Estimating survival in patients with gastrointestinal cancers and brain metastases: An update of the graded prognostic assessment for gastrointestinal cancers (GI-GPA).

BackgroundPatients with gastrointestinal cancers and brain metastases (BM) represent a unique and heterogeneous population. Our group previously published the Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) for patients with GI cancers (GI-GPA) (1985-2007, n = 209). The purpose of this study is to update the GI-GPA based on a larger contemporary database.MethodsAn IRB-approved consortium database analysis was performed using a multi-institutional (18), multi-national (3) cohort of 792 patients with gastrointestinal (GI) cancers, with newly-diagnosed BM diagnosed between 1/1/2006 and 12/31/2017. Survival was measured from date of first treatment for BM. Multiple Cox regression was used to select and weight prognostic factors in proportion to their hazard ratios. These factors were incorporated into the updated GI-GPA.ResultsMedian survival (MS) varied widely by primary site and other prognostic factors. Four significant factors (KPS, age, extracranial metastases and number of BM) were used to formulate the updated GI-GPA. Overall MS for this cohort remains poor; 8 months. MS by GPA was 3, 7, 11 and 17 months for GPA 0-1, 1.5-2, 2.5-3.0 and 3.5-4.0, respectively. >30% present in the worst prognostic group (GI-GPA of ≤1.0).ConclusionsBrain metastases are not uncommon in GI cancer patients and MS varies widely among them. This updated GI-GPA index improves our ability to estimate survival for these patients and will be useful for therapy selection, end-of-life decision-making and stratification for future clinical trials. A user-friendly, free, on-line app to calculate the GPA score and estimate survival for an individual patient is available at brainmetgpa.com

Association of Partner Support and Partner Communication with Provider Prescribed Contraceptive Method Use among Heterosexual Couples in Kisumu, Kenya

We explored partner support and communication factors associated with provider prescribed contraceptive (PPC) use to inform contraception  interventions among heterosexual couples in Kenya. From April 2014 through September 2016, 252 community recruited couples in Kisumu, Kenya, were enrolled. Men and women were surveyed separately and asked about communication regarding sexual/reproductive health and relationship characteristics. PPC use was defined as female reported use of pills, injection, implant, IUD, or tubal ligation. Multivariable Poisson regression with robust variance estimate was used to identify factors associated with PPC. In multivariable modeling, women who reported discussing the future of their relationship with their partner were 2.46 (95% CI: 1.13-5.36) times more likely, and men who reported discussing condom use were 0.83 (95% CI: 0.72-0.95) time less likely, to report PPC use. These findings call for greater attention to involving male partners, incorporating communication skills, and relationship characteristics into interventions in our and similar settings.  Keywords: Family planning, male involvement, reproductive health, agency, Africa Nous avons exploré le soutien des partenaires et les facteurs de communication associés à l'utilisation de contraceptifs prescrits par le fournisseur (PPC) pour informer les interventions de contraception auprès des couples hétérosexuels au Kenya. D'avril 2014 à septembre 2016, 252 couples recrutés par la communauté à Kisumu, au Kenya, étaient inscrits. Les hommes et les femmes ont été interrogés séparément et interrogés sur la communication concernant la santé sexuelle / reproductive et les caractéristiques des relations. L'utilisation du CPP a été définie comme l'utilisation déclarée par les femmes de pilules, d'injection, d'implant, de DIU ou de ligature des trompes. Une régression de Poisson multivariable avec une estimation de variance robuste a été utilisée pour identifier les facteurs associés au CPP. Dans la modélisation multivariable, les femmes qui ont déclaré discuter de l'avenir de leur relation avec leur partenaire étaient 2,46 (IC à 95%: 1,13-5,36) fois plus susceptibles, et les hommes qui ont  déclaré discuter de l'utilisation du préservatif étaient 0,83 (IC à 95%: 0,72-0,95). Moins susceptibles de signaler l'utilisation du PPC. Ces résultats appellent à une plus grande attention à l'implication des partenaires masculins, à l'intégration des compétences en communication et des caractéristiques relationnelles dans les interventions dans notre environnement et dans des environnements similaires. Mots-clés: Planification familiale, implication masculine, santé reproductive, agence, Afriqu

Water, sanitation and hygiene at sex work venues to support menstrual needs

Introduction: Adequate menstrual health and hygiene (MHH) is necessary for women’s health and equity of all menstruators. Female sex workers (FSW) require good MHH to prevent discomfort and exposure to pathogens. No studies have evaluated water, sanitation, and hygiene (WASH) conditions of FSW. We report on a cross-sectional WASH assessment at FSW venues in Kisumu, western Kenya. Methods: Stakeholders identified 77 FSW venues in Kisumu, of which 47 were randomly sampled and visited between April-May 2023. A standardized structured survey of WASH conditions was deployed by trained research staff using Android tablets after proprietor’s consent. WASH scores ranging 0 – 3 were computed based on point each for direct observation of water available, soap available, and acceptable latrine. MHH scores ranging between 0-4 were computed (one point each) for direct observation of: currently available soap and water, locking door on a usable latrine, functional lighting, and a private area for changing clothes or menstrual materials, separate from the latrine(s). WASH and MHH scores were compared by venue type using non-parametric Kruskal-Wallis tests, and non-parametric Spearman rank tests. Results: Full WASH criteria was met by 29.8% of venues; 34.0% had no adequate WASH facilities; 46.8% had no female latrine, and 25.5% provided soap and water in private spaces for women. While 76.6% had menstrual waste disposal only 14 (29.8%) had covered bins. One in 10 venues provided adequate MHM facilities. Poorest WASH facilities were in brothels and in bars, and three-quarters of bars with accommodation had no MHH facilities. Discussion: WASH and MHH services were sub-optimal in the majority of FSW venues, preventing menstrual management safely, effectively, with dignity and privacy. This study highlights the unmet need for MHH support for this population. Poor MHH can deleteriously impact FSW health and wellbeing and compound the stigma and shame associated with their work and ability to stay clean. Acceptable and cost-effective solutions to sustainably improve WASH facilities for these populations are needed

‘Better she gets infected by other diseases but not pregnancy’. Narratives from adolescent girls and community males following pregnancy escalation during COVID-19 lockdown

Introduction: Adolescent sexual and reproductive health in low- and middle-income countries is critical to address following the COVID-19 pandemic. Growing evidence of its’ impact includes increased teenage pregnancies and higher rates of unsafe abortion. Our qualitative study sought to understand perspectives and behaviours around these escalations. Methods: Using random sampling we conducted focus group discussions with adolescent girls and young women (AGYW) from western Kenya to understand perceptions and behaviours that drove high rates of pregnancy and abortion. Alongside, male opinions were sought using opportunistic sampling to recruit participants. Results: Six FGDs with AGYW (n = 54) and five with community males (n = 53) were conducted with data analysed using thematic analysis. Results were grouped under 4 themes: (1) Fear, responsibility and blame; (2) Drivers of abortion; (3) Accessing an abortion; (4) Family planning including condom use. AGYW narratives revealed a dread of unintended pregnancy fearing parental and community reactions whilst men feared unfair blame from the community for impregnating AGYW despite admissions of sexual relationships with schoolgirls. Abortion attempts were common, girls described clandestine bids, including ingestion of dangerous or ineffective products, methods corroborated by the men. Many participants, male and female did nothing to mitigate pregnancy risks, disliking condoms and perceiving family planning as a threat to future fertility, or giving license to girls’ promiscuity. Conclusion: AGYW remain at high pregnancy and unsafe abortion risk until community attitudes and knowledge are challenged. Our findings highlight the need for information and education to dispel myths and misinformation regarding family planning methods, and address inequities in gender norms. Safe, legal and affordable abortion is also paramount. Follow-up is required to assess long term physical and psychological consequences of the high number of unwanted pregnancies and abortions, particularly amongst those who had a failed abortion.</p

Evaluation of large language models within GenAI in qualitative research

Large language models (LLMs) perform tasks such as summarizing information and analyzing sentiment to generate meaningful and natural responses. The application of GenAI incorporating LLMs raises potential utilities for conducting qualitative research. Using a qualitative study that assessed the impact of the COVID-19 pandemic on the sexual and reproductive health of adolescent girls and young women (AGYW) in rural western Kenya: our objective was to compare thematic analyses conducted by GenAI using LLM to qualitative analysis conducted by humans, with regards to major themes identified, selection of supportive quotes, and quality of quotes; and secondarily to explore quantitative and qualitative sentiment analysis conducted by the GenAI. We interfaced with GPT-4o through google colaboratory. After inputting the transcripts and pre-processing, we constructed a standardized task prompt. Two investigators independently reviewed the GenAI product using a rubric based on qualitative research standards. When compared to human-derived themes, we did not find disagreement with the sub-themes raised by GenAI, but did not consider some to rise to level of a theme. Performance was low and variable with regards to selection of quotes that were consistent with and strongly supportive of thematic and sentiment analysis. Hallucinations ranged from a single word or phrase change to truncation or combinations of text that led to modified meaning. GenAI identified numerous and relevant biases, primarily related to the underlying training data and its lack of cultural understanding. Few prior studies have directly compared LLM-driven thematic coding with human coding in qualitative analysis, and our study - grounded in qualitative study rigor - allowed for a thorough evaluation. GenAI implemented in GPT-4o was unable to provide a thematic analysis that is indistinguishable from a human analysis. We recommend that it can currently be used as an aid in identifying themes, keywords, and basic narrative, and potentially as a check for human error or bias. However, until it can eliminate hallucinations, provide better contextual understanding of quotes and undertake a deeper scrutiny of data, it is not reliable or sophisticated enough to undertake a rigorous thematic analysis equal in quality to experienced qualitative researchers.</p

In Vitro Study to Assess Effective Cleaning Techniques for Removing Staphylococcus aureus from Menstrual Cups

Background: We sought to determine the effectiveness of common cleaning procedures in eliminating S. aureus from silicone menstrual cups. Methods: In this in vitro study, we tested four cleaning techniques: (1) cold water; (2) cold water and liquid soap; (3) cold water followed by steeping the cup in boiled water for 5 min in a ceramic mug covered with a small plate; and (4) cold water and soap followed by steeping the cup in boiled water as in (3). Human blood was coated to the inner and outer surface of each cup, dried, and incubated with 106 S. aureus colony-forming units (CFU/mL). All tests were performed in triplicate. Viable bacterial abundance was measured with decadic dilution and drop plate or surface plating. Results: Bacteria were most effectively eliminated by cleaning cups with soap and water and then steeping in boiled water (0 CFU/cup vs. 2.075 × 108/cup no cleaning, p = 0.005). This was not statistically significantly different from washing cups with water only and steeping 5 min in boiled water (14 CFU/cup). Raised lettering on the outer surface of the menstrual cups resulted in more bacterial recovery from pieces with lettering than without lettering. Conclusions: These results advance knowledge of between-period menstrual cup cleaning recommendations, suggesting that the logistical challenges of continuous boiling may be eliminated with steeping at least 5 min

‘once they see blood then the mood for sex is spoiled’ A qualitative exploration of female sex worker’s male client views of menstruation, sex during menses and the menstrual disc

To continue working during menses, female sex workers (FSW) may use unhygienic absorbents to hide their menstrual status. The menstrual disc may provide a solution. Little is known about men’s knowledge and views, specifically around sex during menstruation with FSW, a population who are particularly vulnerable to violence which may be heightened during menses. To identify constructs for successful and safe menstrual disc implementation we sought to identify knowledge and attitudes towards menstruation among male clients of FSW, including views on FSW menstrual disc use during intercourse. We conducted six focus group discussions comprising a total of 51 male clients of FSW, in Kisumu, Kenya, exploring their perceptions of menses and sex during menses. In preparation for future implementation of a menstrual disc intervention, we introduced the disc to participants with an information session, answering their questions and gathering their opinions on it. Thematic analysis found most clients had limited or inaccurate knowledge about menstruation, viewing blood and the menstruator, as dirty or unclean. Sources of knowledge included school, female relatives/partners, community or church. Those reporting formal education described the biological processes more accurately, while church education lent towards stigmatized perceptions. Most participants expressed negative views towards sex during menses (i.e., unpleasurable, forbidden or risky), usually stemming from misconceptions, and reported seeking FSW services because their wife / girlfriend was menstruating. Many felt deceived if a FSW was menstruating, were often aware of materials placed vaginally to absorb blood, but generally continued with the service. No clients had prior knowledge of the menstrual disc but accepted it as a safe, hygienic, and cost-effective alternative, with some voicing interest to purchase for their wife / girlfriend. We conclude there is a need to provide accurate information on menstruation to boys and men including in school curricula and faith teaching to address lack of knowledge and negativity. These findings suggest potential for adoption of menstrual discs by FSW with minimal adverse client reaction, and highlight possible partner support for women considering adopting a menstrual disc

Chlamydia and gonorrhoea infections in young Kenyan HIV-negative cisgender men who have sex with men and transgender women: a multicentre cohort study

Objectives: To assess the prevalence, incidence and factors associated with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection among HIV-negative men who have sex with men (MSM) and transgender women (TGW) in Kenya. Design: Prospective cohort. Setting: Kisumu, Nairobi and coastal Kenya. Participants: 650 young adult participants (570 MSM and 80 TGW) recruited at three research clinics. Inclusion criteria were HIV-negative status, age 18–29 years, assigned male sex at birth, identification as cisgender male or transgender female and reported anal intercourse with a man in the past 3 months. Primary and secondary outcome measures: Urine, rectal and oropharyngeal samples were tested for CT/NG infection at two different time points (∼6 months apart), using nucleic acid amplification. We compared CT/NG prevalence and incidence in MSM versus TGW and used Poisson regression to compare risk for each group after adjustment for other correlates of prevalent and incident CT/NG infection. Results: Prevalence of CT/NG infection at any anatomic site was 15.8% and 27.5% in MSM and TGW, respectively (p=0.009). CT/NG incidence was 27.2 (95% CI 21.3 to 34.7) and 24.5 (95% CI 12.3 to 49.0) per 100 person years for MSM and TGW, respectively (p=0.784). In multivariable analysis, there was no difference in prevalence or incidence by gender identity. Baseline CT/NG infection was more prevalent among TGW (adjusted prevalence ratio 1.61, 95% CI 0.99 to 2.62). Incident CT/NG infection was increased among participants with baseline CT/NG infection (adjusted incidence rate ratio (aIRR) 3.14, 95% CI 1.94 to 5.07) and self-reported pre-exposure prophylaxis use (aIRR 1.75, 95% CI 1.04 to 2.93). Conclusion: Despite higher prevalence of CT/NG infections among TGW at baseline, there were no differences in CT/NG prevalence and incidence between TGW and MSM, after adjustment for potential confounders. Improved condom use, effective partner notification and treatment, and new strategies such as doxycycline post-exposure prophylaxis are needed to reduce CT/NG infections in both MSM and TGW in settings where regular testing is not possible

“Whenever I help her, I am also expecting her vagina in return”: a qualitative analysis to explore men’s and adolescent girls’ perceptions of the impact of the COVID-19 pandemic on the sexual behaviour and health of adolescent girls in rural western Kenya

Introduction: The COVID-19 pandemic caused school closures, which intensified the negative sexual and reproductive health (SRH) of adolescent girls in sub-Saharan Africa (SSA), including increases in transactional sexual partnerships, gender-based violence, risk of early pregnancy and sexually transmitted infections (STIs). We conducted a qualitative study to understand how adolescent girls experienced and reacted to the pandemic restrictions and perceived consequences on their schooling and sexual behaviours. In parallel, we sought community men’s perceptions and opinions on the same issues. Methods: Set in rural western Kenya, the study used six focus group discussions with adolescent girls and five with community males aged 19–41 years, conducted from June 2022 to January 2023. Results: Thematic analysis identified three key themes, parallel in girls and men: (1) impacts of COVID-19 on schooling: girls reported uncertainty around ever returning to education, consequently losing motivation to study, which was also observed by men; (2) drivers that increased sexual activity: transactional sex became a greater necessity due to acute poverty, while opportunity escalated through additional leisure time and (3) sexual behaviours and practices: girls increased the number of partners and frequency of sexual encounters, with power-imbalances reported. Men believed they were assisting girls through transactional sex but this was often conditional on receiving sex in return, viewing themselves as victims of girls’ seductive advances, and blaming girls for transmitting STIs. Conclusion: School closure jeopardised girls’ SRH through acute poverty and increased opportunity for sexual exposure. Mitigation methods are needed now to prevent girls bearing the brunt of ensuing societal disruption and acute poverty in future catastrophes. Deeper understanding of men’s attitudes and behaviours towards adolescent girls are needed to improve the foundation for working with them to reduce power imbalance and compulsion in sexual interactions with adolescent girls

Menstrual cups to reduce bacterial vaginosis and STIs through reduced harmful sexual and menstrual practices among economically vulnerable women: protocol of a single arm trial in western Kenya

Background In western Kenya, menstrual hygiene management (MHM) is a pervasive problem. Challenges are compounded for economically constrained women who continue to engage in sex during menses and resort to practices such as vaginal insertion of tissue and cotton to maintain dryness during sex. These practices can be harmful to the vaginal microbiome (VMB) and can lead to high rates of sexually transmitted infections (STIs) and HIV. This study will evaluate whether menstrual cups that can be worn during intercourse may be beneficial to the VMB and help prevent Bacterial vaginosis (BV) and STI acquisition among these economically vulnerable women. Methods In this single-arm trial among economically vulnerable women in semi-urban western Kenya, we will evaluate the preliminary efficacy of menstrual cups on non-optimal VMB, BV, and STIs, and investigate safety, acceptability, and implementation needs. Through peer referral we aim to recruit 402 menstruating women aged 15–35 who exchange sex for money or basic needs. Women who are pregnant, have delivered in the past six months, or use an intrauterine device (IUD) will not be eligible. Participants will be seen every six months for 24 months and be asked about their sexual and MHM practices, with samples collected to assess BV and VMB. At baseline, 12-, and 24-month visits, additional samples will be collected to measure HIV and STIs (C. trachomatis, N. gonorrhoeae, and T. vaginalis). HSV-2 status will be assessed at baseline. Intervention provision will consist of one reusable disc-shaped menstrual cup per participant and a group-based training within four weeks of the 12-month visit, followed by monthly telephone surveys for the first three months to assess cup use, adverse events, and provide any assistance. Primary analyses of preliminary efficacy will compare probabilities of optimal VMB, BV, and STIs in the pre-intervention period to the post-intervention period. Primary safety analyses will compare occurrence of menstrual toxic shock syndrome and cervicovaginal laceration. Discussion If demonstrated safe and effective, this multipurpose reproductive health intervention will offer a dignified solution for the menstrual hygiene needs of women who engage in sex for livelihood and reduce their occurrence of non-optimal VMB, BV, and STIs