Aims:Musculoskeletal (MSK) injuries are a major cause of morbidity and mortality worldwide. However, research into MSK injuries is hampered by significant challenges and barriers, particularly in low-and middle-income countries (LMICs). Our aim was to identify the most important challenges and barriers to MSK injury care research across Malawi, South Africa, and Tanzania. Methods:We conducted a three-stage modified Delphi study. In Stage 1, healthcare professionals and researchers involved in MSK injury care listed challenges and barriers to conducting MSK injury research, which were consolidated in 25 themes. In Stage 2, participants rated each theme on a five-point Likert scale. In Stage 3, to drive consensus, participants re-rated the themes after viewing group and country-specific feedback from the previous stage. Challenges and barriers were ranked by mean score. Consensus was defined as ≥ 75% of respondents rating a theme as 4 or 5 ('important' and 'most important' on the Likert Scale). Results:A total of 396 participants completed Stage 1, 424 completed Stage 2, and 434 completed Stage 3. Across all participants, consensus (≥ 75%) was reached on nine key challenges and barriers to MSK injury research, including: lack of funding, high clinical workloads, limited training and mentorship, poor-quality data collection practices, healthcare facility resource constraints, patient loss to follow-up, limited research opportunities outside academic institutions, poverty and financial barriers, and healthcare delays. At the country level, the challenges of lack of funding, high clinical workload, and inconsistent data collection practices consistently achieved consensus in Malawi, South Africa, and Tanzania. Conclusion:MSK injuries impose a substantial burden in sub-Saharan Africa, yet research remains limited by funding shortages, high clinical workloads, and inconsistent data collection practices. These challenges, consistently identified across Malawi, South Africa, and Tanzania, highlight the need for targeted investment and regional collaboration to strengthen research capacity and improve patient outcomes.

OBJECTIVES:The paucibacillary nature of spinal tuberculosis (STB) challenges diagnosis. Tissue sites of Mycobacterium tuberculosis (Mtb) and HIV-1 co-infection are suggested to favor reciprocal replication, and reservoir expansion, including in people living with HIV-1 (PLWH) on antiretroviral treatment (ART); however, evidence is scant. This study aimed to evaluate the utility of droplet digital polymerase chain reaction (ddPCR) to detect and quantify Mtb DNA in spinal biopsy tissue, with sensitivity validated against culture and Xpert Mtb/rifampicin (MTB/RIF) Ultra, and determine whether Mtb, and reciprocally HIV-1, DNA abundance is increased in sites of spinal co-infection. METHODS:Overall, 93 spinal biopsy segments from adults (≥18 years; n = 25, 52% PLWH on ART) with presumptive STB in South Africa had DNA extracted and ddPCR quantified copies of Mtb complex (MTBC) (rpoB, IS6110), HIV-1 (pol, gag) and Human (RPP30) genes. RESULTS:ddPCR detected MTBC DNA in biopsies from 10/10 (100%) culture-confirmed STB, 5/6 (83%) Xpert Ultra-confirmed STB and 4/9 (44%) culture and Xpert MTB/RIF Ultra negative patients (all four had previous pulmonary TB). Detected MTBC ranged from 8-59144 rpoB copies/biopsy. RpoB copies/106 human cells were higher in biopsies from PLWH (P = 0.0096) and positively correlated with matched biopsy segment HIV-1 pol copies/106 cells (r = 0.40; P = 0.0003), and not peripheral viral load. HIV-1 pol copies/106 cells were higher in segments with MTBC DNA co-detected (P = 0.011) and also correlated with viral load (r = 0.91; P = 0.0003). CONCLUSION:DdPCR has high sensitivity for STB diagnosis. Confirming reciprocal relationships exists between Mtb and HIV-1 abundance in spinal tissue in PLWH on ART, supports characterizing the immune microenvironment in co-infected tissue sites to elucidate factors that impact HIV-1/Mtb reservoir persistence and/or expansion.

Background. The paucibacillary nature of spinal tuberculosis (STB) makes diagnosis challenging, particularly in people living with HIV-1 (PLWH). It is suggested that HIV-1 and Mycobacterium tuberculosis ( Mtb ) co-infection in tissues favours reciprocal replication, infection and reservoir expansion. Yet, confirmation of this detrimental synergism in diseased tissues is scant. Methods In a prospective study of 25 adults (13 (52%) people living with HIV-1 (PLWH) on antiretroviral treatment (ART)) undergoing spinal biopsy investigation for STB in South Africa, droplet digital PCR (ddPCR) was used to detect and quantify Mtb complex (MTBC) DNA ( rpoB and IS6110 ) in 93 biopsy segments, and HIV-1 DNA ( pol and gag ) in 41 segments from PLWH. ddPCR sensitivity for Mtb was validated against Xpert-Ultra and culture. Relationships between pathogen DNA abundance, co-detection, human cellularity, HIV status, and peripheral viral load (VL) were evaluated. Findings ddPCR detected MTBC DNA in 19/25 (76%) patients (range: 8- 59,144 rpoB copies/biopsy), with increased detection in those with confirmed STB and a history of TB. MTBC rpoB copies/million cells were higher in biopsies from PLWH (p=0.0096) and positively correlated with matched biopsy segment HIV-1 pol copies/million cells (r=0.40; p=0.0003), but not peripheral VL. HIV-1 DNA was detected in all biopsies from PLWH, four with undetectable VL. HIV-1 pol copies/million cells were higher in biopsy segments with MTBC DNA co-detected (p=0.011) and strongly correlated with VL (r=0.91; p=0.0003). Interpretation ddPCR has high sensitivity for Mtb and HIV-1 DNA quantification in STB biopsies. Mtb tissue abundance correlated with localised but not systemic HIV-1 abundance. Increased HIV-1 DNA detection at sites co-localised with Mtb supports further investigating the TB microenvironment as a site for HIV-1 reservoir persistence and expansion in PLWH on ART. Funding Wellcome (203135Z/16/Z); Academy of Science of SA (ASSAf); ORU, UCT; UCT Merit Award. Contacts Anna Coussens, Walter and Eliza Hall Institute of Medical Research (WEHI), 1G Royal Parade, Parkville, 3052, Australia; Tel: +61 3 39452699; Email: coussens.a{at}wehi.edu.au Robyn Waters, Division of Orthopaedic Surgery, University of Cape Town, Anzio Rd, Observatory, 7925, South Africa; Email: robyn.waters{at}uct.ac.za ### Competing Interest Statement The authors have declared no competing interest.

Background Diagnostic specimens for spinal tuberculosis (STB) are mostly collected via open surgery. Percutaneous computed tomography (CT)-guided biopsies are used in times of limited surgical availability. However, poor diagnostic accuracy of Mycobacterium tuberculosis (Mtb) culture has been reported with this method, due to limited sample volume and the paucibacillary nature of STB. We evaluated Xpert MTB/RIF Ultra on open and CT-guided biopsies as compared with the gold standard Mtb culture and histopathology.Methods We conducted a prospective diagnostic accuracy study of Xpert Ultra, as compared with tuberculosis culture and histopathology, in adults with signs and symptoms of STB at a tertiary academic hospital in South Africa from November 2020 to December 2021. Diagnostic testing was performed on 31 patients with available samples.Results Xpert Ultra had a sensitivity of 94.7% (95% CI, 75.3%-99.7%) and specificity of 100% (95% CI, 75.7%-100.0%) against a reference standard of Mtb culture and histopathology. Xpert Ultra had high diagnostic accuracy in open and CT-guided biopsy samples with sensitivity and specificity of 100% and 100% (open) and 89% and 100% (CT), respectively. Mtb culture had limited specificity for CT-guided biopsies (43%; 95% CI, 15.8%-74.9%). HIV-1 coinfection did not affect Mtb abundance measures by Xpert Ultra or culture. Xpert Ultra was also superior to culture for STB diagnosis in patients concurrently treated for pulmonary tuberculosis.Conclusions Xpert Ultra detected more STB cases than culture for CT-guided biopsy samples. There was also no difference in sensitivity for open biopsies, irrespective of HIV-1 status, making it an important tool for rapid diagnosis, especially during times or in locations where open surgery is not possible or concurrent pulmonary tuberculosis treatment is initiated. Xpert MTB/RIF Ultra has a high diagnostic accuracy for spinal tuberculosis in both open and CT-guided biopsy samples, irrespective of HIV-1 coinfection, while tuberculosis culture has limited sensitivity when using CT-guided biopsies, particularly in patients on concurrent pulmonary tuberculosis treatment.

Specific and rapid detection methods for spinal tuberculosis, with sufficient sensitivity in HIV-1 co-infected individuals, are needed, to ensure early initiation of appropriate treatment to prevent physical disability and neurological fallout. In addition, understanding the systemic and local pathophysiology of spinal tuberculosis, and its interaction with HIV-1 infection, is crucial to guide future therapeutic interventions. We prospectively enrolled adult patients presenting with signs and symptoms of suspected spinal tuberculosis, at Groote Schuur Hospital, between November 2020 and December 2021. TB diagnostic testing was performed on open and CT-guided spinal biopsies using Xpert MTB/RIF Ultra compared to gold standards TB culture and histology. A highly sensitive droplet digital PCR assay for detecting and quantifying Mycobacterium tuberculosis complex (MTBC) and HIV-1 DNA was tested. Plasma inflammatory proteins were measured to assess systemic inflammation. Xpert Ultra had a high sensitivity of 94.7% and specificity of 100% for STB against TB culture and histology in both open and CT-guided biopsy samples. The ddPCR assay confirmed TB detection in 94% of patients with positive Xpert Ultra results. Four patients with negative TB diagnostic results had MTBC DNA detected by ddPCR. HIV-1 DNA was detected in the spinal tissues from all HIV-1-infected patients. MTBC DNA levels were significantly higher in HIV-1-co-infected spinal tissue samples (p< 0.01). We identified four biomarkers significantly associated with higher bacterial burden at the disease site (p< 0.01). Xpert Ultra and MTBC ddPCR improve the detection of STB. DdPCR can be utilized as an additional, highly sensitive tool for detecting and quantifying Mtb, in pathological samples that may be paucibacillary. These findings provide novel diagnostic and pathophysiologic insight into STB, in the context of HIV-1 infection, and provide rationale to include these tests in hospital and research settings for patients from communities burdened by TB and HIV-1.

SARS-CoV-2 and Mycobacterium tuberculosis ( Mtb ) are major infectious causes of death, with meta-analyses and population-based studies finding increased mortality in co-infected patients simultaneously diagnosed with COVID-19 and tuberculosis (TB). There is a need to understand the immune interaction between SARS-CoV-2 and Mtb which impacts poor outcomes for those co-infected. We performed a PubMed and preprint search using keywords [SARS-CoV-2] AND [tuberculosis] AND [Immune response], including publications after January 2020, excluding reviews or opinions. Abstracts were evaluated by authors for inclusion of data specifically investigating the innate and/or acquired immune responses to SARS-CoV-2 and Mtb in humans and animal models, immunopathological responses in co-infection and both trials and investigations of potential protection against SARS-CoV-2 by Bacille Calmette Guérin (BCG). Of the 248 articles identified, 39 were included. Incidence of co-infection is discussed, considering in areas with a high burden of TB, where reported co-infection is likely underestimated. We evaluated evidence of the clinical association between COVID-19 and TB, discuss differences and similarities in immune responses in humans and in murine studies, and the implications of co-infection. SARS-CoV-2 and Mtb have both been shown to modulate immune responses, particularly of monocytes, macrophages, neutrophils, and T cells. Co-infection may result in impaired immunity to SARS-CoV-2, with an exacerbated inflammatory response, while T cell responses to Mtb may be modulated by SARS-CoV-2. Furthermore, there has been no proven potential COVID-19 clinical benefit of BCG despite numerous large-scale clinical trials.

Background. The COVID-19 pandemic has impacted on the global surgery landscape. Objectives. To analyse and describe the initial impact of the COVID-19 pandemic on orthopaedic surgery at Groote Schuur Hospital, a tertiary academic hospital in South Africa. Methods. The number of orthopaedic surgical cases, emergency theatre patient waiting times, and numbers of outpatient clinic visits, ward admissions, bed occupancies and total inpatient days for January - April 2019 (pre-COVID-19) were compared with the same time frame in 2020 (COVID-19). The COVID-19 timeframe included initiation of a national 'hard lockdown' from 26 March 2020, in preparation for an increasing volume of COVID-19 cases. Results. April 2020, the time of the imposed hard lockdown, was the most affected month, although the number of surgical cases had started to decrease slowly during the 3 preceding months. The total number of surgeries, outpatient visits and ward admissions decreased significantly during April 2020 (55.2%, 69.1% and 60.6%, respectively) compared with April 2019 (p<0.05). Trauma cases were reduced by 40% in April 2020. Overall emergency theatre patient waiting time was 30% lower for April 2020 compared with 2019. Conclusions. COVID-19 and the associated lockdown has heavily impacted on both orthopaedic inpatient and outpatient services. Lockdown led to a larger reduction in the orthopaedic trauma burden than in international centres, but the overall reduction in surgeries, outpatient visits and hospital admissions was less. This lesser reduction was probably due to local factors, but also to a conscious decision to avoid total collapse of our surgical services.

BACKGROUND:Initial local and global evidence suggests that SARS-CoV-2-infected patients who undergo surgery, and those who become infected perioperatively, have an increased mortality risk post surgery. OBJECTIVES:To analyse and describe the 30-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection rates of patients, both SARS-CoV-2-positive and negative, undergoing orthopaedic surgery at a tertiary academic hospital in South Africa (SA) during the first COVID-19 peak. METHODS:This single-centre, observational, prospective study included patients who underwent orthopaedic procedures from 1 April 2020 (beginning of the COVID-19 case increase in SA) to 31 July 2020 (first COVID-19 peak in SA). All patients were screened for COVID-19 and were confirmed positive if they had a positive laboratory quantitative polymerase chain reaction test for SARS-CoV-2 RNA on a nasopharyngeal or oral swab. Thirty-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection were assessed. RESULTS:Overall, a total of 433 operations were performed on 346 patients during the timeframe. Of these patients, 65.9% (n=228) were male and 34.1% (n=118) were female. The mean (standard deviation) age was 42.5 (16.8) years (range 9 - 89). Of the patients, 5 (1.4%) were identified as COVID-19 patients under investigation (PUI) on admission and tested positive for SARS-CoV-2 before surgery, and 1 (0.3%) contracted SARS-CoV-2 perioperatively; all survived 30 days post surgery. Twenty-nine patients were lost to follow-up, and data were missing for 6 patients. The final analysis was performed excluding these 35 patients. Of the 311 patients included in the final 30-day mortality analysis, 303 (97%) had a follow-up observation ≥30 days after the operation. The overall 30-day mortality for these patients was 2.5% (n=8 deaths). None of the recorded deaths were of screened COVID-19 PUI. CONCLUSIONS:We report a low 30-day mortality rate of 2.5% (n=8) for patients undergoing orthopaedic surgery at our hospital during the first COVID-19 peak. None of the deaths were COVID-19 related, and all patients who tested SARS-CoV-2-positive, before or after surgery, survived. Our overall 30-day mortality rate correlates with several other reports of orthopaedic centres analysing over similar timeframes during the first peak of the COVID-19 pandemic. Regarding mortality and SARS-CoV-2 infection risk, we can conclude that with the appropriate measures taken, it was safe to undergo orthopaedic procedures at our hospital during the first peak of the COVID-19 pandemic in SA.

Accelerated tuberculosis and AIDS progression seen in HIV-1 and Mycobacterium tuberculosis ( Mtb)-coinfected individuals indicates the important interaction between these syndemic pathogens. The immunological interaction between HIV-1 and Mtb has been largely defined by how the virus exacerbates tuberculosis disease pathogenesis. Understanding of the mechanisms by which pre-existing or subsequent Mtb infection may favor the replication, persistence and progression of HIV, is less characterized. We present a rationale for the critical consideration of ‘latent’ Mtb infection in HIV-1 prevention and cure strategies. In support of this position, we review evidence of the effect of Mtb infection on HIV-1 acquisition, replication and persistence. We propose that ‘latent’ Mtb infection may have considerable impact on HIV-1 pathogenesis and the continuing HIV-1 epidemic in sub-Saharan Africa.