Journal articles on the topic 'Malawi. Army'

This article is a partial answer to M. D. D. Newitt, who proposed that settled Maravi states were established only as a result of the rise of Muzura in the first half of the seventeenth century (cf. J. Afr. Hist., 1982, ii). Newitt thereby challenged the more orthodox view that a formal Maravi state system existed already by the middle of the sixteenth century, if not earlier. It is argued here that the orthodox view is still valid in the case of the Lundu state in the lower Shire valley, and perhaps also in the case of some of the neighbouring states. It is shown that around 1590 the then Lundu incumbent embarked on a course of strong state centralisation during which he appropriated the power of the traditional rain priests and thus became both the secular and the ritual leader of the country. It is also argued that this unusual degree of centralisation was achieved and could for a time be maintained with the help of the Zimba, an army of fugitives from the south bank of the Zambezi. However, the present article challenges Malawian historiographical orthodoxy on a very different point, by maintaining that Muzura is not to be identified with the Kalonga dynasty on the south-western shores of Lake Malawi, but with a separate state system in the western Shire Highlands, which gained prominence well before the Kalongas came to the fore.

Mientras la enfermedad hace su aparición en los años 1980, Hervé Guibert aparece como una de las victimas de una afección muy extraña todavia por el mundo de la medicina. Pero no es simplemente una persona infectada, Guibert es el escritor sincero del sida, abiendo escojido las palabras como su unico aliado por su proyecto de volver a nacer con un nuevo yo que no morirà nunca en la memoria de la gente. In the middle of AIDS explosion during the 80’s, Hervé Guibert is one of the victims of this unexpected and unknown illness even for the medecine. He is not an ordinary sick person but he is the writer revealing himself completely and considering writing the only way for struggling against AIDS, against himself in order to reborn as a new spirit thanks to the power of words. Au plein milieu de l'éclatement du sida dans les années 1980, Hervé Guibert se trouve parmi les victimes atteintes par une maladie encore inconnue à l'époque. Mais il n'est pas un malade ordinaire, il sera l'écrivain du sida qui se révèle entièrement, sans pudeur, et pour qui l'écriture reste l'unique arme à lutter contre la maladie, contre le moi malade, pour renaitre plus tard en tant qu'un moi nouveau, étrenel, qui survit grace aux mots.

Background and Objectives: The purpose of this study was to evaluate the feasibility of a customized, culturally sensitive pregnancy wheel given to pregnant women to improve gestational age dating accuracy at the time of delivery and to improve antenatal care attendance. Methods: This was a pilot randomized trial involving pregnant women presenting to a regional hospital in Lilongwe, Malawi. The primary outcome was accuracy of gestational age at the time of presentation to the hospital in labor. The secondary outcome was the number of antenatal visits. Results: At final analysis, 14 subjects were included in the pregnancy wheel (intervention) arm and 11 in the standard care arm. Fifty percent (n=7) of women in the intervention arm were accurately dated at the time of presentation for delivery, compared to only 9% (n=1) in the standard antenatal care arm (p=0.04). There was not a significant difference in the number of antenatal visits between the two study arms. No patients met the World Health Organization’s recommended eight antenatal care visits for prenatal care. Conclusion and Global Health Implications: The customized pregnancy wheel given to patients could improve gestational age dating accuracy, and as a result, clinical decision making. However, the barriers to greater antenatal care access are more complex and likely require a more complex solution. Significant attrition in this pilot trial limited statistical power, suggesting the need for future larger interventions. Accurate gestational dating requires access to ultrasonography and early antenatal care initiation, both of which are inadequate in Malawi. Although the customized pregnancy wheel did not improve antenatal care attendance, it improved gestational age dating accuracy in a pilot study at a central hospital in Lilongwe, Malawi. Copyright © 2021 Stokes et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

IntroductionStreptococcus pneumoniae (the pneumococcus) is commonly carried as a commensal bacterium in the nasopharynx but can cause life-threatening disease. Transmission occurs by human respiratory droplets and interruption of this process provides herd immunity. A 2017 WHO Consultation on Optimisation of pneumococcal conjugate vaccines (PCV) Impact highlighted a substantial research gap in investigating why the impact of PCV vaccines in low-income countries has been lower than expected. Malawi introduced the 13-valent PCV (PCV13) into the national Expanded Programme of Immunisations in 2011, using a 3+0 (3 primary +0 booster doses) schedule. With evidence of greater impact of a 2+1 (2 primary +1 booster dose) schedule in other settings, including South Africa, Malawi’s National Immunisations Technical Advisory Group is seeking evidence of adequate superiority of a 2+1 schedule to inform vaccine policy.MethodsA pragmatic health centre-based evaluation comparing impact of a PCV13 schedule change from 3+0 to 2+1 in Blantyre district, Malawi. Twenty government health centres will be randomly selected, with ten implementing a 2+1 and 10 to continue with the 3+0 schedule. Health centres implementing 3+0 will serve as the direct comparator in evaluating 2+1 providing superior direct and indirect protection against pneumococcal carriage. Pneumococcal carriage surveys will evaluate carriage prevalence among children 15–24 months, randomised at household level, and schoolgoers 5–10 years of age, randomly selected from school registers. Carriage surveys will be conducted 18 and 33 months following 2+1 implementation.AnalysisThe primary endpoint is powered to detect an effect size of 50% reduction in vaccine serotype (VT) carriage among vaccinated children 15–24 months old, expecting a 14% and 7% VT carriage prevalence in the 3+0 and 2+1 arms, respectively.Ethics and disseminationThe study has been approved by the Malawi College of Medicine Research Ethics Committee (COMREC; Ref: P05.19.2680), the University College London Research Ethics Committee (Ref: 8603.002) and the University of Liverpool Research Ethics Committee (Ref: 5439). The results from this study will be actively disseminated through manuscript publications and conference presentations.Trial registration numberNCT04078997.

Abstract Background Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV)–infected individuals globally. Screening for TB at the point of HIV diagnosis with a high-sensitivity assay presents an opportunity to reduce mortality. Methods We performed a cluster randomized trial of TB screening among adults newly diagnosed with HIV in 12 primary health clinics in rural Thyolo, Malawi. Clinics were allocated in a 1:1 ratio to perform either point-of-care Xpert MTB/RIF assay (Xpert) or point-of-care light-emitting diode fluorescence microscopy (LED-FM) for individuals screening positive for TB symptoms. Asymptomatic participants were offered isoniazid preventive therapy in both arms. Investigators, but not clinic staff or participants, were masked to allocation. Our primary outcome was the incidence rate ratio (RR) of all-cause mortality within 12 months of HIV diagnosis. Results Prevalent TB was diagnosed in 24 of 1001 (2.4%) individuals enrolled in clinics randomized to Xpert, compared with 10 of 841 (1.2%) in clinics randomized to LED-FM. All-cause mortality was 22% lower in the Xpert arm than in the LED-FM arm (6.7 vs 8.6 per 100 person-years; RR, 0.78 [95% confidence interval {CI}, .58–1.06]). A planned subgroup analysis suggested that participants with more advanced HIV (World Health Organization clinical stage 3 or 4) disease had lower mortality in clinics randomized to Xpert than to LED-FM (RR, 0.43 [95% CI, .22–.87]). Conclusions In rural Malawi, using point-of-care Xpert MTB/RIF to test symptomatic patients for TB at the time of HIV diagnosis reduced all-cause 12-month mortality among individuals with advanced HIV. Clinical Trials Registration NCT01450085.

Background Undiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART). Methods and findings This cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents (≥15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults (≥40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes. Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI −36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome. Conclusions In this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope. Trial registration Clinicaltrials.gov NCT03541382.

BackgroundMental health problems are common in primary care, with prevalence rates of up to 40% reported in developing countries. The study aim was to evaluate the impact of a specially designed toolkit used to train primary health care (PHC) workers in mental health on the rates of diagnosed cases of common mental disorders, malaria and non-specific musculoskeletal pains in primary care in Malawi.MethodClinics with out-patient services in the designated district were randomly divided into control and intervention arms. Using a two-phase sampling process, Self-Reporting Questionnaire scores, data on diagnoses made by PHC workers and results of the Structured Clinical Interview for DSM-IV for depression were collected from 837 consecutively attending adult patients in the pre-intervention study and 2600 patients in the post-intervention study.ResultsThe point prevalence rates for probable common mental disorder and depression were 28.8% and 19%, respectively. Rates for both anxiety and depression diagnoses by PHC workers at baseline were 0% in both arms. Following training, there were significant differences between the two arms in the rates of diagnosed cases of depression [9.2% v. 0.5%, odds ratio (OR) 32.1, 95% confidence interval (CI) 7.4–144.3, p ⩽ 0.001], anxiety (1.2% v. 0%, p ⩽ 0.001) and malaria (31% v. 40%, OR 0.62, 95% CI 0.43–0.89, p = 0.01). The intervention arm had more cases diagnosed with depression and anxiety while the control arm had more cases diagnosed with malaria.ConclusionsTraining of PHC workers in mental health with an appropriate toolkit will contribute significantly to the quality of detection and management of patients seen in primary care in developing countries.

IntroductionOver 40% of global tuberculosis case notifications are diagnosed clinically without mycobacteriological confirmation. Standard diagnostic algorithms include ‘trial-of-antibiotics’—empirical antibiotic treatment given to mycobacteriology-negative individuals to treat infectious causes of symptoms other than tuberculosis, as a ‘rule-out’ diagnostic test for tuberculosis. Potentially 26.5 million such antibiotic courses/year are prescribed globally for the 5.3 million/year mycobacteriology-negative patients, making trial-of-antibiotics the most common tuberculosis diagnostic, and a global-scale risk for antimicrobial resistance (AMR). Our systematic review found no randomised controlled trial (RCT) to support use of trial-of-antibiotic. The RCT aims to determine the diagnostic and clinical value and AMR consequences of trial-of-antibiotics.Methods and analysisA three-arm, open-label, RCT randomising (1:1:1) Malawian adults (≥18 years) seeking primary care for cough into: (a) azithromycin 500 mg one time per day for 3 days or (b) amoxicillin 1 g three times per day for 5 days or (c) standard-of-care (no immediate antibiotic). We will perform mycobacteriology tests (microscopy, Xpert MTB/RIF (Mycobacterium tuberculosis/rifampicin) andMycobacterium tuberculosisculture) at baseline. We will use audiocomputer-assisted self-interview to assess clinical improvement at day 8. First primary outcome will be proportion of patients reporting day 8 improvement out of those with negative mycobacteriology (specificity). Second primary outcome will be day 29 incidence of a composite endpoint of either death or hospitalisation or missed tuberculosis diagnosis. To determine AMR impact we compare proportion of resistant nasopharyngealStreptococcus pneumoniaeisolates on day 29. 400 mycobacteriology-negative participants/arm will be required to detect a ≥10% absolute difference in diagnostic specificity with 80% power. We will estimate measures of effect by comparing outcomes in antibiotic arms (combined and individually) to standard-of-care.Ethics and disseminationThe study has been reviewed and approved by Malawi College of Medicine Research and Ethics Committee, London School of Hygiene & Tropical Medicine (LSHTM) Research Ethics Committee and Regional Committee for Health and Research Ethics – Norway, and Malawi Pharmacy, Medicines and Poisons Board. We will present abstracts at relevant conferences, and prepare a manuscript for publication in a peer-reviewed journal.Trial registration numberThe clinical trial is registered with ClinicalTrials.gov,NCT03545373

La synthèse en 1863 du trinitrotoluène et son introduction en 1902 dans les obus d’artillerie a marqué une étape dans les techniques de combats. La première guerre mondiale avec ses bombardements intensifs des soldats dans les tranchées a vu l’apparition d’une symptomatologie jusque-là inconnue et nommée par exemple en Grande Bretagne : Not YET Diagnosed, Neurology (NYDN). Ces troubles vont être présents dans toutes les armées du conflit. L’étiologie de ces troubles, relativement protéiforme dans leur présentation, posa de posternombreuses questions entre les tenants de l’organicité et ceux de la psychée, voire de la simulation avec des traitements parfois à la limite de la torture. Les termes utilisés : « les pythiatiques », l’« obusite », le « Shell shock » ; l’avatar moderne devenant le PTSD. Des étiologies neurologiques furent proposées dès 1915 mais sans suites immédiates. Plus récemment, des études contrôlées réalisées par l’US Army font cependant état d’un risque 2 fois plus important de développer une maladie de parkinson chez les vétérans de la WWII que la population contrôle non combattante. Une réhabilitation des pythiatiques de 1915 ?

Background: Patients with tuberculosis (TB) symptoms in low-resource settings face convoluted diagnostic and treatment linkage pathways, incurring substantial health-seeking costs. In the context of a randomised trial looking at the impact of novel diagnostics such as computer-aided chest x-ray diagnosis (CAD4TB), we aimed to investigate the costs incurred by patients seeking TB diagnosis and whether optimised diagnostic interventions could result in a reduction in the cost faced by households. Methods: PROSPECT was a three-arm randomised trial conducted in a public primary health clinic in Blantyre, Malawi during 2018-2019 (trial arms: standard of care [SOC]; HIV testing [HIV]; HIV testing and CAD4TB [HIV/TB]). The direct and indirect costs incurred by 219 PROSPECT participants over the 56-day follow-up period were collected. Costs were deemed catastrophic if they exceeded 20% of annual household income. We compared mean costs and used generalised linear regression models to examine whether the interventions could result in a reduction in total costs. Results: The mean total cost incurred by all 219 participants was US$12.11 (standard error (SE): 1.86). The indirect and direct cost was US$8.47 (SE: 1.66) and US$3.64 (SE: 0.38), respectively. The mean total cost composed of 5.6% of the average annual household income. In total, 5% (9/180) of the participants with complete income data incurred catastrophic costs. Compared to SOC, there was no statistically significant difference in the mean total cost faced by those in the HIV (ratio: 0.77, 95% CI: 0.51, 1.19) and HIV/TB arms (ratio: 0.85, 95% CI: 0.53, 1.37). Conclusions: Despite the absence of user fees, patients seeking healthcare with TB symptoms incurred catastrophic costs. The optimised TB diagnostic interventions that were investigated in the PROSPECT study did not significantly reduce costs. TB diagnosis interventions should be implemented alongside social protection policies whilst ensuring healthcare facilities are accessible by the poor.

The MORDOR study, a masked, community-level randomized clinical trial conducted in Niger, Malawi and Tanzania (2015 to 2017), showed that biannual administration of single-dose azithromycin to preschool children reduced all-cause mortality. We sought to evaluate its impact on causes of death in children aged 1–59 months in Tanzania. A random sampling of 614 communities was conducted in Kilosa District, Tanzania, with simple random assignment of communities to receive either azithromycin or placebo. In these communities, a census was carried out every 6 months and children aged 1–59 months received biannual (every 6 months), single-dose azithromycin (~20mg/kg) or placebo depending on community assignment, over a 2-year period. Mortality was determined at the time of the biannual census. For child deaths, a verbal autopsy was performed to ascertain the cause using a standardized diagnostic classification. A total of 190- (0.58 /100 person-years) and 200 deaths (0.59/100 person-years) were reported in the azithromycin and placebo arms, respectively. Malaria, pneumonia and diarrhea, accounted for 71% and 68% of deaths in the respective arms. Overall, the mortality was not different by treatment arm, nor were the distribution of causes of death after adjusting for community clustering. The cause-specific mortality for diarrhea/pneumonia was no different over time. In children aged 1–5 months, 32 deaths occurred in the placebo arm and 25 deaths occurred in the azithromycin arm; 20 (62.5%) deaths in the placebo- and 10 (40%) in the azithromycin arm were attributed to diarrhea or pneumonia. Neither differences in the number of deaths nor the diarrhea/pneumonia attribution was statistically significant after adjusting for community clustering. In conclusion, azithromycin was not associated with a significant decline in deaths by specific causes compared to placebo. The non-significant lower rates of diarrhea or pneumonia in children <6 months who received azithromycin merit further investigation in high-mortality settings. Trial registration: NCT02048007.

IntroductionCryptococcal meningitis is responsible for around 15% of all HIV-related deaths globally. Conventional treatment courses with amphotericin B require prolonged hospitalisation and are associated with multiple toxicities and poor outcomes. A phase II study has shown that a single high dose of liposomal amphotericin may be comparable to standard treatment. We propose a phase III clinical endpoint trial comparing single, high-dose liposomal amphotericin with the WHO recommended first-line treatment at six sites across five counties. An economic analysis is essential to support wide-scale implementation.Methods and analysisCountry-specific economic evaluation tools will be developed across the five country settings. Details of patient and household out-of-pocket expenses and any catastrophic healthcare expenditure incurred will be collected via interviews from trial patients. Health service patient costs and related household expenditure in both arms will be compared over the trial period in a probabilistic approach, using Monte Carlo bootstrapping methods. Costing information and number of life-years survived will be used as the input to a decision-analytic model to assess the cost-effectiveness of a single, high-dose liposomal amphotericin to the standard treatment. In addition, these results will be compared with a historical cohort from another clinical trial.Ethics and disseminationThe AMBIsome Therapy Induction OptimisatioN (AMBITION) trial has been evaluated and approved by the London School of Hygiene and Tropical Medicine, University of Botswana, Malawi National Health Sciences, University of Cape Town, Mulago Hospital and Zimbabwe Medical Research Council research ethics committees. All participants will provide written informed consent or if lacking capacity will have consent provided by a proxy. The findings of this economic analysis, part of the AMBITION trial, will be disseminated through peer-reviewed publications and at international and country-level policy meetings.Trial registrationISRCTN72509687; Pre-results.

El 9 de diciembre de 1774, Mohamed ben Abdalah, sultán de Marruecos, puso sitio a Melilla que se prolongó hasta el 19 de marzo de 1775. Dada la gravedad de la confrontación bélica, las autoridades españolas habían establecido un buen equipo sanitario, constituido por dos médicos y trece cirujanos, además de un boticario y un sangrador. Manuel Ahuir era el médico titular y Miguel Fernández de Loaiza, el otro médico, fue enviado desde Málaga. De los cirujanos, Antonio Aldana, Ignacio de Arroyo y José Serrano formaban parte de la dotación del Real Hospital de Melilla, mientras que Jorge Grenier, Juan Antonio, Juan Modest y Rodrigo Moreno vinieron de Málaga, y Ramón Bertran, Antonio Busqué, Juan Antonio Coll, Juan Llensa, Pablo Antonio Querol y Francisco Roca fueron enviados por el Real Colegio de Cirugía de Barcelona y llegaron en el jabeque El Pilar. Estos médicos y cirujanos tuvieron que asistir a numerosísimos heridos y en gran parte gracias a ellos la plaza pudo resistir durante más de tres meses, a pesar de los continuos ataques de las tropas enemigas, hasta que el ejército sitiador, impotente ante la heroica resistencia de Melilla, levantó el sitio el día de San José de 1775.On December 9, 1774, Mohammed ben Abdallah, sultan of Morocco, besieged Melilla. This siege lasted until March 19, 1775. Because of the seriousness of military confrontation, the Spanish authorities had established a good medical team, consisting of two doctors and thirteen surgeons, as well as an apothecary and a phlebotomist. Manuel Ahuir was the titular physician and Miguel Fernández de Loaiza, the other doctor, was sent from Malaga. Three surgeons, Antonio Aldana, Ignacio de Arroyo and José Serrano, were part of the crew of the Royal Hospital of Melilla, while Jorge Grenier, Juan Antonio, Juan Modest and Rodrigo Moreno came from Malaga, and Ramón Bertran, Antonio Busqué, Juan Antonio Coll, Juan Llensa, Pablo Antonio Querol and Francisco Roca were sent by the Royal College of Surgery of Barcelona, and arrived in the xebec El Pilar. These physicians and surgeons had to attend numerous wounded and largely thanks to them the place could stand for more than three months, in despite of continuous attacks of the enemy troops, until the besieging army, helpless against the heroic resistance of Melilla, raised the siege the day of Saint Joseph, 1775.

Background Antiretroviral therapy (ART) initiation in the community and outside of a traditional health facility has the potential to improve linkage to ART, decongest health facilities, and minimize structural barriers to attending HIV services among people living with HIV (PLWH). We conducted a systematic review and meta-analysis to determine the effect of offering ART initiation in the community on HIV treatment outcomes. Methods and findings We searched databases between 1 January 2013 and 22 February 2021 to identify randomized controlled trials (RCTs) and observational studies that compared offering ART initiation in a community setting to offering ART initiation in a traditional health facility or alternative community setting. We assessed risk of bias, reporting of implementation outcomes, and real-world relevance and used Mantel–Haenszel methods to generate pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals. We evaluated heterogeneity qualitatively and quantitatively and used GRADE to evaluate overall evidence certainty. Searches yielded 4,035 records, resulting in 8 included studies—4 RCTs and 4 observational studies—conducted in Lesotho, South Africa, Nigeria, Uganda, Malawi, Tanzania, and Haiti—a total of 11,196 PLWH. Five studies were conducted in general HIV populations, 2 in key populations, and 1 in adolescents. Community ART initiation strategies included community-based HIV testing coupled with ART initiation at home or at community venues; 5 studies maintained ART refills in the community, and 4 provided refills at the health facility. All studies were pragmatic, but in most cases provided additional resources. Few studies reported on implementation outcomes. All studies showed higher ART uptake in community initiation arms compared to facility initiation and refill arms (standard of care) (RR 1.73, 95% CI 1.22 to 2.45; RD 30%, 95% CI 10% to 50%; 5 studies). Retention (RR 1.43, 95% CI 1.32 to 1.54; RD 19%, 95% CI 11% to 28%; 4 studies) and viral suppression (RR 1.31, 95% CI 1.15 to 1.49; RD 15%, 95% CI 10% to 21%; 3 studies) at 12 months were also higher in the community-based ART initiation arms. Improved uptake, retention, and viral suppression with community ART initiation were seen across population subgroups—including men, adolescents, and key populations. One study reported no difference in retention and viral suppression at 2 years. There were limited data on adherence and mortality. Social harms and adverse events appeared to be minimal and similar between community ART initiation and standard of care. One study compared ART refill strategies following community ART initiation (community versus facility refills) and found no difference in viral suppression (RD −7%, 95% CI −19% to 6%) or retention at 12 months (RD −12%, 95% CI −23% to 0.3%). This systematic review was limited by few studies for inclusion, poor-quality observational data, and short-term outcomes. Conclusions Based on data from a limited set of studies, community ART initiation appears to result in higher ART uptake, retention, and viral suppression at 1 year compared to facility-based ART initiation. Implementation on a wider scale necessitates broader exploration of costs, logistics, and acceptability by providers and PLWH to ensure that these effects are reproducible when delivered at scale, in different contexts, and over time.

Filariasis adalah penyakit infeksi yang disebabkan oleh cacing Wuchereria Bancrofti, Brugia Malayi, dan Brugia Timori yang menyebabkan cairan limfe tidak dapat tersalurkan dengan baik sehingga menyebabkan pembengkakan pada tungkai dan lengan. Meskipun tidak ada penyebab kematian tetapi menyebabakan cacat permanen dan stigma sosial. Eliminasi Filariasis dilakukan dengan Program Pengobatan Massal ke seluruh penduduk di daerah endemis setahun sekali selama 5 tahun. Keberhasilan program ini memerlukan kepatuhan minum obat pencegahan filariasis. Tujuan penelitian ini untuk mengetahui faktor-faktor yang mempengaruhi ketidakpatuhan minum obat sebagai upaya pencegahan filariasis. Penelitian ini Populasi dalam penelitian ini adalah penduduk berusia 15-65 tahun di dua kelurahan endemis yaitu kelurahan kuripan kertoharjo dan kelurahan jenggot selama mei-juli 2018. Sampel dalam penelitian ini 80 kasus dan 80 kontrol dengan teknik cluster random sampling. Variabel yang terbukti berpengaruh yaitu persepsi kerentanan negatif (OR=4,093) 95%CI=1,356-12,350 dan self efficacy negatif (OR=30,298) 95%CI=8,986-102,156. Persepsi kerentanan negatif dan self efficacy negatif merupakan faktor perilaku yang mempengaruhi ketidakpatuhan minum obat pencegahan filariasis. Diharapkan ada penelitian lanjutan tentang ketidakpatuhan minum obat pencegahan filariasis bukan berwujud persepsi tetapi dengan pengukuran faktor lingkungan sosial secara objektif dengan melakukan intervensi berupa perubahan perilaku. Kata kunci : Filariasis, Ketidakpatuhan, Minum Obat, Mix Method FACTORS THAT INFLUENCE DRINKING DRUG PREVENTION NON COMPLIANCE OF FILARIASIS IN PEKALONGAN CITY ABSTRACT Filariasis is an infectious disease caused by worms Wuchereria Bancrofti, Brugia Malayi, and Brugia Timori, adult worm lives and damage reulting in blockage of lymph channels, causing swelling of the legs and arms. Although no cause of death but causes permanent disability and social stigma. Filariasis elimination done with the Mass Treatment Program to the entire population in endemic areas a year for 5 year. Succesfully this program required a medication adherence. The purpose of this study was to determine the factors that influence drug disobedience as an effort to prevent filariasis. This study uses a mix method. The population in this study were residents aged 15-65 years in two endemic villages, namely kuripan kertoharjo and jenggot villages during May-July 2018. Samples in this study were 80 cases and 80 controls with cluster random sampling technique. Variables that proved influential were perceptions of negative vulnerability (OR = 4,093) 95% CI = 1,356-12,350 and negative self efficacy (OR = 30,298) 95% CI = 8,986-102,156. Negative vulnerability perceptions and negative self efficacy are behavioral factors that influence non-compliance with filariasis prevention drugs. It is expected that further research on non-compliance with taking drugs to prevent filariasis is not a form of perception but objective measurement of social environmental factors by intervening in the form of behavior change. Keywords: Filariasis, Noncompliance, Medication, Mix Method

Background Suboptimal tuberculosis (TB) diagnostics and HIV contribute to the high global burden of TB. We investigated costs and yield from systematic HIV-TB screening, including computer-aided digital chest X-ray (DCXR-CAD). Methods and findings In this open, three-arm randomised trial, adults (≥18 years) with cough attending acute primary services in Malawi were randomised (1:1:1) to standard of care (SOC); oral HIV testing (HIV screening) and linkage to care; or HIV testing and linkage to care plus DCXR-CAD with sputum Xpert for high CAD4TBv5 scores (HIV-TB screening). Participants and study staff were not blinded to intervention allocation, but investigator blinding was maintained until final analysis. The primary outcome was time to TB treatment. Secondary outcomes included proportion with same-day TB treatment; prevalence of undiagnosed/untreated bacteriologically confirmed TB on day 56; and undiagnosed/untreated HIV. Analysis was done on an intention-to-treat basis. Cost-effectiveness analysis used a health-provider perspective. Between 15 November 2018 and 27 November 2019, 8,236 were screened for eligibility, with 473, 492, and 497 randomly allocated to SOC, HIV, and HIV-TB screening arms; 53 (11%), 52 (9%), and 47 (9%) were lost to follow-up, respectively. At 56 days, TB treatment had been started in 5 (1.1%) SOC, 8 (1.6%) HIV screening, and 15 (3.0%) HIV-TB screening participants. Median (IQR) time to TB treatment was 11 (6.5 to 38), 6 (1 to 22), and 1 (0 to 3) days (hazard ratio for HIV-TB versus SOC: 2.86, 1.04 to 7.87), with same-day treatment of 0/5 (0%) SOC, 1/8 (12.5%) HIV, and 6/15 (40.0%) HIV-TB screening arm TB patients (p = 0.03). At day 56, 2 SOC (0.5%), 4 HIV (1.0%), and 2 HIV-TB (0.5%) participants had undiagnosed microbiologically confirmed TB. HIV screening reduced the proportion with undiagnosed or untreated HIV from 10 (2.7%) in the SOC arm to 2 (0.5%) in the HIV screening arm (risk ratio [RR]: 0.18, 0.04 to 0.83), and 1 (0.2%) in the HIV-TB screening arm (RR: 0.09, 0.01 to 0.71). Incremental costs were US$3.58 and US$19.92 per participant screened for HIV and HIV-TB; the probability of cost-effectiveness at a US$1,200/quality-adjusted life year (QALY) threshold was 83.9% and 0%. Main limitations were the lower than anticipated prevalence of TB and short participant follow-up period; cost and quality of life benefits of this screening approach may accrue over a longer time horizon. Conclusions DCXR-CAD with universal HIV screening significantly increased the timeliness and completeness of HIV and TB diagnosis. If implemented at scale, this has potential to rapidly and efficiently improve TB and HIV diagnosis and treatment. Trial registration clinicaltrials.gov NCT03519425.

Background To achieve informed choice within the framework of reproductive autonomy, family planning programs have begun to adopt user-centered approaches to service provision, which highlight the individual client as the focal point of interaction and key decision maker. However, little is known about how user-centered approaches to family planning, particularly family planning counseling, shape contraceptive preferences and choices. Objective We conducted a multiarmed randomized controlled trial to identify the causal impact of user-centered approaches to family planning counseling on women’s contraceptive decision making in urban Malawi. This study aims to determine how a tailored, preference-driven approach to family planning counseling and the involvement of male partners during the counseling process may contribute to shaping women’s contraceptive preferences and choices. Methods Married women aged 18-35 years were recruited and randomly assigned to 1 of the 3 intervention arms or a control arm characterized by the following two interventions: an intervention arm in which women were encouraged to invite their husbands to family planning counseling (husband invitation arm) and an intervention arm in which women received targeted, tailored counseling on up to five contraceptive methods (as opposed to up to 13 contraceptive methods) that reflected women’s stated preferences for contraceptive methods. Women were randomized into a control arm, T0 (no husband invitation, standard counseling); T1 (husband invitation, standard counseling); T2 (no husband invitation, targeted counseling); and T3 (husband invitation, targeted counseling). Following counseling, all women received a package of family planning services, which included free transportation to a local family planning clinic and financial reimbursement for family planning services. Follow-up surveys were conducted with women 1 month after counseling. Results A total of 785 women completed the baseline survey, and 782 eligible respondents were randomized to 1 of the 3 intervention groups or the control group (T1, n=223; T2, n=225; T3, n=228; T0, n=108). Furthermore, 98.1% (767/782) of women were contacted for follow-up. Among the 767 women who were contacted, 95.3% (731/767) completed the follow-up survey. The analysis of the primary outcomes is ongoing and is expected to be completed by the end of 2021. Conclusions The results from this trial will fill knowledge gaps on the effectiveness of tailored family planning counseling and male involvement in family planning on women’s stated and realized contraceptive preferences. More generally, the study will provide evidence on how user-centered counseling may affect women’s willingness to use and continue contraception to realize their contraceptive preferences. Trial Registration American Economics Association’s Registry for Randomized Controlled Trials AEARCTR-0004194; https://www.socialscienceregistry.org/trials/4194/history/46808. Registry for International Development Impact Evaluations RIDIE-STUDY-ID-5ce4f42bbc2bf; https://ridie.3ieimpact.org/index.php?r=search/detailView&id=823. International Registered Report Identifier (IRRID) DERR1-10.2196/24884

Abstract Background Current standard interventions are not universally sufficient for malaria elimination. The effects of community-based house improvement (HI) and larval source management (LSM) as supplementary interventions to the Malawi National Malaria Control Programme (NMCP) interventions were assessed in the context of an intensive community engagement programme. Methods The study was a two-by-two factorial, cluster-randomized controlled trial in Malawi. Village clusters were randomly assigned to four arms: a control arm; HI; LSM; and HI + LSM. Malawi NMCP interventions and community engagement were used in all arms. Household-level, cross-sectional surveys were conducted on a rolling, 2-monthly basis to measure parasitological and entomological outcomes over 3 years, beginning with one baseline year. The primary outcome was the entomological inoculation rate (EIR). Secondary outcomes included mosquito density, Plasmodium falciparum prevalence, and haemoglobin levels. All outcomes were assessed based on intention to treat, and comparisons between trial arms were conducted at both cluster and household level. Results Eighteen clusters derived from 53 villages with 4558 households and 20,013 people were randomly assigned to the four trial arms. The mean nightly EIR fell from 0.010 infectious bites per person (95% CI 0.006–0.015) in the baseline year to 0.001 (0.000, 0.003) in the last year of the trial. Over the full trial period, the EIR did not differ between the four trial arms (p = 0.33). Similar results were observed for the other outcomes: mosquito density and P. falciparum prevalence decreased over 3 years of sampling, while haemoglobin levels increased; and there were minimal differences between the trial arms during the trial period. Conclusions In the context of high insecticide-treated bed net use, neither community-based HI, LSM, nor HI + LSM contributed to further reductions in malaria transmission or prevalence beyond the reductions observed over two years across all four trial arms. This was the first trial, as far as the authors are aware, to test the potential complementary impact of LSM and/or HI beyond levels achieved by standard interventions. The unexpectedly low EIR values following intervention implementation indicated a promising reduction in malaria transmission for the area, but also limited the usefulness of this outcome for measuring differences in malaria transmission among the trial arms. Trial registration PACTR, PACTR201604001501493, Registered 3 March 2016, https://pactr.samrc.ac.za/.

Abstract Background Persons with acute HIV infection (AHI) have heightened transmission risk. We evaluated potential transmission reduction using behavioral and biomedical interventions in a randomized controlled pilot study in Malawi. Methods Persons were randomized 1:2:2 to standard counseling (SC), 5-session behavioral intervention (BI), or behavioral intervention plus 12 weeks of antiretrovirals (ARVs; BIA). All were followed for 26–52 weeks and, regardless of arm, referred for treatment according to Malawi-ARV guidelines. Participants were asked to refer partners for testing. Results Among 46 persons (9 SC, 18 BI, 19 BIA), the average age was 28; 61% were male. The median viral load (VL) was 5.9 log copies/mL at enrollment. 67% (10/15) of BIA participants were suppressed (&lt;1000 copies/mL) at week 12 vs 25% BI and 50% SC (P = .07). Although the mean number of reported condomless sexual acts in the past week decreased from baseline across all arms (1.5 vs 0.3 acts), 36% experienced incident sexually transmitted infection by 52 weeks (12% SC, 28% BI, 18% BIA). Forty-one percent (19/46) of participants referred partners (44% SC, 44% BI, 37% BIA); 15 of the partners were HIV-infected. Conclusions Diagnosis of AHI facilitates behavioral and biomedical risk reduction strategies during a high-transmission period that begins years before people are typically identified and started on ARVs. Sexually transmitted infection incidence in this cohort suggests ongoing risk behaviors, reinforcing the importance of early intervention with ARVs to reduce transmission. Early diagnosis coupled with standard AHI counseling and early ARV referral quickly suppresses viremia, may effectively change behavior, and could have tremendous public health benefit in reducing onward transmission.

Abstract Background The DeWorm3 project is an ongoing cluster-randomised trial assessing the feasibility of interrupting the transmission of soil-transmitted helminths (STH) through mass drug administration (MDA) using study sites in India, Malawi and Benin. In this article, we describe an approach which uses a combination of statistical and mathematical methods to forecast the outcome of the trial with respect to its stated goal of reducing the prevalence of infection to below 2%. Methods Our approach is first to define the local patterns of transmission within each study site, which is achieved by statistical inference of key epidemiological parameters using the baseline epidemiological measures of age-related prevalence and intensity of STH infection which have been collected by the DeWorm3 trials team. We use these inferred parameters to calibrate an individual-based stochastic simulation of the trial at the cluster and study site level, which is subsequently run to forecast the future prevalence of STH infections. The simulator takes into account both the uncertainties in parameter estimation and the variability inherent in epidemiological and demographic processes in the simulator. We interpret the forecast results from our simulation with reference to the stated goal of the DeWorm3 trial, to achieve a target of $$\le 2\%$$ ≤ 2 % prevalence at a point 24 months post-cessation of MDA. Results Simulated output predicts that the two arms will be distinguishable from each other in all three country sites at the study end point. In India and Malawi, measured prevalence in the intervention arm is below the threshold with a high probability (90% and 95%, respectively), but in Benin the heterogeneity between clusters prevents the arm prevalence from being reduced below the threshold value. At the level of individual study arms within each site, heterogeneity among clusters leads to a very low probability of achieving complete elimination in an intervention arm, yielding a post-study scenario with widespread elimination but a few ‘hot spot’ areas of persisting STH transmission. Conclusions Our results suggest that geographical heterogeneities in transmission intensity and worm aggregation have a large impact on the effect of MDA. It is important to accurately assess cluster-level, or even smaller scale, heterogeneities in factors which influence transmission and aggregation for a clearer perspective on projecting the outcomes of MDA control of STH and other neglected tropical diseases.

Lymphatic filariasis (LF) is a tropical disease caused by infection with the parasitic filarial worms: Wuchereria bancrofti, Brugia malayi, and Brugia timori. The symptoms of this chronic disease appear in adults (in men more than in women) and include damage to the lymphatic system, arms, legs, and genitals, which cause significant pain, reducing productivity, and social problems. LF is a cause of continued disability, pain, disfigurement, and sexual disability in the world, so the knowledge of the disease and the infection control is very important. In addition to the importance of prevention, that includes giving medicine and using controlling ways of mosquitoes. Moreover, the prevention of disease is important, that includes giving medicine and using controlling ways of mosquitoes. However, although the efforts of health organizations to reduce the LF infections, there are still many challenges including the early diagnosis and control of infection among people.

Abstract Background House improvement (HI) to prevent mosquito house entry, and larval source management (LSM) targeting aquatic mosquito stages to prevent development into adult forms, are promising complementary interventions to current malaria vector control strategies. Lack of evidence on costs and cost-effectiveness of community-led implementation of HI and LSM has hindered wide-scale adoption. This study presents an incremental cost analysis of community-led implementation of HI and LSM, in a cluster-randomized, factorial design trial, in addition to standard national malaria control interventions in a rural area (25,000 people), in southern Malawi. Methods In the trial, LSM comprised draining, filling, and Bacillus thuringiensis israelensis-based larviciding, while house improvement (henceforth HI) involved closing of eaves and gaps on walls, screening windows/ventilation spaces with wire mesh, and doorway modifications. Communities implemented all interventions. Costs were estimated retrospectively using the ‘ingredients approach’, combining ‘bottom-up’ and ‘top-down approaches’, from the societal perspective. To estimate the cost of independently implementing each intervention arm, resources shared between trial arms (e.g. overheads) were allocated to each consuming arm using proxies developed based on share of resource input quantities consumed. Incremental implementation costs (in 2017 US$) are presented for HI-only, LSM-only and HI + LSM arms. In sensitivity analyses, the effect of varying costs of important inputs on estimated costs was explored. Results The total economic programme costs of community-led HI and LSM implementation was $626,152. Incremental economic implementation costs of HI, LSM and HI + LSM were estimated as $27.04, $25.06 and $33.44, per person per year, respectively. Project staff, transport and labour costs, but not larvicide or screening material, were the major cost drivers across all interventions. Costs were sensitive to changes in staff costs and population covered. Conclusions In the trial, the incremental economic costs of community-led HI and LSM implementation were high compared to previous house improvement and LSM studies. Several factors, including intervention design, year-round LSM implementation and low human population density could explain the high costs. The factorial trial design necessitated use of proxies to allocate costs shared between trial arms, which limits generalizability where different designs are used. Nevertheless, costs may inform planners of similar intervention packages where cost-effectiveness is known. Trial registration Not applicable. The original trial was registered with The Pan African Clinical Trials Registry on 3 March 2016, trial number PACTR201604001501493

Parkinson's malady is the most common neurodegenerative confusion influencing more than 10 million individuals around the world. There is no single test which can be regulated for diagnosing Parkinson's illness. In light of these challenges, to explore a machine learning way to deal with precisely analyze Parkinson's, utilizing a given dataset. To keep this issue in medicinal parts need to anticipate the malady influenced or not by discovering exactness figuring utilizing AI strategies. The point is to examine AI based methods for Parkinson sickness by expectation results in best precision with finding arrangement reportIn the beginning times of Parkinson ailment, your face may appear practically zero articulation. Your arms may not swing when you walk.. At times, your specialist may recommend medical procedure to manage certain locales of your cerebrum and improve your indications.To propose, an AI based strategy to precisely foresee the illness by discourse and tremor manifestations by expectation results as best exactness from looking at administer grouping AI calculations. Also, to look at furthermore, talk about the execution of different AI calculations from the given transport traffic division dataset with assessment arrangement report, distinguish the outcome demonstrates that the viability of the proposed AI calculation procedure can be thought about with best exactness with accuracy, Recall and F1 Score.

ABSTRACT Introduction Obstetric fistulae are a leading scourge for women in developing countries resulting, in severe individual suffering and devastating socio-economic repercussions for her family and community. The underlying causes of obstetric fistula stem from multiple factors to include poor nutrition, early marriage, insufficient education and inferior social status of women as well as substandard medical care. The US Agency for International Development (USAID) has invested more than $100 million globally since 2004 to address these factors as well as support women suffering with fistulae. The ultimate goal is to eradicate obstetric fistula in Bangladesh in the next 20 years. Despite these efforts, nearly 20,000 women in Bangladesh, still suffer with this malady. Methods To close this gap, USAID and the Department of Defense (DOD) developed a novel Interagency Agreement (IAA) leveraging the surgical skills of military health professionals to scale-up the ongoing fistula care program. The agreement outlined three lines of effort: (1) treat existing fistulae by bolstering surgical capacity of the existing USAID fistula care program; (2) promote fistula mitigation with lectures and hands-on teaching of obstetric care as well as safe gynecologic surgery; and (3) assist with advocacy at higher levels of the Bangladesh government. A Bangladesh Fistula Mission Partnership working group was formed to design and implement this IAA. Critical partners from the US Embassy in Dhaka included USAID (Health, Legal, Contracting), the DOD (Office of Defense Cooperation), and Department of State (Regional Security Officer). Partners from the US Army included United States Army-Pacific Command (Surgeon, Legal, Finance, Security Cooperation, Contracting), Regional Health Command-Pacific (Operations, Legal, Public Affairs), and Tripler Army Medical Center (Department of OBGYN, Operations, Public Affairs). Institutional Review Board approval was not required as the treatments offered were standard of care. Results The Tripler Army Medical Center (TAMC) health professionals executed the IAA with one pre-deployment site survey and two surgical missions in 2016–2017. The military team supported the surgical repair of 40 pelvic fistulae and perineal tears and provided operative management for an additional 25 patients with pelvic organ prolapse. Furthermore, the team conducted 19 professional lectures and multiple educational forums at hospitals in Kumudini, Khulna and the premier medical university in Dhaka for over 800 attendees including physicians, nurses and students to help prevent obstetric and surgical fistulae. Importantly, the team assisted USAID as subject matter experts in its advocacy to the Bangladesh Ministry of Health for improved maternity care and regulatory oversight. During the missions, the team enhanced their readiness by exercising individual and collective tasks while exposing personnel to the cultural context of the region. Conclusion This IAA was the first USAID funded and DoD-executed health mission in the US Indo-Pacific Command Area of Responsibility. Direct participation in the IAA enabled TAMC to support the US Indo-Pacific Command Theater Campaign Plan, the Department of Defense Instruction 2000.30 on Global Health Engagements, the USAID Country Development Cooperation Strategy, and the US Ambassadors Integrated Country Strategy Objectives in Bangladesh. This effort can serve as a model for future cooperation between USAID and the DoD.

Abstract Background With the global shortage of skilled health workers estimated at 7.2 million, outpatient tuberculosis (TB) care is commonly task-shifted to lay health workers (LHWs) in many low- and middle-income countries where the shortages are greatest. While shown to improve access to care and some health outcomes including TB treatment outcomes, lack of training and supervision limit the effectiveness of LHW programs. Our objective was to refine and evaluate an intervention designed to address common causes of non-adherence to TB treatment and LHW knowledge and skills training needs. Methods We employed a pragmatic cluster randomized controlled trial. Participants included 103 health centres (HCs) providing TB care in four districts in Malawi, randomized 1:1 stratified by district and HC funding (Ministry of Health, non-Ministry funded). At intervention HCs, a TB treatment adherence intervention was implemented using educational outreach, a point-of-care reminder tool, and a peer support network. Clusters in the control arm provided usual care. The primary outcome was the proportion of patients with successful TB treatment (i.e., cure or treatment completion). We used a generalized linear mixed model, with district as a fixed effect and HC as a random effect, to compare proportions of patients with treatment success, among the trial arms, with adjustment for baseline differences. Results We randomized 51 HCs to the intervention group and 52 HCs to the control group. Four intervention and six control HCs accrued no eligible patients, and 371 of 1169 patients had missing outcome, HC, or demographic data, which left 74 HCs and 798 patients for analysis. Randomization group was not related to missing outcome, however, district, age, and TB type were significantly related and included in the primary analysis model. Among the 1153 patients with HC and demographic data, 297/605 (49%) and 348/548 (64%) in the intervention and control arms, respectively, had treatment success. The intervention had no significant effect on treatment success (adjusted odds ratio 1.35 [95% confidence interval 0.93–1.98]). Conclusion We found no significant effect of the intervention on TB treatment outcomes with high variability in implementation quality, highlighting important challenges to both scale-up and sustainability. Trial registration ClinicalTrials.gov NCT02533089. Registered August 20, 2015.

Abstract Background Retention of HIV-infected mothers in integrated HIV and healthcare facilities is effective at reducing mother-to-child-transmission (MTCT) of HIV. In the context of Option B+, we examined maternal and HIV-exposed infant retention across three study arms to 18 months postpartum: mother-and-infant clinics (MIP), MIP with short-messaging service (MIP + SMS) and standard of care (SOC). In particular, we focused on the impact of mothers receiving an infant’s HIV PCR test result on maternal and infant study retention. Methods A quantitative sub-study nested within a cluster randomised trial undertaken between May 2013 and August 2016 across 30 healthcare facilities in rural Malawi enrolling HIV-infected pregnant mothers and HIV-exposed infants on delivery, was performed. Survival probabilities of maternal and HIV-exposed infant study retention was estimated using Kaplan-Meier curves. Associations between mother’s receiving an infant’s HIV test result and in particular, an infant’s HIV-positive result on maternal and infant study retention were modelled using time-varying multivariate Cox regression. Results Four hundred sixty-one, 493, and 396 HIV-infected women and 386, 399, and 300 HIV-exposed infants were enrolled across study arms; MIP, MIP + SMS and SOC, respectively. A total of 47.5% of mothers received their infant’s HIV test results < 5 months postpartum. Receiving an infant’s HIV result by mothers was associated with a 70% increase in infant non-retention in the study compared with not receiving an infant’s result (HR = 1.70; P-value< 0.001). Receiving a HIV-positive result was associated with 3.12 times reduced infant retention compared with a HIV-negative result (P-value< 0.001). Of the infants with a HIV-negative test result, 87% were breastfed at their final study follow-up. Conclusions Receiving an infant’s HIV test result was a driving factor for reduced infant study retention, especially an infant’s HIV-positive test result. As most HIV-negative infants were still breastfed at their last follow-up, this indicates a large proportion of HIV-exposed infants were potentially at future risk of MTCT of HIV via breastfeeding but were unlikely to undergo follow-up HIV testing after breastfeeding cessation. Future studies to identify and address underlying factors associated with infant HIV testing and reduced infant retention could potentially improve infant retention in HIV/healthcare facilities. Trial registration Pan African Clinical Trial Registry: PACTR201312000678196.

Hundreds of thousands of Australian children were born in the shadow of the Great War, fathered by men who had enlisted between 1914 and 1918. Their lives could be and often were hard and unhappy, as Anzac historian Alistair Thomson observed of his father’s childhood in the 1920s and 1930s. David Thomson was son of a returned serviceman Hector Thomson who spent much of his adult life in and out of repatriation hospitals (257-259) and whose memory was subsequently expunged from Thomson family stories (299-267). These children of trauma fit within a pattern suggested by Marianne Hirsch in her influential essay “The Generation of Postmemory”. According to Hirsch, “postmemory describes the relationship of the second generation to powerful, often traumatic, experiences that preceded their births but that were nevertheless transmitted to them so deeply as to seem to constitute memories in their own right” (n.p.). This article attempts to situate George Johnston’s novel My Brother Jack (1964) within the context of postmemory narratives of violence that were complicated in Australia by the Anzac legend which occluded any too open discussion about the extent of war trauma present within community, including the children of war.“God knows what damage” the war “did to me psychologically” (48), ponders Johnston’s protagonist and alter-ego David Meredith in My Brother Jack. Published to acclaim fifty years after the outbreak of the First World War, My Brother Jack became a widely read text that seemingly spoke to the shared cultural memories of a generation which did not know battlefield violence directly but experienced its effects pervasively and vicariously in the aftermath through family life, storytelling, and the memorabilia of war. For these readers, the novel represented more than a work of fiction; it was a touchstone to and indicative of their own negotiations though often unspoken post-war trauma.Meredith, like his creator, is born in 1912. Strictly speaking, therefore, both are not part of the post-war generation. However, they are representative and therefore indicative of the post-war “hinge generation” which was expected to assume “guardianship” of the Anzac Legend, though often found the narrative logic challenging. They had been “too young for the war to have any direct effect”, and yet “every corner” of their family’s small suburban homes appear to be “impregnated with some gigantic and sombre experience that had taken place thousands of miles away” (17).According to Johnston’s biographer, Garry Kinnane, the “most teasing puzzle” of George Johnston’s “fictional version of his childhood in My Brother Jack is the monstrous impression he creates of his returned serviceman father, John George Johnston, known to everyone as ‘Pop.’ The first sixty pages are dominated by the tyrannical figure of Jack Meredith senior” (1).A large man purported to be six foot three inches (1.9 metres) in height and weighing fifteen stone (95 kilograms), the real-life Pop Johnston reputedly stood head and shoulders above the minimum requirement of five foot and six inches (1.68 metres) at the time of his enlistment for war in 1914 (Kinnane 4). In his fortieth year, Jack Johnston senior was also around twice the age of the average Australian soldier and among one in five who were married.According to Kinnane, Pop Johnston had “survived the ordeal of Gallipoli” in 1915 only to “endure three years of trench warfare in the Somme region”. While the biographer and the Johnston family may well have held this to be true, the claim is a distortion. There are a few intimations throughout My Brother Jack and its sequel Clean Straw for Nothing (1969) to suggest that George Johnston may have suspected that his father’s wartime service stories had been embellished, though the depicted wartime service of Pop Meredith remains firmly within the narrative arc of the Anzac legend. This has the effect of layering the postmemory violence experienced by David Meredith and, by implication, his creator, George Johnston. Both are expected to be keepers of a lie masquerading as inviolable truth which further brutalises them.John George (Pop) Johnston’s First World War military record reveals a different story to the accepted historical account and his fictionalisation in My Brother Jack. He enlisted two and a half months after the landing at Gallipoli on 12 July 1915 and left for overseas service on 23 November. Not quite the imposing six foot three figure of Kinnane’s biography, he was fractionally under five foot eleven (1.8 metres) and weighed thirteen stone (82.5 kilograms). Assigned to the Fifth Field Engineers on account of his experience as an electric tram fitter, he did not see frontline service at Gallipoli (NAA).Rather, according to the Company’s history, the Fifth Engineers were involved in a range of infrastructure and support work on the Western Front, including the digging and maintenance of trenches, laying duckboard, pontoons and tramlines, removing landmines, building huts, showers and latrines, repairing roads, laying drains; they built a cinema at Beaulencourt Piers for “Brigade Swimming Carnival” and baths at Malhove consisting of a large “galvanised iron building” with a “concrete floor” and “setting tanks capable of bathing 2,000 men per day” (AWM). It is likely that members of the company were also involved in burial details.Sapper Johnston was hospitalised twice during his service with influenza and saw out most of his war from October 1917 attached to the Army Cookery School (NAA). He returned to Australia on board the HMAT Kildonian Castle in May 1919 which, according to the Sydney Morning Herald, also carried the official war correspondent and creator of the Anzac legend C.E.W. Bean, national poet Banjo Paterson and “Warrant Officer C G Macartney, the famous Australian cricketer”. The Herald also listed the names of “Returned Officers” and “Decorated Men”, but not Pop Johnston who had occupied the lower decks with other returning men (“Soldiers Return”).Like many of the more than 270,000 returned soldiers, Pop Johnston apparently exhibited observable changes upon his repatriation to Australia: “he was partially deaf” which was attributed to the “constant barrage of explosions”, while “gas” was suspected to have “left him with a legacy of lung disorders”. Yet, if “anyone offered commiserations” on account of this war legacy, he was quick to “dismiss the subject with the comment that ‘there were plenty worse off’” (Kinnane 6). The assumption is that Pop’s silence is stoic; the product of unspeakable horror and perhaps a symptom of survivor guilt.An alternative interpretation, suggested by Alistair Thomson in Anzac Memories, is that the experiences of the vast majority of returned soldiers were expected to fit within the master narrative of the Anzac legend in order to be accepted and believed, and that there was no space available to speak truthfully about alternative war service. Under pressure of Anzac expectations a great many composed stories or remained selectively silent (14).Data gleaned from the official medical history suggest that as many as four out of every five returned servicemen experienced emotional or psychological disturbance related to their war service. However, the two branches of medicine represented by surgeons and physicians in the Repatriation Department—charged with attending to the welfare of returned servicemen—focused on the body rather than the mind and the emotions (Murphy and Nile).The repatriation records of returned Australian soldiers reveal that there were, indeed, plenty physically worse off than Pop Johnston on account of bodily disfigurement or because they had been somatically compromised. An estimated 30,000 returned servicemen died in the decade after the cessation of hostilities to 1928, bringing the actual number of war dead to around 100,000, while a 1927 official report tabled the medical conditions of a further 72,388 veterans: 28,305 were debilitated by gun and shrapnel wounds; 22,261 were rheumatic or had respiratory diseases; 4534 were afflicted with eye, ear, nose, or throat complaints; 9,186 had tuberculosis or heart disease; 3,204 were amputees while only; 2,970 were listed as suffering “war neurosis” (“Enlistment”).Long after the guns had fallen silent and the wounded survivors returned home, the physical effects of war continued to be apparent in homes and hospital wards around the country, while psychological and emotional trauma remained largely undiagnosed and consequently untreated. David Meredith’s attitude towards his able-bodied father is frequently dismissive and openly scathing: “dad, who had been gassed, but not seriously, near Vimy Ridge, went back to his old job at the tramway depot” (9). The narrator-son later considers:what I realise now, although I never did at the time, is that my father, too, was oppressed by intimidating factors of fear and change. By disillusion and ill-health too. As is so often the case with big, strong, athletic men, he was an extreme hypochondriac, and he had convinced himself that the severe bronchitis which plagued him could only be attributed to German gas he had swallowed at Vimy Ridge. He was too afraid to go to a doctor about it, so he lived with a constant fear that his lungs were decaying, and that he might die at any time, without warning. (42-3)During the writing of My Brother Jack, the author-son was in chronically poor health and had been recently diagnosed with the romantic malady and poet’s disease of tuberculosis (Lawler) which plagued him throughout his work on the novel. George Johnston believed (correctly as it turned out) that he was dying on account of the disease, though, he was also an alcoholic and smoker, and had been reluctant to consult a doctor. It is possible and indeed likely that he resentfully viewed his condition as being an extension of his father—vicariously expressed through the depiction of Pop Meredith who exhibits hysterical symptoms which his son finds insufferable. David Meredith remains embittered and unforgiving to the very end. Pop Meredith “lived to seventy-three having died, not of German gas, but of a heart attack” (46).Pop Meredith’s return from the war in 1919 terrifies his seven-year-old son “Davy”, who accompanies the family to the wharf to welcome home a hero. The young boy is unable to recall anything about the father he is about to meet ostensibly for the first time. Davy becomes overwhelmed by the crowds and frightened by the “interminable blaring of horns” of the troopships and the “ceaseless roar of shouting”. Dwarfed by the bodies of much larger men he becomestoo frightened to look up at the hours-long progression of dark, hard faces under wide, turned-up hats seen against bayonets and barrels that are more blue than black ... the really strong image that is preserved now is of the stiff fold and buckle of coarse khaki trousers moving to the rhythm of knees and thighs and the tight spiral curves of puttees and the thick boots hammering, hollowly off the pier planking and thunderous on the asphalt roadway.Depicted as being small for his age, Davy is overwrought “with a huge and numbing terror” (10).In the years that follow, the younger Meredith desires emotional stability but remains denied because of the war’s legacy which manifests in the form of a violent patriarch who is convinced that his son has been rendered effeminate on account of the manly absence during vital stages of development. With the return of the father to the household, Davy grows to fear and ultimately despise a man who remains as alien to him as the formerly absent soldier had been during the war:exactly when, or why, Dad introduced his system of monthly punishments I no longer remember. We always had summary punishment, of course, for offences immediately detected—a cuffing around the ears or a sash with a stick of a strap—but Dad’s new system was to punish for the offences which had escaped his attention. So on the last day of every month Jack and I would be summoned in turn to the bathroom and the door would be locked and each of us would be questioned about the sins which we had committed and which he had not found out about. This interrogation was the merest formality; whether we admitted to crimes or desperately swore our innocence it was just the same; we were punished for the offences which, he said, he knew we must have committed and had to lie about. We then had to take our shirts and singlets off and bend over the enamelled bath-tub while he thrashed us with the razor-strop. In the blind rages of these days he seemed not to care about the strength he possessed nor the injuries he inflicted; more often than not it was the metal end of the strop that was used against our backs. (48)Ironically, the ritualised brutality appears to be a desperate effort by the old man to compensate for his own emasculation in war and unresolved trauma now that the war is ended. This plays out in complicated fashion in the development of David Meredith in Clean Straw for Nothing, Johnston’s sequel to My Brother Jack.The imputation is that Pop Meredith practices violence in an attempt to reassert his failed masculinity and reinstate his status as the head of the household. Older son Jack’s beatings cease when, as a more physically able young man, he is able to threaten the aggressor with violent retaliation. This action does not spare the younger weaker Davy who remains dominated. “My beating continued, more ferociously than ever, … . They ceased only because one day my father went too far; he lambasted me so savagely that I fell unconscious into the bath-tub, and the welts across my back made by the steel end of the razor-strop had to be treated by a doctor” (53).Pop Meredith is persistently reminded that he has no corporeal signifiers of war trauma (only a cough); he is surrounded by physically disabled former soldiers who are presumed to be worse off than he on account of somatic wounding. He becomes “morose, intolerant, bitter and violently bad-tempered”, expressing particular “displeasure and resentment” toward his wife, a trained nurse, who has assumed carer responsibilities for homing the injured men: “he had altogether lost patience with her role of Florence Nightingale to the halt and the lame” (40). Their marriage is loveless: “one can only suppose that he must have been darkly and profoundly disturbed by the years-long procession through our house of Mother’s ‘waifs and strays’—those shattered former comrades-in-arms who would have been a constant and sinister reminder of the price of glory” (43); a price he had failed to adequately pay with his uncompromised body intact.Looking back, a more mature David Meredith attempts to establish order, perspective and understanding to the “mess of memory and impressions” of his war-affected childhood in an effort to wrest control back over his postmemory violation: “Jack and I must have spent a good part of our boyhood in the fixed belief that grown-up men who were complete were pretty rare beings—complete, that is, in that they had their sight or hearing or all of their limbs” (8). While the father is physically complete, his brooding presence sets the tone for the oppressively “dark experience” within the family home where all rooms are “inhabited by the jetsam that the Somme and the Marne and the salient at Ypres and the Gallipoli beaches had thrown up” (18). It is not until Davy explores the contents of the “big deep drawer at the bottom of the cedar wardrobe” in his parents’ bedroom that he begins to “sense a form in the shadow” of the “faraway experience” that had been the war. The drawer contains his father’s service revolver and ammunition, battlefield souvenirs and French postcards but, “most important of all, the full set of the Illustrated War News” (19), with photographs of battlefield carnage. These are the equivalent of Hirsch’s photographs of the Holocaust that establish in Meredith an ontology that links him more realistically to the brutalising past and source of his ongoing traumatistion (Hirsch). From these, Davy begins to discern something of his father’s torment but also good fortune at having survived, and he makes curatorial interventions not by becoming a custodian of abjection like second generation Holocaust survivors but by disposing of the printed material, leaving behind artefacts of heroism: gun, the bullets, the medals and ribbons. The implication is that he has now become complicit in the very narrative that had oppressed him since his father’s return from war.No one apparently notices or at least comments on the removal of the journals, the images of which become linked in the young boys mind to an incident outside a “dilapidated narrow-fronted photographer’s studio which had been deserted and padlocked for as long as I could remember”. A number of sun-damaged photographs are still displayed in the window. Faded to a “ghostly, deathly pallor”, and speckled with fly droppings, years earlier, they had captured young men in uniforms before embarkation for the war. An “agate-eyed” boy from Davy’s school joins in the gazing, saying nothing for a long time until the silence is broken: “all them blokes there is dead, you know” (20).After the unnamed boy departs with a nonchalant “hoo-roo”, young Davy runs “all the way home, trying not to cry”. He cannot adequately explain the reason for his sudden reaction: “I never after that looked in the window of the photographer’s studio or the second hand shop”. From that day on Davy makes a “long detour” to ensure he never passes the shops again (20-1). Having witnessed images of pre-war undamaged young men in the prime of their youth, he has come face-to-face with the consequences of war which he is unable to reconcile in terms of the survival and return of his much older father.The photographs of the young men establishes a causal connection to the physically wrecked remnants that have shaped Davy’s childhood. These are the living remains that might otherwise have been the “corpses sprawled in mud or drowned in flooded shell craters” depicted in the Illustrated News. The photograph of the young men establishes Davy’s connection to the things “propped up our hallway”, of “Bert ‘sobbing’ in the backyard and Gabby Dixon’s face at the dark end of the room”, and only reluctantly the “bronchial cough of my father going off in the dawn light to the tramways depot” (18).That is to say, Davy has begun to piece together sense from senselessness, his father’s complicity and survival—and, by association, his own implicated life and psychological wounding. He has approached the source of his father’s abjection and also his own though he continues to be unable to accept and forgive. Like his father—though at the remove—he has been damaged by the legacies of the war and is also its victim.Ravaged by tuberculosis and alcoholism, George Johnston died in 1970. According to the artist Sidney Nolan he had for years resembled the ghastly photographs of survivors of the Holocaust (Marr 278). George’s forty five year old alcoholic wife Charmian Clift predeceased him by twelve months, having committed suicide in 1969. Four years later, in 1973, George and Charmian’s twenty four year old daughter Shane also took her own life. Their son Martin drank himself to death and died of organ failure at the age of forty three in 1990. They are all “dead, you know”.ReferencesAWM. Fifth Field Company, Australian Engineers. Diaries, AWM4 Sub-class 14/24.“Enlistment Report”. Reveille, 29 Sep. 1928.Hirsch, Marianne. “The Generation of Postmemory.” Poetics Today 29.1 (Spring 2008): 103-128. <https://read.dukeupress.edu/poetics-today/article/29/1/103/20954/The-Generation-of-Postmemory>.Johnston, George. Clean Straw for Nothing. London: Collins, 1969.———. My Brother Jack. London: Collins, 1964.Kinnane, Garry. George Johnston: A Biography. Melbourne: Nelson, 1986.Lawler, Clark. Consumption and Literature: the Making of the Romantic Disease. Basingstoke: Palgrave Macmillan, 2006.Marr, David, ed. Patrick White Letters. Sydney: Random House, 1994.Murphy, Ffion, and Richard Nile. “Gallipoli’s Troubled Hearts: Fear, Nerves and Repatriation.” Studies in Western Australian History 32 (2018): 25-38.NAA. John George Johnston War Service Records. <https://recordsearch.naa.gov.au/SearchNRetrieve/Interface/ViewImage.aspx?B=1830166>.“Soldiers Return by the Kildonan Castle.” Sydney Morning Herald, 10 May 1919: 18.Thomson, Alistair. Anzac Memories: Living with the Legend. Clayton: Monash UP, 2013.