98.7% respectively.6 This modality involves a screening test and all positive screens must be confirmed by laboratory based diagnosis. HIV self-testing kits have primarily been used during targeted interventions in high risk groups in Jamaica using assisted self-testing 11. The HIVSTI/Tb Unit of the Jamaica Ministry of Health wishes to develop a comprehensive programme to ensure the maximum possible benefits of HIVST on the HIV epidemic. The HIV treatment cascade for Jamaica in 2020 shows many gaps affecting population viral suppression. Firstly, there is an approximate 14% decline between those estimated to be infected and those diagnosed with HIV and secondly, a further 45% reduction in those retained in care12. In 2013, the National HIV/STI/Tb Unit (HSTU) of the Ministry of Health and Wellness (MOHW), introduced a policy supporting universal routine HIV screening for attendees of healthcare facilities in Jamaica. However, the coverage and constancy of this intervention has remained low13. Consultations at public healthcare facilities in Jamaica revealed competing priorities, limited structural capacity and insufficient human resources as key barriers to increasing coverage, particularly in hospital settings. Prior Work At the University Hospital of the West Indies (UHWI), preliminary research conducted within the Department of Medicine outpatient clinics, on routine HIV screening showed high acceptability: 80% uptake for HIV rapid tests, along with high capture of positive HIV diagnoses, prevalence 1.8 (above the National HIV prevalence), and significant improvements for linkage to care were achieved at this location14. Increasing the capture and linkage of People Living with HIV (PLHIV) to this site can therefore have significant effects on HIV epidemic control and provide a high-quality service to improve the lives of patients. In the Emergency Medicine Division (EMD) at the University Hospital of the West Indies, the triage system used to see patients is the Emergency Severity Index (ESI)15. It is a five-tier emergency department triage system where patients are stratified to an ESI level from 1 through 5, on the basis of acuity and resource need, where 1 is the most urgent and 5 the least urgent. The EMD is physically sectioned into three areas, Fast-track where the ESI level 4 and 5 patients are seen, Intermediate for ESI Level 3, and the ‘Main’ section where ESI level 1 and 2 patients are seen. HIV testing has been previously used in two ways in the EMD. Laboratory based screening has always been available for patients irrespective of acuity, but over the last decade, targeted testing of symptomatic patients with rapid test kits has also been available. These clients are often sicker with Emergency Severity Index scores of less than 4, suggesting greater morbidity/severity of illness. Patients ESI 4 and 5 are not routinely offered HIV screening. Generally, HIV testing algorithms have employed both screening with the HIV Determine® rapid test kit followed by laboratory confirmation using the Trinity Biotech Uni-Gold HIV test and and SD BIOLINE HIV-1/2 3.0 test, run sequentially. Any discrepancies are resolved using the Abbott Architect HIV-1/2 Ag/Ab Combo test. HIVST is being explored for expanded implementation in Jamaica by the Ministry of Health and Wellness as exemplified by its inclusion in the HIV epidemic control strategies listed in the Jamaica National HIV Strategic Plan 2020-2025.16 Prior to HIVST being made available, HIV screening in the EMD has been limited by physical space, confidential areas to perform point-of-care rapid testing, human resource capacity, the staff to perform testing and counselling, and the time to perform rapid testing. The Research to Practice Gap A literature search of the implementation of home-based HIV self-test distribution in an emergency medicine department setting identified limited studies or information on factors influencing successful implementation. The studies generally identified positive attributes of self-testing to fill gaps in current HIV testing models17. Common influencing factors included cost 18, 19, usability 20 and supportive policy environments 1, 21 A systematic review of HIV screening in emergency departments 22 highlighted the central role of emergency department testing in epidemic control in the United States, and the paucity of such applications found in the literature for low and middle income countries. The review outlined a high prevalence of HIV among those attending the emergency departments including high proportions of previously undiagnosed persons. The review concluded that HIV testing in these locations offer a “unique testing venue” with a high probability of successful capture of PLHIV. One randomized controlled trial indicated the gap in testing coverage in an EMD can be filled with HIVST. 23 However, a strategy of referral cards for increasing distribution among sexual networks was not successful as none of the cards were used to access HIVST kits. The strategy proposed by Patel et al. was to provide the study participant with referral cards that would be distributed throughout the participants’ network. The recipients would subsequently use the cards to access HIV self-test kits for themselves.. Rationale for Proposed Research Introducing HIVST in the context of the EMD is well placed to be an effective intervention and acceptable to patients. This method of HIV screening can compensate for limited human resources and structural capacity that are generally required for other modalities of testing. We hypothesise the introduction of HIVST distribution in EMDs for unassisted testing will expand coverage of HIV testing and increase the capture and linkage of asymptomatic, undiagnosed HIV positive patients, a key intervention to achieve the UNAIDS 2025 AIDS targets.24 We will use an implementation science framework to assess determinants that hinder/enhance HIV screening implementation and guide the process of overcoming barriers to implementation—the Health Equity Implementation Framework.25 This framework also specifies a process or implementation strategy, known as facilitation, to overcome barriers related to equity in HIV care in this context to launch HIVST in this setting and sustain it long term. This framework also specifies domains to assess and consider when facilitating implementation of HIVST: the innovation itself (HIVST using oral fluid); factors of the people offering HIVST (staff, providers) and those who are targeted recipients of HIVST (patients), especially their cultural norms and beliefs; clinical encounter between EMD staff/providers and patients; local context of the emergency medicine clinical service, such as leadership support and culture regarding clinical changes; organizational context of the larger emergency medicine department; outer context of the University Hospital of the West Indies; and societal context, such as legal ramifications of being criminalized for same-sex behaviour in Jamaica (a key risk behaviour of HIV in the country) or economic concerns about limited healthcare coverage if a person was to test positive for HIV. We chose to use the Health Equity Implementation Framework for the following reasons: 1) detailed focus on facilitation, our key implementation strategy; 2) focus on domains that we believe contribute to poor uptake of HIVST in Jamaica, such as cultural norms of patients (“recipients”) and physical structures in the EMD such as limited confidentiality for private matters such as HIV screening; and 3) use of many of its domains in a prior HIV screening implementation project that was successful.26 Research Question, Aims and Objectives Research Question The following research questions will be addressed: • How can HIV Self-Testing using oral fluid to diagnose non-emergency patients in an urban hospital’s emergency department be implemented effectively? • What is the potential public health impact of implementing facility-based HIV Self Testing access at healthcare locations in Jamaica? Aims The aims of this study are: 1. To assess the factors that influence the implementation of the HIV Self Testing intervention. 2. To determine the effectiveness of the HIV Self Testing intervention to promote access to antiretroviral therapy. Objectives The Implementation Objectives are as follows: 1. To document the implementation strategies of the HIVST intervention. 2. To evaluate the facilitators and barriers of HIVST implementation in the EMD. 3. To determine the acceptability of the HIVST intervention by EMD patients 4. To determine the reach of HIV screening for i. EMD patients ii. The secondary contacts of EMD patients 5. To determine the costs associated with implementing this HIVST intervention from the payer’s perspective. 6. To measure the fidelity to HIVST activities delineated in the study protocol at the participant level (Implementation Fidelity27, 28) The Effectiveness Objectives are as follows: 1. To evaluate the effectiveness of the HIVST intervention to detect undiagnosed HIV positive EMD clients. 2. To determine the effectiveness of risk network referrals to detect HIV positive secondary contacts of EMD clients. 3. To determine the effectiveness of the HIV Self Testing intervention to link positive HIV diagnoses to treatment and care. Methods (Description) Study Design This is an implementation study design, specifically a hybrid type III 29 which includes implementation and effectiveness outcome measures, with an emphasis on implementation since HIVST has well-established efficacy already.30 We will conduct a cross-sectional, pre-post comparison over a 3-month period. A retrospective review of EMD patients previously tested for HIV will form the basis of the interrupted time series analysis. An outline of the essential elements of the study flow is detailed in Figure 1. The Standards for Reporting Implementation Studies (StaRI) 31 and the 10 key elements described by Proctor et al. 32will be used to guide the reporting of this study. The documentation of the intervention component of this report will follow the STROBE statement.33 Setting and participants (Context) The Emergency Medicine Department at the University Hospital of the West Indies, located in Kingston Jamaica, will be the location for the implementation of this intervention. The UHWI is in the urban area of Kingston, Jamaica. It is a 579-bed type A regional referral hospital with all major medical and surgical subspecialties. A total of approximately 49,000 to 53,000 patients are seen per year with an annual hospital admission rate of 15%.34 The department provides services to between 3000 and 5000 patients per month. Based on the severity of illness, the department is divided into three clinical areas: Main area (ESI 1 and 2), Intermediate (ESI 3) and Fast-track (ESI 4 and 5). This study will be situated in the ambulatory area, where the ESI 4 and 5 patients are seen. These patients are non-urgent and can easily be approached by the implementation team, without any delay in the patient’s clinical management. Three intervention recipient populations (participants) will be included: 1. EMD patients: The population who will be included in this study are adult patients, over the age of 17, of the EMD, UHWI. Patients with the lowest ESI scores (scores of 4 and 5) will be invited to participate in the study. Those who have had a previous HIV positive diagnosis or who have been tested for HIV within the last 12 months will be excluded. 2. EMD Staff: A range of staff categories including Emergency Medicine Consultants, program residents, non-program residents, senior house officers, emergency medicine trained nurses, emergency room technicians, patient care advocates, registration, and billing. The number and specification of individuals will be determined during the pre-implementation activities. 3. Study Staff: The study team who will guide implementation are comprised of EMD staff, one EMD consultant physicians, acting as an internal facilitator, one Head of Department, and one external facilitator outside the healthcare system. Non-EMD study staff will be comprised of two to four research assistants. The effectiveness evaluation component will include comparing EMD patients who were previously tested for HIV in the EMD to those tested after HIVST is implemented. The retrospective analysis will include 3 years of data commencing in January 2018. Description of the Implementation Strategies Facilitation is our primary implementation strategy to prepare for, launch, and maintain HIVST in the EMD.25 Facilitation is an umbrella implementation strategy, such that it involves key steps (e.g., working with stakeholders to develop and execute an implementation plan) that can involve other specific implementation strategies as needed.25 We anticipate using at least these specific implementation strategies drawn from the list of Expert Recommendations for Implementing Change( compilation 35-37, although others may be used: 1. Develop patient educational materials 2. Distribute patient educational materials 3. Involve patients 4. Assess for readiness and identify barriers and facilitators 5. Develop staff/provider educational materials 6. Distribute staff/provider educational materials 7. Conduct staff/provider educational meetings 8. Develop a formal implementation blueprint 9. Access new funding Facilitators will work to initiate and enact these strategies, which will be critical for successful initial implementation of HIV screening, and for its sustainability and scale-out in Jamaica. There are multiple barriers to implementation and the emergency department, where screening is to be implemented, is nested within and overlaps with other organizational contexts. Thus, the complexity of the healthcare contexts and need for scale-out in subsequent initiatives warrant facilitation. Additionally, facilitation allows for a focus on capacity building of UHWI staff in implementation science during and after the project. Description of the Intervention The HIVST intervention will be comprised of three activities: 1. HIVST Package i. Three HIV OraQuick® test kits. 1. One for the EMD patient 2. One for the EMD patient to distribute to a secondary contact ii. Information leaflet iii. Follow-up contact information iv. Condoms 2. Active follow-up by research team at three time points: i. Within two (2) days of receiving test kits (as determined by the participant) ii. 1 week after receiving test kits. iii. 1 month after receiving test kits. 3. Access to 24-hour information hotline The HIVST Intervention Details 1. The HIVST Package i. Jamaica MOHW national policy on HIV screening recommends the use of opt-out testing. However, due to the requirement of patient consent for participation, an opt-in approach will be adopted. ii. Consent will be garnered from the participants specifically for the following processes: 1. Follow up calls by the research team. 2. Ascertaining HIVST result status. 3. Confidential reporting of potential positive status to the Jamaica National Public Health Reporting System (Class I Notification). 4. Active follow up by the study team for participants with a positive HIVST to link them to confirmatory testing at the UHWI and further HIV treatment and care as required. iii. The consented participants will then be provided with the HIVST package as outlined above. Participants will be encouraged to perform their self-tests kits at a secure location, for example at home. However, access to a secure location will be provided for those who wish to perform unassisted facility-based testing. iv. Participants will also be encouraged to provide the third HIVST kit to a secondary contact, which may include a present or previous sexual partner, family member or friend. Educational materials and follow-up information will be provided along with the additional kit. v. EMD clients that are unable to perform HIVST (for example the elderly or infirmed), HIV screening, using the hospital laboratory-based HIV testing algorithm, will be recommended as an included component of their visit to their EMD care team. 2. Active follow-up activities will be performed for participants. a. Follow-up of participants will be conducted by the designated research team members via telephone or face to face. b. Follow-up will be conducted at three time points: 1. Within 2 days of participant receiving the test kits to be determined in conjunction with the participant. The following activities will be performed:  Address technical difficulties.  Document test result.  Provide post-test information  Assessment of any adverse event  Schedule follow-up and linkage activities 2. One week after enrolment. The following activities will be performed: i. Address technical difficulties (if not previously done) ii. Document test result (If not previously done) iii. Document post-test information (if not previously done)  Exit survey  Assessment of adverse events  Schedule follow-up and linkage activities iv. One month after enrolment. The following activities will be performed: v. Address technical difficulties (if not previously done) vi. Document test result (If not previously done) vii. Document post-test information (if not previously done)  Exit survey (if not previously performed)  Assessment of adverse events  Schedule follow-up and linkage activities 3. For participants where follow-up has been unsuccessful, referral to an appropriate agency’s linkage team will be performed. The linkage processes will follow the national HSTU guidelines and include telephone contact, referral to a Contact Investigator and home visits as required. c. Upon linkage activities will be tailored based on the HIVST result i. Positive HIVST 1. Confirmatory testing at the UHWI. 2. Post-test counselling. 3. Submitting Class I notification form to MOHW for confirmed positive tests. 4. Enrolment to preferred provider for further HIV treatment and care. ii. Negative HIVST 1. Post-test counselling 2. Referral to preferred provider for combination HIV prevention 3. Access to a 24-hour hotline a. A hotline, manned by the study team, will also be provided to participants and their secondary contacts to address any emergency occurrences related to the study activities. Methods (Evaluation) Documenting Implementation Strategies In our process evaluation, we will document implementation strategies used before and during the demonstration project and track any adaptations to those strategies. To document strategies, we will use the Pragmatic Implementation Strategy Reporting Tool which allows researchers to track strategies used with specificity according to top recommendations.38 We will collect this information during weekly team meetings of the facilitation team. Each strategy will be detailed by the specific actions that required, the personnel that will be performing each action, and the period over which each strategy will be performed. Subsequently, the frequency and duration of each action will be determined along with the total time spent by the assigned personnel. Implementation and Effectiveness Outcomes and Measures We will use the RE-AIM39 framework to select outcomes to assess public health impact of implementing HIVST in one emergency medicine department in Jamaica. RE-AIM represents five constructs to evaluate: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Assessing Reach involves evaluating whether HIVST is reaching the intended population by describing which patients are offered and accept HIVST. Assessing Effectiveness involves evaluating how well HIVST is detecting HIV and leads to linkage of people testing positive for HIV to treatment for the virus. Adoption typically refers to clinicians deciding to use the intervention, and we will not assess Adoption in this study because our study staff will be offering HIVST to patients. Assessing Implementation involves evaluating a range of factors affecting how HIVST is actually used in routine practice.40 In this study, we will assess Implementation as 1) fidelity to the HIVST intervention with each patient and 2) costs associated with implementing the package of HIVST and facilitation. Maintenance refers to how each of the aforementioned constructs are maintained or sustained at a later timepoint; because this is a 3-month demonstration project, we will not assess Maintenance. The evaluation methods for the implementation outcomes reach, implementation fidelity and cost, and acceptability will follow a mixed-methods approach and are summarized below (Table 1). Implementation cost will be guided by the methodology of time-driven activity-based costing. 41 The main effectiveness outcome is HIV testing uptake of the primary recipient, the EMD patient, but also uptake in the secondary recipient (the risk network of EMD patients). More detail is in Table 1. Acceptability to Patients Patient perspectives on HIV testing modalities have previously shown to be a critical factor in successful implementation. We will gather critical information on patient experiences and recommendations will be incorporated for the scale-out of HIVST beyond the EMD context. We use the theoretical framework of acceptability as proposed by Sekhon et al. 42 They propose acceptability as a multi-component construct which can be assessed before, during or after the intervention. We utilize this framework to perform a qualitative patient-level retrospective assessment of this HIVST implementation programme focusing on eight components of the acceptability construct, concentrating on the lived experience of the participants and their intention for future HIVST. Sample Size Sample size was determined by accounting for internal and external context, resource capacity and outcome timelines. The contextual factors considered included patient visit load to the EMD, estimated acceptance to participate, national prevalence of HIV, estimated response rate of participants. The capacity of the research team to conduct follow-up activities and total costs of the demonstration project were also included in sample size considerations. Lastly was the need for rapid production of data to influence national decision making on HIVST implementation. Based on the national HIV prevalence of 1.8 in the general population and the sensitivity of the OraQuick® HIV test of 91.7% 6, if no attrition is assumed, approximately 10 positive tests are estimated. Estimates of the total number of patients fulfilling the inclusion/exclusion criteria is not currently available for the EMD as numbers based on Emergency Severity Index scores are not tracked and reported routinely. However, this information will be captured during the study period to provide a denominator for the relevant indicators. A total of 600 participants will be enrolled in the study over a 3-month period. Data Analysis A mixed methods approach to data collection will be used. Quantitative data will be collected and managed using structured data capture forms using the REDCap 43, 44 electronic data capture tools hosted at The University of the West Indies, Mona Campus. Qualitative data will be collected using voice recorders and subsequently transcribed by the study team. Inaudible segments will be discussed within the study team and resolved by the Principal Investigator. Most quantitative and qualitative data will be collected and analysed simultaneously (see Table 1) and a concurrent triangulation technique to be employed 45 for interpretation. Implementation Reach and Fidelity Analysis Implementation reach will be operationalized as the proportion of clients who satisfy the inclusion/exclusion criteria that have been approached and agree to participate in the study. We will also assess demographic characteristics of those participants (e.g., gender identity, income). We will use descriptive statistics to analyse these data. Fidelity will be assessed from the participant perspective. It will be operationalized as the proportion of participants who perform the HIVST testing procedure as described in the educational materials provided. Implementation Cost Analysis Total costs of facilitation will be calculated by combining human resource costs and the additional fixed costs and their associated expenses required for each strategy, consistent with time-driven activity-based costing.41 Effectiveness Analysis The main indicator of increased HIV testing uptake will be analysed using an interrupted time series analysis46. The hypothesized impact model is one with no lag and a level change. The proposed segmented regression model will take the general form: Yt = β0 + β1T + β2 Xt + ε Where β0 represents the baseline HIV testing level at time T=0, β1 is interpreted as the change in HIV testing associated with a time unit increase, β2 is the level change in HIV testing following the introduction of the HIVST intervention. Patient Acceptability Analysis A thematic approach will be used to analyse qualitative data from patient interviews on acceptability of HIVST47. Themes will be chosen based on the pre-identified implementation outcomes (deductive approach) and additions will be made based on the analysis of the transcripts (inductive approach). The methodology of coding the data has been previously documented48. Identified themes will be triangulated with quantitative data collected under the implementation outcomes. Discussion Principal Results The investigation into HIVST implementation attempts to produce data that can maximize the utility of HIVST in Jamaica. HIV screening at healthcare facilities has historically had higher yields as compared to national HIV prevalence. However, the coverage in these settings has been limited. The introduction of HIVST present an opportunity to increase the coverage of routine HIV screening in healthcare facilities. Also, the potential impact of a novel approach to risk network referrals for HIV self-testing can improve the utility of this technology. EMD patient participants will be provided with additional HIVST kits which are to be distributed to a secondary contact, who can be a friend, family member, or sexual contact. As opposed to traditional definitions of risk network referrals, where affected individuals are required to be aware of their symptoms, this method is aimed at diagnosing HIV prior to symptom presentation and thus have a greater impact on epidemic control. This approach represents an adaption of previously attempted interventions aimed at leveraging social networks and HIV testing access. In patient acceptability interviews, participant responses to educational material will be used to assess the promotional material for uptake but also linkage to care. Linkage following HIVST has previously been an inhibiting factor for implementation 49. Here, we will be using resource intensive method of active follow up of EMD patient participants to gather critical information particularly around acceptability, but also a resource light approach with risk network referral of secondary contacts. Limitations The physical structural capacity restrictions in the EMD to provide confidential spaces where study activities can be performed introduce a manufactured limitation on the potential expansion of HIV testing. The baseline procedures, including in-depth interviews, result in a maximum of 8 participants able to be enrolled per day. This limits the interrupted time series analysis to only a level-change but not a gradient change. This can result in an underestimate of the potential impact of HIVST on HIV testing coverage expansion. The accuracy of HIV positive case finding using HIVST is solely dependent on self-reported diagnosis of participants. This effect may be even larger for risk network referral participants for whom an active initiation of engagement in the study is required. This will also affect the evaluation of linkage to care. In addition, the impact of the COVID-19 epidemic on how the population accesses services in the EMD at UHWI, their willingness to participate in research study activities and the work flows within the department will need to be considered when interpreting the data. This demonstration project has already been delayed for one year due to the pandemic. Conclusions This study will use implementation science frameworks and outcome measures to assess the potential of HIVST to expand access to HIV testing in an emergency medicine department in Jamaica. The ultimate goal of this research is to provide an adequate baseline understanding of HIVST implementation to inform decisions on expanding access to HIVST in other settings. Ethics and Funding This proposal has been granted ethical approval by the University of the West Indies, Mona Campus Research Ethics Committee (March 23, 2020; Reference number ECP108, 18/19). The study is supported by ViiV Healthcare. Acknowledgements GB was responsible for the conception and initial design, all authors contributed to the ideas and development of this protocol. GB, EWW, ENW, SD and DS led the writing of this paper, and all authors approved the final version. ViiV Healthcare is funding this study, GB received compensation as the principal investigator of this study. ENW refined implementation evaluation procedures and served as external facilitator (receiving compensation for facilitation and capacity building activities through funding from ViiV healthcare). ENW’s contribution to writing the manuscript was supported by Career Development Award Number IK2 HX003065 from the United States (U.S.) Department of Veterans Affairs Health Services Research and Development (HSRD) Service. ENW is a fellow with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (5R25MH08091607). Disclaimer: The views expressed in this article are those of the author(s) and do not necessarily represent the views of the U.S. Department of Veterans Affairs. Conflicts of Interest Disclose any personal financial interests related to the subject matters discussed in the manuscript here. If none, indicate with “none declared”. DS is an employee and shareholder of GSK/ViiV Healthcare. Abbreviations HIVST: HIV self-testing EMD: Emergency Medicine Department ESI: Emergency Severity Index HSTU: HIV/STI/Tb Unit MOHW: Ministry of Health and Wellness RE-AIM: Reach Effectiveness Adoption Implementation Maintenance UHWI: University Hospital of the West Indies Online paper registration: https://viivhealthcare.com/en-gb/implementation-science-overview/

Background: Cervical spine injuries are myriad and ubiquitous, however the related demographic information has not been documented for the Jamaican or Caribbean population. These injuries can be life threatening and so it is important for the Emergency Physician to adhere to guidelines which direct management decisions including the need for imaging. This study therefore is an effort to report on the epidemiology of patients with cervical spine injuries presenting to the Emergency Department (ED) at the University Hospital of the West Indies (UHWI) and the use of clinical rules in the diagnosis of these injuries.This was a retrospective study. The log books from the ED at the UHWI were used to identify patients presenting with possible cervical spine injuries from January 1, 2013 to December 31, 2016. Inclusion/exclusion criteria were applied to select study patients. Demographical and clinical information was collected and evaluated. Results: 1,380 charts were identified as possible subjects. Of these, 887 charts were located and 806 (90.9%) were eligible. Ages ranged from 16 to 101 years with an average of 37.5 years. The majority of subjects were male, with a male to female ratio of 3:1. The main causes of these injuries were motor-vehicle collision (46.4%), motor-bike collision (23.8%) and fall from elevation (13.1%). Cervical spine injuries were identified in 20 (2.48%) subjects where motor-vehicle collision (45%) and motor-bike collisions (25%) were the main cause for injuries. Documentation of clinical rules applied to determine the need for radiological testing were present for 37.7% of the study population (NEXUS 36.2%, CCR 0.4% and combination 1.1%) Conclusion: The main source of injuries was due to road traffic accidents. This suggests more needs to be done regarding road safety. There is also room for improvement as it relates to the use of decision rules which may reduce the occurrence of unnecessary imaging.

African Americans are disproportionately burdened by mental health issues (e.g., stress, chronic depression, and post-traumatic stress disorder). Upon review of mental health local/state/national data, a highly-engaged faith-based Community Action Board (CAB) raised concerns about the mental health needs of African Americans and addressed mental health as a priority health area in African American Kansas City churches. African Americans tend to experience barriers to mental health services (e.g., limited access, high cost, mental health-related stigma, non-culturally tailored mental health care). African American churches have many strengths that could increase reach, acceptability feasibility, and impact of mental health interventions tailored for African Americans. The CAB conducted a health needs assessment survey (N=463; 11 churches) to identify health concerns and potential strategies to inform the design of a church-based mental health intervention. Using a faith-community-engaged approach, the CAB developed the survey and used its findings to design a religiously-tailored, multilevel mental health intervention focused on prevention, screening, and linkage to care. The needs assessment identified intervention strategies (e.g., church-based screening, stress reduction/exercise programs, pastors promoting mental health) that were: (1) rated as highly important/feasible to implement, (2) included in the intervention design, and (3) successfully implemented in African American churches by faith leaders and university students and faculty.

The updated National HIV/AIDS Strategy recommends widespread HIV education and testing and calls the faith community to assist in these efforts. Yet, limited information exist on church-based HIV testing interventions. This study examined feasibility and assessed HIV testing outcomes of Taking It to the Pews (TIPS), a multilevel HIV education and testing intervention. Four African American churches were matched and randomized to TIPS or a standard-information control arm. Intervention churches delivered the religiously-tailored TIPS Tool Kit, which included educational materials to individuals and ministry groups; pastoral activities (e.g., sermons preached, receipt of HIV testing role-modeled), responsive readings, and church bulletin inserts in church services; and HIV testing during church services and church outreach events. All churches delivered 2–3 tools/month and coordinated 3 HIV testing events. At 12 months, significant increases in receipt of HIV testing (59% vs. 42%, p = 0.008), and particularly church-based testing (54% vs. 15%, p < 0.001), relative to controls were found. TIPS has great potential to increase reach, feasibility, and impact of HIV testing in African American churches.

There are many well-documented obstacles to routine laparoscopy, but the contribution of healthcare workers' (HCWs') attitudes has not been examined. A questionnaire study was performed to evaluate HCWs' attitudes toward laparoscopic cholecystectomy (LC) in operating rooms of all public hospitals in Jamaica. There were 285 HCWs interviewed from 12 hospitals across the nation. All HCWs were aware of the theoretic advantages of LC, but 56% opposed a suggestion to routinely offer LC to elective patients and 89% opposed LC for acute cholecystitis. Those in opposition were more commonly members of the nursing profession (71.8% vs 25.8%; P < 0.0001), older than 50 years (79.3% vs 50.2%; P < 0.0001), and those who graduated from their basic medical degree >20 years ago (72% vs 42.5%; P < 0.0001). Although some HCWs cited valid reasons to oppose LC, some made erroneous statements such as LC was for patients who were overly concerned with esthetics (48%), LC was unsafe when a conversion was required (35%), LC compromised patient safety for esthetics (25%), LC was inferior to open surgery (21%), LC brought no advantage over open surgery (21%), and LC was harmful (20%). These beliefs are not aligned with local or international data, and they add drag to the lethargic pace of laparoscopy in Jamaica. A change in HCWs' attitudes is necessary to overcome the stagnation in laparoscopic practice. We propose short-term and long-term strategies that may potentially change HCWs' attitudes. This study identified the HCW population to be targeted.

Acute pancreatitis (AP) is a common cause of gastrointestinal emergencies which is associated with significant morbidity and mortality. The diagnosis of AP is established by any two of the following: a) typical symptoms, b) elevated amylase or lipase and c) radiological features. Trans-abdominal ultrasound should be performed in all patients with suspected acute pancreatitis to evaluate the biliary tract and determine the presence of gallstones. The majority of cases of AP are due firstly, to biliary disease and secondly, alcohol use. It is important to determine the severity of AP which will indicate course and prognosis. The prognostic features can be initially assessed by clinical impression, the APACHE 11 score, the C-reactive protein and evidence of persistent organ failure. The severity of AP is classified as mild, moderately severe and severe. In mild disease, there is no organ failure, local or systemic complications. Patients with moderately severe AP have transient, less than 48 hours, organ failure or systemic complications. Severe AP is associated with persistent organ failure and/or systemic or local complications. The initial management consists of early aggressive fluid resuscitation, 250. 500 mL per hour or 5-10 mL per kilogram bodyweight per hour of isotonic crystalloid solution. Use of prophylactic antibiotics is not recommended. Antibiotics should be administered in suspected or confirmed extra-pancreatic infection or infected pancreatic necrosis. Feeding of patients should be commenced early and after adequate fluid resuscitation. The enteral route utilizing a nasogastric tube in patients with gut dysfunction in severe AP and oral feeding in patients with normal gut function in mild AP are appropriate.

Elevated blood pressure (BP) is common among emergency department (ED) patients. While some data exist on the association between ED BP and hypertension (HTN) in the USA, little is known about this relationship in Afro-Caribbean nations. The aim of the study was to evaluate the relationship between elevated systolic BP in the ED and a previous diagnosis of HTN, accounting for potential factors that could contribute to poor HTN control among those with a previous diagnosis: socioeconomic status, health-seeking behavior, underlying HTN illness beliefs, medication adherence, and perceived adherence self-efficacy.

Introduction: Epistaxis is one of the most common otolaryngology emergencies.There is no published data in the West Indian literature regarding its management.This study was conducted to describe the clinical characteristics and treatment outcomes of patients admitted to the University Hospital of the West Indies (UHWI) with epistaxis and to determine the prevalence of hypertension in patients presenting with epistaxis.Methods: A retrospective chart review was performed on 40 patients admitted to the Ear, nose and throat ward through the Accident and Emergency (A&E) Department at the UHWI between February 2007 and February 2014 with a diagnosis of epistaxis.The data were analysed using SPSS statistics 22 software.Results: There were 40 patients with a diagnosis of epistaxis admitted to the ear, nose and throat ward.There were 22 males and 18 females.The mean age was 52.5 years (standard deviation [SD], 17.8).The prevalence of hypertension among patients with epistaxis was 72.5%.The commonest cause of epistaxis was idiopathic accounting for 72.5%, followed by nasal masses 10% and trauma and aspirin each 5%.Anterior nasal bleeding accounted for 52.5% of cases.Ninety-five per cent of patients were managed initially with nasal packing.Surgical measures were carried out in 18% of patients who had initially been packed (p = 0.046).The overall mean hospital stay was six (6.75) days.There was no mortality in this series. Conclusions:The majority of nose bleeds in this review were anterior.Idiopathic remains the leading cause.Most cases of epistaxis can be managed successfully with non-surgical treatment.There is a high prevalence of elevated blood pressure readings and hypertension among this group of patients with epistaxis.

BACKGROUND:Acute pancreatitis (AP) is a significant cause of acute abdominal pain, morbidity and hospitalisation. There was previously a dearth of studies exploring the incidence, risk factors and outcome of AP in the Caribbean region. MATERIALS AND METHODS:All patients with a diagnosis of AP admitted to the University Hospital of the West Indies (UHWI) between 2006 and 2012 were reviewed. The epidemiological profile, risk factors, clinical presentation and outcomes of patients with AP were retrospectively studied. RESULTS:There were 70 females and 21 males with a median age of 44 years (range 2-86). The median age of males was significantly higher than that of females (p = 0.041). The incidence of AP was 74 per 100,000 admissions per year. Vomiting and abdominal tenderness were noted in the majority of patients. The most common aetiology was biliary disease (71.4%), idiopathic (12%), post-ERCP (6.6%) and alcohol (5.5%). Alcoholic pancreatitis was only seen in males whereas idiopathic and post-ERCP pancreatitis only occurred in females. The mean duration of hospitalisation was 9.51 ± 8.28 days. Disease severity was mild in 61.1%, moderately severe in 26.7%, and severe in 12.2% of patients. Factors associated with more severe disease included overweight/obesity, idiopathic aetiology and post-ERCP status. The case fatality rate was 2%. CONCLUSION:The incidence of AP was 74/100,000 hospital admissions annually. There was an unusual female preponderance, with biliary pancreatitis being the most common type occurring at an equal frequency among males and females. Only 12.2% of the total cases seen were severe. The case fatality rate was 2%. Local health policy should target timely interventions for biliary pancreatitis and should also address the local factors affecting disease severity.

Objectives: To determine the cause of death diagnoses and the discrepancy rate between clinical and autopsy diagnoses in the Emergency Department (ED) of the University Hospital of the West Indies (UHWI). Methods: Clinical and post-mortem records were reviewed for all the patients dying in the ED of the UHWI within 24 hours of their admission, during the period January 2007 to December 2010. The patients' demographic data, clinical cause of death and cause of death established at autopsy were documented for each case. The clinical diagnoses were classified as being either concordant (similar) or discrepant (dissimilar) with respect to the pathologic diagnosis, using a modified Underwood classification. The frequencies of diagnostic discrepancy were analysed with respect to disease category, gender and age. Results: For the study period, 68 of the 180 patients who died in the ED within 24 hours of their admission received autopsies (autopsy rate, 37.8%), and they ranged in age from 11-92 years (mean 54.9); M:F ratio, 1.4:1. The commonest autopsy cause of death category was circulatory disorders; cardiovascular diseases were more common than cerebrovascular diseases. The discrepancy rate between the clinical and autopsy cause of death diagnoses was 36.8%. The frequency of discrepancies increased with age; the majority (57.9%) occurred in patients >= 50 years of age. Conclusions: The autopsy rate, distribution of cause of death diagnoses and discrepancy rate documented in our ED are comparable to similar studies. The high frequency of discrepant diagnoses among older age groups, combined with the diagnostic challenges in the ED related to time and patient co-morbidities, warrant a concerted effort to increase the autopsy rate.

•African American churches have many strengths to address health disparity issues.•African American faith leaders were engaged in a health needs assessment (HNA).•Diabetes and heart disease/stroke were identified as priority health issues.•Important/feasible health promotion church intervention strategies were identified.•A multilevel health promotion church intervention was designed from HNA findings.

Synopsis: Life saving measures for acute myocardial infarction include reperfusion therapy.There have been international studies done looking at factors contributing to prehospital

Objective: To determine the breast cancer IHC receptor status for tests performed at the UWI from January 2002 to December 2007, and to investigate for an association between receptor profile and patient age, tumour grade and stage. Methods: The UWI breast cancer IHC receptor database was examined to determine receptor profile, patient age, tumour histology, grade, size and lymph node status. Results: 1,383 breast cancer cases were tested for ER and HER 2 status during the study period; PR testing was not performed. Receptor profiles were: ER+/HER2(50.2%), ER-/ HER2(28.1%), ER+/HER2+ (15.3%) and ER-/ HER2+ (6.4%). Across all age groups, ER+/HER2was the most frequent profile (4552%) and ER-/ HER2was second most frequent (27-34%). There was no statistically significant association between receptor profile and age (p = .079). Amongst Grade III tumours, ER-/HER2was most prevalent profile (44.6%); ER+/HER2was most prevalent for Grade I and Grade II tumors (60.7% and 48.8% respectively). There was a statistically significant association between receptor profile and tumour grade (p=< .001). There was no statistically significant association between receptor profile and tumour stage (p =.359). Conclusions: The prevalence of ER/HER2-negative breast cancer was 28%, in keeping with TNBC prevalence in African-American populations. There was a statistically significant association between receptor profile and tumour grade (p< .001) (most Grade III tumours were ER-/HER2-), in keeping with the biologically aggressive behavior of TNBC.

INTRODUCTION The recurrent laryngeal nerve (RLN) innervates all the important laryngeal muscles except the cricothyroid. Careful dissection of the RLN during surgery reduces the risk of damage. The non-RLN (NRLN) is a rare anatomical anomaly of the RLN, with an incidence of 0.5 to 0.7% in thyroid surgery (1). It is difficult to identify this anomaly preoperatively unless an

Objective: Complicated sinusitis is rare. It might not be identified early and might expose the patient to an unfavourable outcome. There is a paucity of data regarding this condition in the Caribbean. This study was undertaken to describe the clinical characteristics and treatment outcomes of patients admitted with this condition. Methods: A retrospective chart review was performed on patients admitted to the University Hospital of the West Indies (UHWI) with complicated sinusitis between 1999 to 2011. The data were analysed using SPSS statistics 22 software. Results: There were 30 patients (23 males and 7 females). The mean standard deviation (SD) age was 19 (13.96) years. Twenty-two had orbital complications, two had intracranial complications and one had both. The most common organisms isolated were streptococcus and the most common sensitivity was to amoxicillin and clavulinic acid. Sixteen patients who had an external surgical approach had a mean SD hospital stay of 8.8 (3.71) days compared to the three patients who had a purely endoscopic approach who had a mean SD hospital stay of 7.67 (0.577) days. There was no statistical difference in the mean hospital stay between these two groups (95% CI, -3.49, 5.78; p = 0.609). The mean duration of hospital stay for those treated medically was six days versus ten days for the surgical group. The mean difference was three days (95% CI, 0.193, 6.595; p = 0.039). Conclusions: Acute complicated sinusitis is seen more commonly in adolescent males. The most common complication was orbital. Surgical treatment is indicated for those patients who fail medical management and should consist of an endoscopic approach which may be combined with open approaches if indicated.

BACKGROUND:Although tetanus is still endemic in Jamaica, the epidemiologic profile has not been evaluated.METHODS:Admission registers at the main tertiary referral hospital were accessed to identify all patients diagnosed with tetanus from 1 January 1993 to 1 December 2010.RESULTS:There were 26 cases of tetanus (annual incidence of 0.57 cases per 1,000,000 population). Tetanus was more common in men (5.2:1) at a mean age of 59 ± 18.1 years. Persons in high-risk occupations (farmers, gardeners and construction workers) accounted for 52% of cases.CONCLUSIONS:Tetanus remains endemic in Jamaica, occurring more commonly in elderly men. Doctors should be educated about the importance of a high index of suspicion, an immunisation history and promoting booster shots in high-risk groups.