Fertility desire and family-planning demand among HIV-positive women and men undergoing antiretroviral treatment in Addis Ababa,Ethiopia

Little information exists about desire to have children and family-planning use among HIV-positive individuals and how this may vary according to individual, social, health and demographic characteristics, especially in developing countries. To assess these topics in Ethiopia, a facility-based cross-sectional study was undertaken among 460 HIV-positive individuals receiving follow-up care at antiretroviral treatment (ART) centres in six public hospitals in Addis Ababa in 2006. One hundred and nine of the women (44.7%), 76 of the men (35.2%), and 40.2% overall of the HIV-positive individuals receiving care desired to have children. In comparison to those who said they did not desire to have children, those who did desire children tended to be younger (18–29 years) (adjusted odds ratio [OR]: 3.05, 95% CI: 1.5–6.4), married or in a relationship (adjusted OR: 3.4, 95% CI: 2.1–5.6), without a child (adjusted OR: 11.5, 95% CI: 5.3–24.9), and with a partner who also desired to have children (adjusted OR: 38.7, 95% CI: 16.7–89.1). Two hundred and forty-six individuals (53.5%) were using family planning (e.g. condoms, abstinence, injectables) and 85 wanted to use family planning in the future. The fertility desire and family-planning needs of these ART clients have implications for preventing vertical and heterosexual transmission of HIV, and the need for appropriate counselling and delivery of services.     

Health Service Use and Quality of Life Recovery 12 Months Following Major Osteoporotic Fracture: Latent Class Analyses of the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)

Major osteoporotic fractures (MOFs) are associated with a rapid decline in health-related quality of life (HRQoL); however, there is limited knowledge about which healthcare services positively affect HRQoL postfracture. This study aimed to identify specific combinations of health service use associated with recovery of HRQoL 12 months post-MOF. The analyses included 4126 adults aged ≥50 years with an MOF (1657 hip, 1354 distal forearm, 681 vertebrae, 434 humerus) participating in the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS), a multinational observational study (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, United Kingdom, and United States). HRQoL at prefracture and 12 months postfracture was measured using the EuroQoL questionnaire (EQ-5D-3L). Health service use data were collected via participant interviews and medical record reviews including in-hospital care; outpatient care; community services; and medication use. Data analyses involved two stages: (i) latent class analyses to identify different combinations of health service use (“classes”); and (ii) logistic regression to assess effects of classes on HRQoL recovery. Analyses were repeated excluding hip fractures (non-hip MOFs). Overall, 2057 MOF participants (49.9%) recovered to their prefracture HRQoL at 12-month follow-up; this proportion was higher for non-hip MOFs (n = 1439; 58.3%). Several distinct classes were identified across countries (range, 2–5 classes). Classes that were associated with increased odds of HRQoL recovery were characterized by a combination of hospital presentations without admission; outpatient department visits; allied health visits; vitamin D/calcium supplementation; and/or non-opioid analgesic use. Similar classes were observed for non-hip MOFs. Understanding country-specific healthcare service pathways that influence greater recovery of HRQoL, particularly services that are uncommon in some countries and routine in others, could improve postfracture care on a global scale. © 2020 American Society for Bone and Mineral Research (ASBMR).     

Community approaches to preventing mother-to-child HIV transmission: perspectives from rural Lesotho

This paper examines the cultural and structural difficulties surrounding effective prevention of mother-to-child HIV transmission (PMTCT) in rural Lesotho. We argue for three strategies to improve PMTCT interventions: community-based research and outreach, addressing cultural and structural dynamics, and working with the relevant social groups that impact HIV prevention. These conclusions are based on interviews and participant observation conducted within the rural Mokhotlong district and capital city of Maseru, involving women and men of reproductive age, grandmothers serving as primary caretakers, HIV/AIDS programme staff, and medical professionals. Qualitative analysis focused on rural women's socio-medical experience with the four measures of PMTCT (educational outreach, voluntary counselling and testing, antiretroviral interventions, and safe infant feeding). Based on these results, we conclude that intervention models must move beyond a myopic biomedical 'best-practices' approach to address the social groups and contextual determinants impacting vertical HIV transmission. Given the complexities of effective PMTCT, our results show that it is necessary to consider the biomedical system, women and children, and the community as valuable partners in achieving positive health outcomes.     

Bone Fractures in Children and Young Adults With Type 1 Diabetes: Age Distribution,Fracture Location,and the Role of Glycemic Control

Type 1 diabetes (T1D) is a known risk factor for fractures, but the underlying pathophysiology is still not fully understood. This study aims to define age peaks and frequent fracture sites of children and young adults with T1D. Additionally, associations of fractures with metabolic and lifestyle factors as well as with additional complications in individuals with T1D were analyzed. A total of 750 individuals with T1D aged ≤25 years with fractures were matched to 3750 patients with T1D without fractures by demographics and insulin regimen. Hemoglobin A1c (HbA1c) values were compared using linear regression, and logistic regression was used to calculate odds ratios (OR) for fractures in individuals with acute complications and diseases. Median (Q1–Q3) age was 12.7 (9.9 to 14.9) years in individuals with fractures and 16.3 (12.6 to 17.8) years in the entire control group with 65% versus 53% males. Peak age for fractures was 7 to <15 years in males and 9 to <11 years in females, which is earlier than reported for the general population. HbA1c (%) was significantly higher in individuals with fractures than in controls (difference of estimated means: 0.26%; 95% confidence interval [CI] 0.07–0.46), especially in postpubertal females (0.68; 0.10–1.26). Significantly higher odds for fractures were observed in individuals with severe hypoglycemia (OR = 1.90; 95% CI 1.47–2.47), especially in prepubertal females (OR = 2.81; 1.21–6.52]) and postpubertal males (2.44; 1.11–5.38), celiac disease (2.02; 1.67–2.45), and with a history of smoking (1.38; 1.02–1.88). The age peak of fractures seems to be earlier in T1D than in the general population. Poor glycemic control is related to fractures, even before puberty. Associations of HbA1c and severe hypoglycemia with fractures highly depend on age and sex. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).     

Cost‐effectiveness of alendronate for the treatment of osteopenic postmenopausal women in Japan

Many postmenopausal women have osteopenia, a condition characterized by loss of bone mineral density (BMD) that is not as severe as in osteoporosis. The objective of this study was to estimate the cost‐effectiveness of alendronate to prevent fractures in osteopenic postmenopausal women without a history of fracture in Japan. An individual simulation model was developed to predict lifetime costs and quality‐adjusted life years (QALYs) of 5 years of preventive alendronate therapy versus no preventive therapy. The risk of hip and vertebral fracture associated with age and BMD was derived from epidemiologic studies in Japan. We ran the model with different combinations of age (65, 70, and 75 years), BMD (70%, 75%, and 80% of young adult mean [YAM]), and additional clinical risk factors. For 70‐year‐old women with a BMD of 70% of the YAM having one of the following risk factors: a family history of hip fracture, high alcohol intake, or current smoking, the incremental cost‐effectiveness ratio (ICER) of alendronate was $92,937, $126,251, and $129,067 per QALY, respectively. These results were sensitive to age, BMD, and number of clinical risk factors. Probabilistic sensitivity analysis for the base case showed that in the presence of one, two, and three risk factors, alendronate was cost‐effective in 0.2% to 2.6%, 13.1% to 56.1%, and 99.1% of the simulations, respectively, if society is willing to pay $50,000 per QALY. Additional analysis indicated that alendronate can be a good value in osteopenic women if the 10‐year probability for a osteoporotic hip or vertebral fracture is more than 26.2%. Our results indicate that whether to treat osteopenia with alendronate should be determined on the basis of age, BMD, and number of clinical risk factors in terms of cost‐effectiveness. © 2013 American Society for Bone and Mineral Research     

Responses to VCT for HIV among young people in Kampala,Uganda

Attitudes to voluntary counselling and testing (VCT) for HIV among young men and women in a slum area of Kampala, Uganda, were studied through 22 individual semi-structured interviews and 5 focus group discussions. Attitudes to VCT ranged from having no problem with the procedure to being very reluctant. Despite fear of stigma, the participants perceived 'positive living' after HIV testing as realistic. VCT was regarded as an important step to avoid HIV infection, but informants expressed the need for the service to be more accessible in terms of cost, time and quality of pre- and post-test counselling. We argue that counselling without HIV testing should be available for those who are reluctant to test. Poverty and gender power imbalances appeared to limit youths' possibility of making rational decisions about sexual behaviour and accessing VCT. The importance of considering the context in which such issues are being negotiated and decided is highlighted.     

A Research and Development Framework for the School Drop-out Problem

Persistent school drop-out rates signal limitations in existing research and development frameworks. Alternatives are needed. The alternative framework provided here begins with a new conception of student success. It illuminates the need for P-16, whole systems education reform. It emphasizes early warning and rapid response systems focused on four target populations, while illuminating the special needs of high-poverty school communities challenged by social exclusion and social isolation. Improved dropout planning depends on expanded models of school improvement, new roles for social/health service providers, expanded conceptions of teaching and learning, and genuine collaboration.