• Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a systematic review and meta-analysis

      Chacko, Liza; Ford, Nathan; Sbaiti, Mariam; Siddiqui, Ruby; Imperial College London, St Mary's Hospital, London, UK; Médecins Sans Frontières, Doctors without Borders (MSF-UK), London, UK; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa (BMJ Publishing Group, 2012-02-13)
      ObjectiveTo assess adherence to post-exposure prophylaxis (PEP) for the prevention of HIV infection in victims of sexual assault.MethodsThe authors carried out a systematic review, random effects meta-analysis and meta-regression of studies reporting adherence to PEP among victims of sexual violence. Seven electronic databases were searched. Our primary outcome was adherence; secondary outcomes included defaulting, refusal and side effects.Results2159 titles were screened, and 24 studies matching the inclusion criteria were taken through to analysis. The overall proportion of patients adhering to PEP (23 cohort studies, 2166 patients) was 40.3% (95% CI 32.5% to 48.1%), and the overall proportion of patients defaulting from care (18 cohorts, 1972 patients) was 41.2% (95% CI 31.1% to 51.4%). Adherence appeared to be higher in developing countries compared with developed countries.ConclusionsAdherence to PEP is poor in all settings. Interventions are needed to support adherence.
    • The aftermath of Cyclone Idai—building bridges where we can

      Frieden, M (BMJ Publishing Group, 2019-04-03)
      Marthe Frieden is the medical team leader in MSF’s emergency response to the destruction caused by tropical Cyclone Idai. On the night of 15 March, the cyclone hit Zimbabwe’s mountainous Manicaland province, causing flooding and deadly landslides, particularly in the Chimanimani District. Before Idai hit, Marthe was working on an MSF pilot project for managing diabetes and hypertension in the nearby Chipinge District, in partnership with Zimbabwe’s health ministry. Writing from the worst hit districts of Chimanimani and Chipinge, Marthe describes the events of the first six days as an MSF team of 10 people rapidly switched from their regular activities to emergency mode.
    • Anthropology in public health emergencies:what is anthropology good for?

      Stellmach, D; Beshar, I; Bedford, J; du Cros, P; Stringer, B (BMJ Publishing Group, 2018-03-25)
      Recent outbreaks of Ebola virus disease (2013-2016) and Zika virus (2015-2016) bring renewed recognition of the need to understand social pathways of disease transmission and barriers to care. Social scientists, anthropologists in particular, have been recognised as important players in disease outbreak response because of their ability to assess social, economic and political factors in local contexts. However, in emergency public health response, as with any interdisciplinary setting, different professions may disagree over methods, ethics and the nature of evidence itself. A disease outbreak is no place to begin to negotiate disciplinary differences. Given increasing demand for anthropologists to work alongside epidemiologists, clinicians and public health professionals in health crises, this paper gives a basic introduction to anthropological methods and seeks to bridge the gap in disciplinary expectations within emergencies. It asks: 'What can anthropologists do in a public health crisis and how do they do it?' It argues for an interdisciplinary conception of emergency and the recognition that social, psychological and institutional factors influence all aspects of care.
    • The availability of global guidance for the promotion of women’s, newborns’, children’s and adolescents’ health and nutrition in conflicts

      Aboubaker, S; Evers, ES; Kobeissi, L; Francis, L; Najjemba, R; Miller, NP; Wall, S; Martinez, D; Vargas, J; Ashorn, P; et al. (BMJ Publishing Group, 2020-11-01)
      Background Significant global gains in sexual, reproductive, maternal, newborn, child and adolescent health and nutrition (SRMNCAH&N) will be difficult unless conflict settings are adequately addressed. We aimed to determine the amount, scope and quality of publically available guidance documents, to characterise the process by which agencies develop their guidance and to identify gaps in guidance on SRMNCAH&N promotion in conflicts. Methods We identified guidance documents published between 2008 and 2018 through English-language Internet sites of humanitarian response organisations, reviewed them for their scope and assessed their quality with the AGREE II (Appraisal of Guidelines for REsearch and Evaluation II) tool. Additionally, we interviewed 22 key informants on guidance development, dissemination processes, perceived guidance gaps and applicability. Findings We identified 105 conflict-relevant guidance documents from 75 organisations. Of these, nine were specific to conflicts, others were applicable also to other humanitarian settings. Fifteen documents were technical normative guidelines, others were operational guides (67), descriptive documents (21) or advice on legal, human rights or ethics questions (2). Nutrition was the most addressed health topic, followed by communicable diseases and violence. The documents rated high quality in their ‘scope and purpose’ and ‘clarity of presentation’ and low for ‘rigour of development’ and ‘editorial independence’. Key informants reported end user need as the primary driver for guideline development and WHO technical guidelines as their main evidence base. Insufficient local contextualisation, lack of inter-agency coordination and lack of systematic implementation were considered problems in guideline development. Several guidance gaps were noted, including abortion care, newborn care, early child development, mental health, adolescent health beyond sexual and reproductive health and non-communicable diseases. Interpretation Organisations are motivated and actively producing guidance for SRMNCAH&N promotion in humanitarian settings, but few documents address conflicts specifically and there are important guidance gaps. Improved inter-organisation collaboration for guidance on SRMNCAH&N promotion in conflicts and other humanitarian settings is needed.
    • Beyond Open Data: Realising the Health Benefits of Sharing Data

      Pisani, E; Aaby, P; Breugelmans, JG; Carr, D; Groves, T; Helinski, M; Kamuya, D; Kern, S; Littler, K; Marsh, V; et al. (BMJ Publishing Group, 2016-10-10)
    • Bridging research integrity and global health epidemiology (BRIDGE) guidelines: explanation and elaboration

      Alba, S; Lenglet, A; Verdonck, K; Roth, J; Patil, R; Mendoza, W; Juvekar, S; Rumisha, SF (BMJ Publishing Group, 2020-10-28)
      Over the past decade, two movements have profoundly changed the environment in which global health epidemiologists work: research integrity and research fairness. Both ought to be equally nurtured by global health epidemiologists who aim to produce high quality impactful research. Yet bridging between these two aspirations can lead to practical and ethical dilemmas. In the light of these reflections we have proposed the BRIDGE guidelines for the conduct of fair global health epidemiology, targeted at stakeholders involved in the commissioning, conduct, appraisal and publication of global health research. The guidelines follow the conduct of a study chronologically from the early stages of study preparation until the dissemination and communication of findings. They can be used as a checklist by research teams, funders and other stakeholders to ensure that a study is conducted in line with both research integrity and research fairness principles. In this paper we offer a detailed explanation for each item of the BRIDGE guidelines. We have focused on practical implementation issues, making this document most of interest to those who are actually conducting the epidemiological work.
    • Bridging research integrity and global health epidemiology (BRIDGE) statement: guidelines for good epidemiological practice

      Alba, S; Verdonck, K; Lenglet, A; Rumisha, SF; Wienia, M; Teunissen, I; Straetemans, M; Mendoza, W; Jeannetot, D; Weibel, D; et al. (BMJ Publishing Group, 2020-10-28)
      Background Research integrity and research fairness have gained considerable momentum in the past decade and have direct implications for global health epidemiology. Research integrity and research fairness principles should be equally nurtured to produce high-quality impactful research—but bridging the two can lead to practical and ethical dilemmas. In order to provide practical guidance to researchers and epidemiologist, we set out to develop good epidemiological practice guidelines specifically for global health epidemiology, targeted at stakeholders involved in the commissioning, conduct, appraisal and publication of global health research. Methods We developed preliminary guidelines based on targeted online searches on existing best practices for epidemiological studies and sought to align these with key elements of global health research and research fairness. We validated these guidelines through a Delphi consultation study, to reach a consensus among a wide representation of stakeholders. Results A total of 45 experts provided input on the first round of e-Delphi consultation and 40 in the second. Respondents covered a range of organisations (including for example academia, ministries, NGOs, research funders, technical agencies) involved in epidemiological studies from countries around the world (Europe: 19; Africa: 10; North America: 7; Asia: 5; South-America: 3 Australia: 1). A selection of eight experts were invited for a face-to-face meeting. The final guidelines consist of a set of 6 standards and 42 accompanying criteria including study preparation, protocol development, data collection, data management, data analysis, dissemination and communication. Conclusion While guidelines will not by themselves guard global health from questionable and unfair research practices, they are certainly part of a concerted effort to ensure not only mutual accountability between individual researchers, their institutions and their funders but most importantly their joint accountability towards the communities they study and society at large.
    • Congo’s Ebola epidemic—a failed response and the need for a reset

      Huster, K; Healy, J (BMJ Publishing Group, 2019-05-24)
    • Cost and cost-effectiveness of a real-world HCV treatment program among HIV-infected individuals in Myanmar.

      Marquez, LK; Chaillon, A; Soe, KP; Johnson, DC; Zosso, JM; Incerti, A; Loarec, A; Nguyen, A; Walker, JG; Mafirakureva, N; et al. (BMJ Publishing Group, 2021-02-01)
      Introduction: Over half of those hepatitis C virus (HCV)/HIV coinfected live in low-income and middle-income countries, and many remain undiagnosed or untreated. In 2016, Médecins Sans Frontières (MSF) established a direct-acting antiviral (DAA) treatment programme for people HCV/HIV coinfected in Myanmar. The purpose of our study was to evaluate the real-world cost and cost-effectiveness of this programme, and potential cost-effectiveness if implemented by the Ministry of Health (MoH). Methods: Costs (patient-level microcosting) and treatment outcomes were collected from the MSF prospective cohort study in Dawei, Myanmar. A Markov model was used to assess cost-effectiveness of the programme compared with no HCV treatment from a health provider perspective. Estimated lifetime and healthcare costs (in 2017 US$) and health outcomes (in disability-adjusted life-years (DALYs)) were simulated to calculate the incremental cost-effectiveness ratio (ICER), compared with a willingness-to-pay threshold of per capita Gross Domestic Product in Myanmar ($1250). We evaluated cost-effectiveness with updated quality-assured generic DAA prices and potential cost-effectiveness of a proposed simplified treatment protocol with updated DAA prices if implemented by the MoH. Results: From November 2016 to October 2017, 122 with HIV/HCV-coinfected patients were treated with DAAs (46% with cirrhosis), 96% (n=117) achieved sustained virological response. Mean treatment costs were $1229 (without cirrhosis) and $1971 (with cirrhosis), with DAA drugs being the largest contributor to cost. Compared with no treatment, the program was cost-effective (ICER $634/DALY averted); more so with updated prices for quality-assured generic DAAs (ICER $488/DALY averted). A simplified treatment protocol delivered by the MoH could be cost-effective if associated with similar outcomes (ICER $316/DALY averted). Conclusions: Using MSF programme data, the DAA treatment programme for HCV among HIV-coinfected individuals is cost-effective in Myanmar, and even more so with updated DAA prices. A simplified treatment protocol could enhance cost-effectiveness if further rollout demonstrates it is not associated with worse treatment outcomes.
    • Cost-effectiveness of new MDR-TB regimens: study protocol for the TB-PRACTECAL economic evaluation substudy.

      Sweeney, S; Gomez, G; Kitson, N; Sinha, A; Yatskevich, N; Staples, S; Moodliar, R; Motlhako, S; Maloma, M; Rassool, M; et al. (BMJ Publishing Group, 2020-10-10)
      Introduction: Current treatment regimens for multidrug-resistant tuberculosis (MDR-TB) are long, poorly tolerated and have poor outcomes. Furthermore, the costs of treating MDR-TB are much greater than those for treating drug-susceptible TB, both for health service and patient-incurred costs. Urgent action is needed to identify short, effective, tolerable and cheaper treatments for people with both quinolone-susceptible and quinolone-resistant MDR-TB. We present the protocol for an economic evaluation (PRACTECAL-EE substudy) alongside an ongoing clinical trial (TB-PRACTECAL) aiming to assess the costs to patients and providers of new regimens, as well as their cost-effectiveness and impact on participant poverty levels. This substudy is based on data from the three countries participating in the main trial. Methods and analysis: Primary cost data will be collected from the provider and patient perspectives, following economic best practice. We will estimate the probability that new MDR-TB regimens containing bedaquiline, pretomanid and linezolid are cost-effective from a societal perspective as compared with the standard of care for MDR-TB patients in Uzbekistan, South Africa and Belarus. Analysis uses a Markov model populated with primary cost and outcome data collected at each study site. We will also estimate the impact of new regimens on prevalence of catastrophic patient costs due to TB. Ethics and dissemination: Ethical approval has been obtained from the London School of Hygiene & Tropical Medicine and Médecins Sans Frontières. Local ethical approval will be sought in each study site. The results of the economic evaluation will be shared with the country health authorities and published in a peer-reviewed journal.
    • Diagnostics for filovirus detection: impact of recent outbreaks on the diagnostic landscape

      Emperador DM; Mazzola LT; Trainor BW; Chua A; Kelly-Cirino C (BMJ Publishing Group, 2019-02-07)
      Ebolaviruses and Marburg virus (MARV) both belong to the family Filoviridae and cause severe haemorrhagic fever in humans. Due to high mortality rates and potential for spread from rural to urban regions, they are listed on the WHO R&D blueprint of high-priority pathogens. Recent ebolavirus outbreaks in Western and Central Africa have highlighted the importance of diagnostic testing in epidemic preparedness for these pathogens and led to the rapid development of a number of commercially available benchtop and point-of-care nucleic acid amplification tests as well as serological assays and rapid diagnostic tests. Despite these advancements, challenges still remain. While products approved under emergency use licenses during outbreak periods may continue to be used post-outbreak, a lack of clarity and incentive surrounding the regulatory approval pathway during non-outbreak periods has deterred many manufacturers from seeking full approvals. Waning of funding and poor access to samples after the 2014–2016 outbreak also contributed to cessation of development once the outbreak was declared over. There is a need for tests with improved sensitivity and specificity, and assays that can use alternative sample types could reduce the need for invasive procedures and expensive equipment, making testing in field conditions more feasible. For MARV, availability of diagnostic tests is still limited, restricted to a single ELISA test and assay panels designed to differentiate between multiple pathogens. It may be helpful to extend the target product profile for ebolavirus diagnostics to include MARV, as the viruses have many overlapping characteristics.
    • Dual Screen and Confirm Rapid Test Does Not Reduce Overtreatment of Syphilis in Pregnant Women Living in a Non-venereal treponematoses Endemic Region: a Field Evaluation Among Antenatal Care Attendees in Burkina Faso

      Langendorf, C; Lastrucci, C; Sanou-Bicaba, I; Blackburn, K; Koudika, MH; Crucitti, T (BMJ Publishing Group, 2018-12-22)
      In resource-limited settings, screening pregnant women for syphilis using rapid diagnostic tests (RDTs) is a key tool in the prevention of congenital syphilis. However, most syphilis RDTs detect only treponemal antibodies (T-RDT), meaning antibiotics may be provided unnecessarily to previously treated pregnant women, particularly in non-venereal treponematoses endemic regions. We estimated the potential reduction in overtreatment when comparing T-RDT (SD Bioline) to a newer rapid test (Dual Path Platform (DPP) Screen and Confirm Assay, Chembio) detecting both treponemal and non-treponemal antibodies.
    • Dual screen and confirm rapid test does not reduce overtreatment of syphilis in pregnant women living in a non-venereal treponematoses endemic region: a field evaluation among antenatal care attendees in Burkina Faso.

      Langendorf, C; Lastrucci, C; Sanou-Bicaba, I; Blackburn, K; Koudika, MH; Crucitti, T (BMJ Publishing Group, 2019-09-01)
      OBJECTIVES: In resource-limited settings, screening pregnant women for syphilis using rapid diagnostic tests (RDTs) is a key tool in the prevention of congenital syphilis. However, most syphilis RDTs detect only treponemal antibodies (T-RDT), meaning antibiotics may be provided unnecessarily to previously treated pregnant women, particularly in non-venereal treponematoses endemic regions. We estimated the potential reduction in overtreatment when comparing T-RDT (SD Bioline) to a newer rapid test (Dual Path Platform (DPP) Screen and Confirm Assay, Chembio) detecting both treponemal and non-treponemal antibodies. METHODS: Pregnant women in Déou, Burkina Faso, screened for syphilis during antenatal care (ANC) visits were prospectively enrolled in the study after providing consent. DPP and T-RDT tests were performed on whole blood specimens. Plasma was tested in an international reference laboratory by Treponema pallidum passive particle agglutination (TPPA) and quantitative rapid plasma reagin (RPR). Presumptive active syphilis was defined as a result that was both TPPA and RPR reactive. RESULTS: Of the 242 pregnant women included in the study, 91 (37.6%) had presumptive active syphilis and 19.0% had RPR titres ≥8. DPP testing did not reduce the number of pregnant women who would have been overtreated compared with T-RDT (0.0% vs 2.5%; p=0.218) and had a higher proportion of underdiagnosis (48.4% vs 2.2%; p<0.001). Seven women with high RPR titres ≥8 would not have received treatment had only DPP testing been used. CONCLUSION: In the first evaluation comparing DPP with traditional screening methods in pregnant women, we saw no reduction in unnecessarily treated syphilis and an underestimation of those needing treatment. High seroprevalence in the population may indicate the presence of other treponemal infections in the area, and further study of DPP in a variety of Sahelian and other contexts is warranted.
    • Duty of care and health worker protections in the age of Ebola: lessons from Médecins Sans Frontières

      McDiarmid, M; Crestani, R (BMJ Publishing Group, 2019-08-31)
      Health workers were differentially infected during the 2014 to 2016 Ebola outbreak with an incidence rate of 30 to 44/1000 depending on their job duties, compared to the wider population’s rate of 1.4/1000, according to the WHO. Médecins Sans Frontières (MSF) health workers had a much lower incidence rate of 4.3/1000, explained as the result of MSF’s ‘duty of care’ toward staff safety. Duty of care is defined as an obligation to conform to certain standards of conduct for the protection of others against an unreasonable risk of harm. The duty of care was operationalised through four actions: performing risk assessments prior to deployment, organising work and work practices to minimise exposure, providing extensive risk communication and training of staff and providing medical follow-up for staff exposures. Adopting and consistently enforcing these broader, duty of care safety policies in deployed teams augments and fortifies standard infection prevention practices, creating a more protective, comprehensive safety programme. Prioritising staff safety by taking such actions will help avoid the catastrophic loss of the health work force and assist in building resilient health systems.
    • The Ebola Clinical Trials: a Precedent for Research Ethics in Disasters

      Calain, P (BMJ Publishing Group, 2016-08-29)
      The West African Ebola epidemic has set in motion a collective endeavour to conduct accelerated clinical trials, testing unproven but potentially lifesaving interventions in the course of a major public health crisis. This unprecedented effort was supported by the recommendations of an ad hoc ethics panel convened in August 2014 by the WHO. By considering why and on what conditions the exceptional circumstances of the Ebola epidemic justified the use of unproven interventions, the panel's recommendations have challenged conventional thinking about therapeutic development and clinical research ethics. At the same time, unanswered ethical questions have emerged, in particular: (i) the specification of exceptional circumstances, (ii) the specification of unproven interventions, (iii) the goals of interventional research in terms of individual versus collective interests, (iv) the place of adaptive trial designs and (v) the exact meaning of compassionate use with unapproved interventions. Examination of these questions, in parallel with empirical data from research sites, will help build pragmatic foundations for disaster research ethics. Furthermore, the Ebola clinical trials signal an evolution in the current paradigms of therapeutic research, beyond the case of epidemic emergencies.
    • Effect of Community ART Groups on Retention-In-Care Among Patients on ART in Tete Province, Mozambique: A Cohort Study

      Decroo, T; Telfer, B; Dores, C; White, R; Santos, N; Mkwamba, A; Dezembro, S; Joffrisse, M; Ellman, T; Metcalf, C (BMJ Publishing Group, 2017-08-11)
      Estimate the effect of participation in Community ART Groups (CAG) versus individual care on retention-in-care (RIC) on antiretroviral therapy (ART).
    • Europe’s migrant containment policies threaten the response to covid-19

      Hargreaves, S; McKee, M; Jones, L; Veizis, A (BMJ Publishing Group, 2020-03-26)
    • Exploring global and country-level barriers to an effective supply of leishmaniasis medicines and diagnostics in eastern Africa: a qualitative study.

      Sunyoto, T; Potet, J; den Boer, M; Ritmeijer, K; Postigo, JAR; Ravinetto, R; Alves, F; Picado, A; Boelaert, M (BMJ Publishing Group, 2019-05-30)
      OBJECTIVES: To understand stakeholders' perceptions of the access barriers to quality-assured diagnostics and medicines for leishmaniasis in the high-burden region of eastern Africa, and to identify key bottlenecks to improve the supply of commodities for neglected tropical diseases. DESIGN: Desk reviews and qualitative in-depth interview study with purposive sampling. METHODS: A landscape analysis through literature and desk review was performed. Next, 29 representatives from international organisations, non-governmental agencies, national control programmes from six countries (Ethiopia, Kenya, Somalia, South Sudan, Sudan and Uganda) and manufacturers were interviewed between May and July 2018. Participants were selected purposively and expanded through a snowballing technique.Data analysis was aided by NVivo, applying the framework method as a part of the thematic content analysis approach. RESULTS: The barriers along the visceral leishmaniasis (VL) supply chain were identified as emerging themes, grouped across supply chain activities and health systems component(s). Stakeholders expressed the perception of progress, but bottlenecks persist. VL medicines, in general, lack multisource production capacity and with small market volume, expansion of suppliers is difficult. Procurement is plagued by forecasting difficulties, complex regulatory policies and procedures, and distribution challenges. Weak communication and coordination across different levels resulted in shortages and loss of trust among different actors. Cross-cutting issues spanned from limited political and resource commitment due to low awareness and limited in-country capacity. However, study respondents were optimistic to pursue several remedies, most importantly to build bridges between supply and demand sides through continued dialogue and collaborations. Diagnostics supply has mostly been overlooked; thus, improved investment in this area is needed. CONCLUSIONS: Addressing supply barriers in eastern Africa requires consistent, specific efforts at the global and national levels, progressing from current partnerships and agreements. Priority actions include pooled procurement, improved forecast, and increased commitment and resources. Sustainability remains an elusive goal, yet to be integrated into discussions moving forward.
    • Eye exam with indirect ophthalmoscopy for diagnosis of disseminated tuberculosis in patients with HIV/AIDS

      Heiden, David; Margolis, Todd P; Lowinger, Alan; Saranchuk, Peter (BMJ Publishing Group, 2013-05-01)