Acceptability, safety, and patterns of use of oral tenofovir disoproxil fumarate and emtricitabine for HIV pre-exposure prophylaxis in South African adolescents: an open-label single-arm phase 2 trial

BACKGROUND

HIV incidence among adolescents in southern Africa remains unacceptably high. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention intervention but there are few data on its implementation among adolescents. We aimed to investigate the safety, feasibility, and acceptability of PrEP with oral tenofovir disoproxil fumarate and emtricitabine as part of a comprehensive HIV prevention package in an adolescent population in South Africa.

METHODS

This open-label single-arm phase 2 study (PlusPills) was done in two research clinics in Cape Town and Johannesburg, South Africa. Adolescents aged 15-19 years were recruited into the study through recruitment events and outreach in the community. Potential participants were eligible for enrolment if they reported being sexually active. Exclusion criteria were a positive test for HIV or pregnancy at enrolment, breastfeeding, or any relevant co-morbidities. Participants were given oral tenofovir disoproxil fumarate and emtricitabine for PrEP to take daily for the first 12 weeks and were then given the choice to opt in or out of PrEP use at three monthly intervals during scheduled clinic visits. Participants were invited to monthly visits for adherence counselling and HIV testing during the study period. The primary outcomes were acceptability, use, and safety of PrEP. Acceptability was measured by the proportion of participants who reported willingness to take up PrEP and remain on PrEP at each study timepoint. Use was defined as the number of participants who continued to use PrEP after the initial 12-week period until the end of the study (week 48). Safety was measured by grade 2, 3, and 4 laboratory and clinical adverse events using the Division of AIDS table for grading the severity of adult and paediatric adverse events, version 1.0. Dried blood spot samples were collected at each study time-point to measure tenofovir diphosphate concentrations. This trial is registered with ClinicalTrials.gov, NCT02213328.

FINDINGS

Between April 28, 2015, and Nov 11, 2016, 244 participants were screened, and 148 participants were enrolled (median age was 18 years; 99 participants [67%] were female) and initiated PrEP. PrEP was stopped by 26 of the 148 (18%) participants at 12 weeks. Cumulative PrEP opt-out, from the total cohort, was 41% (60 of 148 participants) at week 24 and 43% (63 of 148 participants) at week 36. PrEP was well tolerated with only minor adverse events (grade 2) thought to be related to study drug, which included headache (n=4, 3%), gastrointestinal upset (n=8, 5%), and skin rash (n=2, 1%). Two participants (1%) experienced grade 3 weight loss, which was deemed related to the study drug and resolved fully when PrEP was discontinued. Tenofovir diphosphate concentrations were detectable (>16 fmol/punch) in dried blood spot samples in 108 (92%) of 118 participants who reported PrEP use at week 12, in 74 (74%) of 100 participants at week 24, and in 22 (59%) of 37 participants by the study end at week 48.

INTERPRETATION

In this cohort of self-selected South African adolescents at risk of HIV acquisition, PrEP appears safe and tolerable in those who continued use. PrEP use decreased throughout the course of the study as the number of planned study visits declined. Adolescents in southern Africa needs access to PrEP with tailored adherence support and possibly the option for more frequent and flexible visit schedules.

FUNDING

National Institute of Allergy and Infectious Diseases of the US National Institutes of Health.

Randomized controlled trial of multi-modular motion-assisted memory desensitization and reconsolidation (3MDR) for male military veterans with treatment-resistant post-traumatic stress disorder

OBJECTIVE

To explore the potential efficacy of multi-modular motion-assisted memory desensitization and reprocessing (3MDR) in British military veterans with treatment-resistant service-related PTSD.

METHODS

Exploratory single-blind, randomized, parallel arm, cross-over controlled trial with nested process evaluation to assess fidelity, adherence and factors that influence outcome.

RESULTS

A total of 42 participants (all male) were randomized with 83% retention at 12 weeks and 86% at 26 weeks. The difference in mean Clinician-Administered PTSD Scale for DSM-5 scores between the immediate and delayed 3MDR arms was -9.38 (95% CI -17.33 to -1.44, P = 0.021) at 12 weeks and -3.59 (-14.39 to 7.20, P = 0.513) at 26 weeks when both groups had received 3MDR. The likely effect size of 3MDR was found to be 0.65. Improvements were maintained at 26-week follow-up. 3MDR was found to be acceptable to most, but not all, participants. Several factors that may impact efficacy and acceptability of 3MDR were identified.

CONCLUSION

3MDR is a promising new intervention for treatment-resistant PTSD with emerging evidence of effect.

How Individuals Who Self-Harm Manage Their Own Risk-'I Cope Because I Self-Harm, and I Can Cope with my Self-Harm'

Self-harm is a complex and idiosyncratic behaviour. This article focuses on how those who self-harm manage their own risk. Utilising opportunity sampling, ten members of a self-harm support group were interviewed about how they risk manage their self-harm and the data analysed using interpretative phenomenological analysis. The analysis showed that all participants were actively involved in risk management of their self-harm. Through a process of managing consequences, exercising control in the process, and an awareness of the social context. It is posited that people who self-harm should be viewed as actively engaging with the risks of self-harm whilst it is a coping mechanism, as opposed to passive or ignoring. This understanding can be integrated into current risk management plans within services and invites a more dynamic conversation of self-harm between services users and services. Effective risk management involves good relationships between individuals who self-harm and clinicians, services which promote positive risk taking as opposed to defensive practice, and true collaboration between services and service users.

Qualitative Ampule and Multitest for Beta-Lactam Residues in Fluid Milk Products: Collaborative Study

A collaborative study was performed on a rapid Bacillus stearothermophilus agar diffusion ampule method to detect low levels of penicillin G in 7 types of fluid milk products. A multitest technique for processing a large number of samples simultaneously was also studied. Slight modifications were made in the original method to establish more uniformity and to eliminate doubtful responses by specifying a confirmation procedure. Twenty samples spiked with penicillin G (0.000 to 0.008 IU/mL) and tetracycline hydrochloride were frozen and sent to 20 laboratories in the ampule test, and 16 laboratories in the multitest. Each analyst was asked to do a screening run and a confirmation run. Results were reported by color reaction and also as positive or negative for β-lactam inhibitors. The concentrations (penicillin G) where percent positive results equal 100 or not significantly less than 100 (α = 0.05) ranged from 0.005 to 0.007 IU/mi in the ampule test and from 0.004 to 0.007 IU/mL in the multitest. Both techniques have been adopted official first action.

Rapid Screening Assay for Beta-Lactam Antibiotics in Milk: Collaborative Study

A 15 min assay for beta-lactam antibiotics has been used by dairies for several years as a screening procedure for testing milk tankers before they unload. The test is based on a competition between 14C-penicillin and beta-lactam antibiotics in the milk samples for sites on a microbial cell wall that specifically binds beta-lactam. In a collaborative study, 11 laboratories correctly distinguished 10 coded zero penicillin G samples and 10 coded 0.01 IU/mL samples. The proposed test is qualitative, positive or negative, and can detect the presence of beta-lactam antibiotics at the 0.01 IU/mL level. The control point for determining positive or negative samples is more than 3 standard deviations from the mean of 0.01 IU/mL. The method has been adopted official first action.

Genomic epizootiology of a Brucella abortus outbreak in Northern Ireland (1997-2012)

BACKGROUND

In the recent past (1997-2012), Northern Ireland in the United Kingdom suffered an outbreak of Brucella abortus, which at its height affected over 200 cattle herds. Initially, isolates were characterized using multi-locus variable number tandem repeats analysis (MLVA). While informative in this setting, hyper-variability in some loci limited the resolution necessary to infer fine-scale disease transmission networks. Consequently, we applied whole-genome sequencing to isolates from this outbreak to evaluate higher resolution markers for disease epizootiology.

RESULTS

Phylogenetic analysis revealed that the B. abortus outbreak in Northern Ireland was caused by two distinct pathogen lineages. One contained isolates consistent with the 1997-2012 outbreak being linked to a previous endemic infection thought eradicated. The dominant second lineage exhibited little genetic diversity throughout the recrudescent outbreak, with limited population sub-structure evident. This finding was inconsistent with prior MLVA molecular characterizations that suggested the presence of seven clonal complexes. Spatio-temporal modeling revealed a significant association of pairwise SNP differences between isolates and geographic distances. However, effect sizes were very small due to reduced pathogen diversity.

CONCLUSIONS

Genome sequence data suggested that hyper-variability in some MLVA loci contributed to an overestimate of pathogen diversity in the most recent outbreak. The low diversity observed in our genomic dataset made it inappropriate to apply phylodynamic methods to these data. We conclude that maintaining data repositories of genome sequence data will be invaluable for source attribution/epizootiological inference should recrudescence ever re-occur. However genomic epizootiological methods may have limited utility in some settings, such as when applied to recrudescent/re-emergent infections of slowly-evolving bacterial pathogens.

The Intensity-Modulated Pelvic Node and Bladder Radiotherapy (IMPART) Trial: A Phase II Single-Centre Prospective Study

AIMS

Node-positive bladder cancer (NPBC) carries a poor prognosis and has traditionally been treated palliatively. However, surgical series suggest that a subset of NPBC patients can achieve long-term control after cystectomy and lymph node dissection. There is little published data regarding the use of radiotherapy to treat NPBC patients. This is in part due to concerns regarding the toxicity of whole-pelvis radiotherapy using conventional techniques. We hypothesised that, using intensity-modulated radiotherapy (IMRT), the pelvic nodes and bladder could be treated within a radical treatment volume with acceptable toxicity profiles.

MATERIALS AND METHODS

The Intensity-modulated Pelvic Node and Bladder Radiotherapy (IMPART) trial was a phase II single-centre prospective study designed to assess the feasibility of delivering IMRT to treat the bladder and pelvic nodes in patients with node-positive or high-risk node-negative bladder cancer (NNBC). The primary end point was meeting predetermined dose constraints. Secondary end points included acute and late toxicity, pelvic relapse-free survival and overall survival.

RESULTS

In total, 38 patients were recruited and treated between June 2009 and November 2012; 22/38 (58%) had NPBC; 31/38 (81.6%) received neoadjuvant chemotherapy; 18/38 (47%) received concurrent chemotherapy; 37/38 (97%) patients had radiotherapy planned as per protocol. Grade 3 gastrointestinal and genitourinary acute toxicity rates were 5.4 and 20.6%, respectively. At 1 year, the grade 3 late toxicity rate was 5%; 1-, 2- and 5-year pelvic relapse-free survival rates were 55, 37 and 26%, respectively. The median overall survival was 1.9 years (95% confidence interval 1.1-3.8) with 1-, 2- and 5-year overall survival rates of 68, 50 and 34%, respectively.

CONCLUSION

Delivering IMRT to the bladder and pelvic nodes in NPBC and high-risk NNBC is feasible, with low toxicity and low pelvic nodal recurrence rates. Long-term control seems to be achievable in a subset of patients. However, relapse patterns suggest that strategies targeting both local recurrence and the development of distant metastases are required to improve patient outcomes.

Stigma and behavioral health literacy among individuals with proximity to mental health or substance use conditions

BACKGROUND

Stigma reduction has been identified as a key public health strategy to increase enrollment in behavioral health services. As our understanding about stigma reduction has become more sophisticated, there has been an increased recognition that efforts to reduce stigma must engage the complex relationships between stigma, literacy, and contact with others who have a behavioral health condition.

AIMS

The goal of this project was to improve understanding about the relationships between behavioral health literacy, stigma, and contact to inform efforts to increase public behavioral health literacy and decrease stigma. Specifically, this project explored how the structure of these relationships varied for different substance use and mental health conditions.

METHOD

Structural equation modeling was used to depict relationships with data from a nationally-representative survey on behavioral health literacy and stigma.

RESULTS

The impact of prior contact and literacy on stigma varied by behavioral health condition.

CONCLUSIONS

Stigma reduction efforts will be most successful when they match the level of literacy and prior contact with the condition among the target audience for stigma reduction efforts.

117 Supplementation of IVF medium with nerve growth factor improved bovine embryonic cleavage rates during summer months

Nerve growth factor-β (NGF), a protein originally associated with regulation of neuron development, has been found to play a role in the reproductive system of mammals. Previous research showed that administration of NGF to cows resulted in enhanced conceptus development. Although these effects were speculated to be a result of improved corpus luteum function, whether NGF could act directly on the embryo remained undetermined. Therefore, the direct effects of NGF on fertilization and embryo development warrant investigation to see whether it can be used as a novel tool to improve cleavage and blastocyst rates when producing embryos via IVF during periods of suboptimal oocyte quality, such as with heat stress. The objective of this study was to explore how supplementation of NGF, purified from bull seminal plasma, during IVF may directly affect embryo development in oocytes harvested in the summer. Abattoir-derived bovine ovaries were used for recovery of cumulus-oocyte complexes (COCs) over eight replicates through May and June. On Day −1, COCs were collected and matured for 20h in oocyte maturation medium incubated at 38.5°C. On Day 0, matured oocytes were added to a solution of IVF-Tyrode's albumin lactate pyruvate (TALP) and either phosphate-buffered saline (PBS; control) or 100ngmL−1 NGF. Pooled frozen-thawed semen from two different bulls per replicate were added to the IVF solutions and incubated with COCs for 20h at 38.5°C in a humidified atmosphere of 5% CO2. On Day 1, zygotes were washed in HEPES-TALP, and cumulus cells were removed using 1% hyaluronidase. The zygotes were plated in synthetic oviductal fluid (SOF-BE2) culture medium and incubated at 38.5°C in a tri-gas chamber (5% CO2, 5% O2, and balanced N2). Cleavage rates were recorded at 24 and 48h, calculated by dividing the number of cleaved embryos by the total zygote count. Embryos were incubated until Day 8, when the rate of blastocysts was assessed. This study found that the treatment of IVF medium with NGF increased the cleavage rate of embryos after 48h (Control: 59%; NGF: 66%; P=0.04) and the hatched blastocyst percentage per oocyte on Day 8 (Control: 6.7%; NGF: 9.4%; P=0.01). The treatment did not affect the percentage of blastocysts per cleaved embryos (Control: 21%; NGF: 22%; P=0.16) or the hatched blastocyst rate at Day 8 (Control: 53%; NGF: 55%; P=0.67). These results show that NGF can act directly on the oocyte during fertilization to alter subsequent development, specifically through increased embryonic cleavage rates. Further studies are needed to assess different dosages of NGF in order to mitigate the detrimental effects of heat stress on oocyte competence for use in IVF. Follow-up studies using a whole-animal model are needed to understand the clinical relevance of these findings in the ability of embryos to promote maternal recognition of pregnancy.