To examine substance abuse treatment providers’ views on engaging clients in Pre-exposure Prophylaxis (PrEP) care and research trials.Thirty-six medical and counseling service providers in six New York City outpatient substance abuse treatment programs participated in semi-structured qualitative interviews. Thematic content analysis was conducted by three coders, independently.Providers’ perspectives toward PrEP were characterized by six salient themes: 1) Limited PrEP awareness. 2) Ambivalence about PrEP; 3) Perception of multiple challenges to delivery; 4) Uncertainty about clients’ ability to be adherent to medication; 5) Concerns about medication safety/side effects; and 6) Perception of multiple barriers to conducting clinical trials.Despite anticipated challenges, providers supported the introduction of PrEP in outpatient substance abuse treatment. Comprehensive training for providers is needed and should include PrEP eligibility criteria, strategies to support adherence and medication monitoring guidelines. Linkages between substance abuse treatment and primary care and/or enhancement of capacity within clinics to offer PrEP may help facilitate PrEP delivery. When conducting research in outpatient clinics, it is particularly important to protect client confidentiality. In the US, there are approximately two million substance users in community treatment programs who are at risk for HIV . BecauseStudies of New York City substance users in (D.C. ) and outThe interrelationship between HIV and substance abuse necessitates a coordinated effort for providers  of substance abuse treatment  to preveWhile primary care providers in community clinics have expressed willingness to prescribe PrEP to patients that are at risk for HIV, they sometimes do not agree on how to determine PrEP eligibility. Likewise, they noted implementation challenges including: difficulties monitoring PrEP within the current primary care structure, managing adherence issues and side effects . PhysiciSubstance abuse treatment providers are fundamental to the adoption and delivery of PrEP, and the implementation of PrEP research, through their roles in counseling and coordination of care with clients’ primary care providers. Yet, the personal and organizational motives and challenges that providers can anticipate -- in delivering PrEP and participating in PrEP research – are not known. Such information is crucial to developing PrEP programs in substance abuse treatment – that offer the greatest promise for integrating PrEP, or linkage to PrEP, within substance abuse treatment. Such information is also crucial to identifying potential approaches to engage substance users in PrEP, and monitor and support their adherence.To fill these important gaps, we conducted a qualitative study of outpatient substance abuse treatment providers’ perspectives toward providing PrEP in their programs. This leveraged the existing platform of the Greater New York Node of the NIDA Clinical Trials Network (CTN) – a network of community-based treatment and medical care facilities dedicated to carrying out effectiveness trials of proven  interventions for substance users. Outpatient substance abuse treatment programs in New York City include psychosocial programs, methadone maintenance programs, and harm reduction programs that offer syringe exchange. In this study we included four programs that offer psychosocial treatment and two programs that offer both psychosocial and methadone maintenance. Three programs were hospital-based and three were community-based. In each of six programs, a complement of providers – including counselors, physician and Director – was recruited. Each provider participated in a semi-structured interview – which elicited his/her views of important issues for PrEP program and research implementation. In doing so, this study aimed to obtain critical information for the integration of PrEP into treatment. In particular, we aimed to: 1) inform best practices for implementing PrEP research in substance abuse treatment; 2) suggest strategies to optimize delivery of PrEP; and 3) identify needs for provider training and potential salient targets for training.Eligible agencies offered: 1) outpatient substance abuse treatment services in New York City and 2) were in the Clinical Trials Network (CTN). Twelve agencies were eligible. Seven executive directors (EDs) were successfully contacted by the PI, first by introductory email, and then with a follow-up phone call. The PI explained the purpose of the study, inclusion criteria, and incentives. Further, inclusion criteria for participants required that six providers  from each agency be interviewed. Each interviewee would receive a $40 cash incentive. Six EDs agreed to participate in the study. One ED declined to participate due to restructuring at the hospital where the program was based. All human subjects procedures were approved by the appropriate Institutional Review Board.Using a community based participatory research approach (CBPR), which has been shown over the past two decades to enhance the external validity and relevance of research findings , the semThe PI conducted interviews at each site in a private office space provided. The clinic director at each site scheduled interviews in advance so as not to disturb the workflow in the clinic and minimize burden on the clinic staff. Interviews lasted approximately 30 minutes and were audio recorded and transcribed verbatim. No names or any other identifying information were recorded. At the start of the interview, participants received a study information sheet, as well as a packet of information summarizing the “state of the art” evidence-based behavioral and bio-behavioral HIV prevention strategies and PrEP. Participants were guided through the information and were encouraged to ask questions about PrEP and to reflect upon what they had learned. Through open-ended questions, providers were asked to describe their reactions to PrEP, how they might anticipate implementing PrEP at their clinics and to what extent they would be receptive to conducting PrEP trials at their clinics. They were asked to describe barriers and promoters to these PrEP initiatives.36 Providers (N = 36) were surveyed from 6 outpatient substance abuse treatment clinics . Two of the three hospital based programs and one of the Community based programs offered Methadone Maintenance. Eight providers were medical, six were clinic directors, and 22 were counselors.The providers at the agencies held the following licenses/degrees: 10 held Masters of Social Work degrees, 5 held both Masters of Social Work degrees and Credentialed Alcohol and Substance Abuse Counselor (CASAC) designation, 1 had a Master of Social Work and a Master of Exercise Physiology degree, 2 held Bachelor’s degrees and CASAC, 2 held Bachelor’s degrees, 6 providers held only CASAC, one provider was a Licensed Practical Nurse, 1 provider was Registered Nurse, 1 provider was a Nurse Practitioner, 1 provider was a Physician Assistant, 5 providers were Medical Doctors, 1 provider held a Master of Science in Vocational Counseling.Data analysis was conducted by the PI and the two community consultants, over a series of in person meetings, based on a modified Grounded Theory approach using thematic content analysis  and orgaThe panel of three coders independently coded the first two interviews using a line-by-line open-coding strategy according to thematic content analysis to identify chunks of text that fall under the themes of inquiry, PrEP: 1) awareness/experiences; 2) barriers/promoters, and 3) strategies to overcome challenges and 4) providers’ perspectives, opinions, and practices related to PrEP. Meetings to compare coding and to achieve 100% consensus were held in order to build a codebook.Subsequently coders coded the next two interviews and met to discuss and compare, adding additional domains as they emerged and meeting regularly until saturation occurred. Saturation of data occurred after twelve interviews. The codebook was finalized at this point. We then analyzed all transcripts based upon the codebook, which contained definitions of each domain. These definitions were used to mark the text of all transcripts. We marked only text that matched the definitions in the codebook. Once we determined which passages in the transcripts best represent the constructs in the codebook, a grid containing these passages was created. These passages (“quotes”) were then reviewed, and revised for grammatical clarity and entered into HyperResearch qualitative data management software.Reports were extracted based upon the findings that emerged related to PrEP and organized according to content analysis. This resulted in the analysis of salient themes. Based upon the themes of inquiry, six areas emerged as most salient for the providers. These are: 1) Limited awareness of PrEP. 2) Ambivalent perspectives toward offering PrEP. 3) Challenges in delivering PrEP. 4) Uncertainty about adherence to PrEP. 5) Concerns about safety/side effects. 6) Barriers to conducting clinical trials.Findings are presented across job roles, organizations, and educational backgrounds.There was an overall lack of awareness of PrEP in this sample, with only four of the 36 providers having had prior awareness of PrEP. One was a hospital administrator, a psychiatrist, who has had extensive involvement in clinical and behavioral research trials as a site co-PI with academic partners; one who was a psychiatrist who had recently completed a post-graduate research fellowship in addiction; one was a nurse practitioner who recently graduated with a Masters in nursing; and one was an MSW-level social worker who had recently completed graduated school. The remaining 32 providers said they had never heard of PrEP or were not aware that there were pharmacological approaches to HIV prevention. For 32 of the providers surveyed, the informational materials provided by the PI were the first instance they were learning of PrEP.The four providers that already knew about PrEP felt favorably toward offering PrEP to their clients, stating that it would be beneficial to substance using clients, particularly because of sexual, and in some cases, needle-sharing risk. One medical provider mentioned that he had read “some studies” describing PrEP trials, however he was unaware that PrEP had since received FDA approval. Therefore, while this provider was aware of PrEP, the lack of awareness of PrEP’s availability would have prevented the provider from presenting this as an option to an at-risk client.“Yes. I’ve heard about -- research related to it. That you take high-risk people, like injection drug users, or people with high risk sexual behavior, and prophylactically give them antiretrovirals. And -- and my understanding of the research is that it’s highly effective in preventing, you know, similar to -- similar to giving antiretrovirals to mothers who were pregnant, you know, seriously reduced the risk of kids getting it” .“I think if they’re already engaging in risky behaviors, I think it’s safe to be safer, and to have something in place, and not to just tell them not to do the risky behavior. You could work on the risky behaviors while they’re taking the pill and being safe at the same time. So then we could discuss how to discontinue risky behaviors but in the meantime you’re safe until they get to that point so I think that’s excellent.” .For those providers who had not heard of PrEP, initial reactions to learning about PrEP were overwhelmingly positive. 29 providers stated that PrEP was a welcome advance in prevention and that it would be a benefit to their clients. All of the medical providers had a strongly positive reaction to PrEP and stated their support for offering PrEP to their clients. Counseling providers in general reacted favorably and considered PrEP as a tool that could be used as a complement to counseling. “I already know that everything is not for everybody, because we have some people that have very promiscuous behaviors. And I think a drug like this would probably or could -- has the potential to make them, like I said, more promiscuous.” .Four providers reacted negatively and 2 were neutral, mainly due to a belief in “risk compensation,” the notion that PrEP would result in a client feeling protected against HIV and therefore more likely to engage in risky sexual behavior . These santicipated practices for delivering PrEP in their outpatient substance abuse treatment setting. In other words, how they anticipate the process of implementation may look or how they suppose barriers to implementation may present.Providers had never implemented PrEP in their clinics, nor had they participated in PrEP research trials. Providers’ were asked about their Providers anticipated the following challenges regarding offering PrEP: 1) Educating clients through counseling about PrEP, when they themselves had very little/limited information about PrEP, 2) Prescribing and/or monitoring PrEP without qualified medical staff to prescribe  and without sufficient funding for medication monitoring through blood tests, 3) determining eligibility criteria , 4) making referrals to (primary care) providers who can prescribe PrEP without referral-making procedures and policies in place.“Right. Yeah. I would empower them, you know, with having, you know, that as a choice, you know, an option, you know, in their life, you know, it’s the same way I would -- might tell them, you know, about other programs and resources that are out there.” .Nearly all of the counseling and some medical providers stated that their PrEP implementation would consist mainly of offering education and information to clients about PrEP as an option for HIV prevention. They were willing to discuss PrEP, hand out written materials, and offer general information about the availability of PrEP. “Yeah, serious training. Just, basically, what to say, how to say it, and really something that we will remember as far as our own interpreting it into our own words and giving it to the client.”-counselor, community based.However, in order to do so providers stated that they would need training about PrEP and how to present the information to clients. “I think I would, you know, I would educate them about it. You know, I wouldn’t necessarily-- maybe I wouldn’t go ahead and make a direct referral to them….but I would raise it, you know, raise it to the client’s attention, you know, that it’s something, you know, that’s available, you know” .“I’d just educate them. I wouldn’t recommend it. I would educate them that it’s out there, and that’s it.” .“Yeah, we have to offer the alternatives. Now, I’m not endorsing it. That’s the caveat. I’m not endorsing it, but these are your options. This is what’s out there, you know, and please speak to your physician.” .Despite willingness to offer information, only 7 said that they would make a referral for a client to obtain PrEP at a primary care clinic or in the case of hospital based programs that offered primary care, at primary care onsite services. “Well, we’re lucky, in a sense, that we can -- we do have, like, a very, very strong sort of medically-based presence here in this treatment program. Many programs do not have that luxury. But then, we also are, you know, in a hospital. We can have a relationship with the virology clinic”-.A few medical providers were inclined to make referrals and to help the client obtain PrEP. Being situated in a hospital setting seemed to encourage referral making, especially for primary care and HIV antibody testing because of the natural link between the substance abuse program and the larger health care system. “I think what you’re going to hear from many of the staff is that they feel like it’s just one more thing on my plate. They feel like they have so much work to do because, as I mentioned,-- our staffing has gone down but the amount of work that we do has stayed the same. So you basically have fewer people doing more work. You know, at least in our clinic, in our setting -- and I know other settings have been different, but we’d never had productivity requirements. Now all the providers have productivity requirements.” .The program directors shared the following concerns: 1) that they did not have prescribers and/or sufficient staff available, 2) did not have the capacity to monitor PrEP adherence, and 3) were unsure about how PrEP would be covered in terms of third-party reimbursement. “So, I think that that would depend -- they would require a lot of education, because I think our staff, in general… Well, I would say the younger staff is more open, and they have more education. We do have some older staff who have been in the field for a long time, maybe don’t have as much education, and tend to shy away from medications, in general. So, even to get them to understand, like, a co-occurring disorder, and a client would benefit from taking a psychotropic medication of some sort along with their treatment regimen -- is a good thing. It -- that requires a lot of education.” .Two program directors reported that their staff would need comprehensive training on PrEP in order to be able to educate clients. Further, one program director noted that staff needed training in psychopharmacology in general because many clients are dually-diagnosed with mental health conditions and require counseling around medication adherence for other disorders and conditions. “So if you look at something like that and you take an assessment of how -- what risk level they’re at, then I would suggest absolutely, why not put the medication in there. But I think there should be a -- there should definitely be a risk level and -- yeah.” .Overall providers’ criteria for clients to receive PrEP was two-fold: exhibiting a demonstrated risk either through exchange sex, unprotected sex with multiple partners, or needle sharing; and exhibiting psychosocial stability demonstrated by stable housing, program attendance, sobriety, medication compliance and overall medical health. When asked what types of clients would be good candidates for PrEP, 22 providers said that the client’s level of risk should guide the assessment of whether they are offered PrEP. “OK, well, a client that -- let’s say a client that has reported a sex addiction, and has multiple partners, doesn’t wear a condom, things of that nature. Clients such as that I would probably recommend that to.” (Counselor community based).“Or just, you know, like I said, people who are high risk because maybe they are promiscuous or maybe they are interested in, you know, using prostitutes or because they are still sharing needles” .When asked to elaborate they used the following terms to describe such clients: “high risk”, “risky behaviors”, “don’t want to use condoms” or “multiple partners” and “promiscuous” to describe the ideal candidate for PrEP. Two providers stated that PrEP would be ideal for “prostitutes” and three mentioned IDUs. “You know, young people who are sleeping around -- I mean, you know, that would be a great thing to take. You could prevent it -- if you can’t convince them to wear a condom, you could take this.” .Eight providers stated that PrEP would be ideal for serodiscordant couples and one counselor described PrEP as a way for his HIV positive client to have “normal marital relations”. Providers appeared most comfortable and approving when discussing using PrEP for serodiscordant couples. One provider explicitly stated that that takes the “moral question” out of it. Two providers mentioned young age as a criterion, stating that they felt that younger clients (under age 30) are most at risk due to having greater numbers of sexual partners and being generally more sexually active, whereas the older clients were engaged in stable and presumably monogamous partnerships. “it’s counterintuitive, because the client who’s going to be a client that would benefit from this is likely to be a client who would be least likely to comply with all the stipulations that would be associated with it…Yeah, the two things would go hand in hand, because the person who’s running around having a lot of risky behaviors is generally not a person who’s going to a primary-care doctor, and not a person… You know”- Program Director, community based.“If you know your patient has history of multiple partners, and a history of being homeless, and a history of selling her body, and a history of constantly using drugs, then you may be hesitant on giving this patient this pill. You know what I mean? But, you may say here, you need it. So you’ve got to weigh your pros and cons, and every patient’s different. Their social -- you know, their social skills, their living situation, everything you’ve got to take into account”.- medical provider, hospital based.Four providers stated that being “stable” medically and having achieved a minimum length of time (between three and six months) of abstinence from drugs were requisites, as well as being compliant with their other medication regimens . One provider mentioned stable housing as a requirement. One director of a program mentioned that regular attendance and not missing appointments were important criteria. Seventeen providers comprised of both counselors and medical providers, reported that adherence would be a serious concern for their clients. They stated that their clients’ continued drug use, unstable housing, or simply forgetting to take the medication may impinge upon clients’ ultimate ability to maintain compliance of daily dosing. Uncertainty about adherence gave some providers pause when considering whether they would recommend PrEP, particularly in light of the potential consequences of skipping doses . One psychiatrist asked, “How long does it last?” in an effort to establish the length of time that a client would experience a prophylactic effect even if they were to miss a dose.“They would definitely need to be monitored, I’m sure. With these kind of clients they need consistency. So they’re not going to do it on their own. They’re not going to remember.”- .Most of the medical staff reported that they were concerned about non-compliance with this population. “..you have outpatient, then you have the methadone clients. Those guys I don’t think would have a problem [with adherence]. – .Five non-medical providers reported that adherence would not be a concern and that their clients would indeed be able to comply with medication, particularly because many clients already take medication for medical or mental health conditions. “Right. OK. Yeah. I think definitely, because you want to find out in the event that, you know, is it safe to take with methadol. Is it take to -- take with suboxone, is it safe to, actually, take with any other medications they may be taking for their medical issues.”- .The majority of providers relayed concerns about long-term effects of PrEP and safety for clients that have co-morbid medical issues  some asked about how PrEP may interact with other medications that clients were taking . One provider asked about PrEP’s safety during pregnancy, and one provider asked about whether PrEP had been tested with adolescents. Most providers, both medical and non-medical, were reluctant to offer or recommend PrEP to clients that were already ill with chronic conditions because of concerns about liver toxicity. Concerns over side effects were less prevalent than safety concerns, although one provider pointed out that if the client experiences side effects he/she may discontinue the medication therefore it is important to consider the severity of the potential side effects.Most providers agreed that participating in a trial of PrEP would be a benefit to their clients because they would be able to secure access to the medication for no cost. Nearly all of the providers stated that they would be willing to be involved with a PrEP trial in terms of conducting study tasks and procedures .“But will people will come saying, you know, I have a partner or I have, you know. And then, at that point, does the HIV status of the partner become identified? Hopefully not. That’s not what we’re interested in. We’re interested in protecting the patient.”- .Three main areas of concern emerged. 1) Informed consent. Providers affirmed necessity of clients understanding the risks and benefits prior to engaging in PrEP research. They stated that clients would need to be well counseled around drug safety and potential side effects, particularly because many clients have a low education level and may be compromised cognitively due to drug use. 2) Maintaining confidentiality. Seven providers were concerned about securing confidentiality in offering PrEP on site through clinical trials. They were hesitant to engage clients in trials if there was a risk of clients being stigmatized by peers or staff due to being perceived as “at risk” or as part of a serodiscordant couple. Moreover, concerns about maintaining the confidentiality of clients’ partners or significant others arose because peers may conclude HIV status of partners if the client is enrolled in a PrEP trial. “I don’t know. I think people like, just medication in general, they think of the side effects, they think of testing as being used as guinea pigs, as research work as guinea pigs, and what if there is something along the way that comes up?”- .3) Mistrust toward research. Five counseling providers mentioned mistrust toward research as a potential barrier to engaging clients in PrEP trials. Clients may be reluctant to take PrEP and/or enroll in trials for fear of being treated as “guinea pigs”. Providers related this perception to historical abuses of vulnerable populations and people of color in general by the scientific community, as well as to conspiracy theory beliefs about HIV.4) Role of incentives in recruitment. Six providers advocated monetary incentives as the most important strategy that may help overcome barriers to enrolling clients in PrEP trials.If the incentives were good, definitely a lot of people are open to research trials. – .One limitation of our study was the selective nature of the sample as being nominated by the program directors for the interviews. However, despite being hand-selected by the administrators, the providers interviewed were not exceptionally knowledgeable about HIV, nor particularly experienced with HIV prevention. Therefore, we believe that the providers interviewed are adequate representatives of their respective organizations. Thus, the same themes and issues emerged across clinic and across job role from our data suggesting that this population has many common concerns and practices. The main limitation was that the clinics in this study might not represent all substance use treatment programs in the U.S. or in New York. The clinics we interviewed are relatively well resourced and participate in the Clinical Trials Network (CTN), therefore may be more receptive to research than non-CTN affiliated clinics.To our knowledge, this is the first study to explore substance abuse treatment providers’ views on PrEP. Given the HIV risk faced by many substance-using clients, it is crucial to assess the potential for implementation of PrEP within substance abuse treatment settings and to understand the perspectives, barriers and promoters from the standpoint of the providers that will ultimately be responsible for PrEP’s uptake in these settings. A few major themes emerged from our study of medical staff, counseling providers and directors. These findings cut across the various job roles and clinic settings.Only a small proportion of our sample (approximately 10%) had ever heard of PrEP prior to the interview. This was surprising, given the fact that the clinics are located in New York City, the epicenter of the HIV epidemic and boasting cutting-edge HIV research and services. The overwhelmingly positive response of most providers upon first learning of PrEP was encouraging given the controversy surrounding PrEP, and suggests that this work force is open to innovation and to using pharmacological interventions. This is not surprising given the fact that many work with clients that are prescribed psychotropic medications and opiate-substitution regimens. The providers who voiced objections to PrEP did so mostly on the basis of risk compensation, which is an argument that has, in the past, been used to argue against oral contraception, condoms, etc. Risk compensation has been shown in some populations  with regard to inconsistent condom use leading to riskier sex with multiple casual partners, however, there is yet to be any empirical support for risk compensation among those receiving PrEP .Behavioral counseling has been recommended as a strategy to use in concert with pharmacological interventions like PrEP in order to increase clients’ risk perception and to mitigate the potential consequences of risk compensation . Thus coProviders perceived their roles in PrEP implementation in different ways. Because our sample consisted mostly of counselors (78%) that do not prescribe medication it is not surprising that counselors considered their primary role to offer clients PrEP “information and education”. However, even medical providers in our sample that could prescribe PrEP, declined to do so because their roles in the clinics were not to provide primary care but rather, psychiatric care  or care related directly to substance use . Nearly all providers, medical and counseling, were willing to offer information or education to clients . While this is an important initial step toward engaging clients in PrEP, it is equally important to help clients gain access to PrEP through formal referrals to obtain the medication, and only 20% of our sample including medical and non-medical providers, stated that they would be willing to offer referrals for obtaining PrEP. While most providers stated that they felt PrEP would be a benefit to their clients, their lack of willingness to make referrals indicates ambivalence toward PrEP and/or perhaps, toward making referrals. Future research needs to develop and test strategies to overcome barriers to referral making among providers of substance abuse services. Likewise, developing strategies to foster linkages between substance abuse treatment medical staff, counseling staff, and primary care services may help to facilitate referrals for PrEP.The program directors’ concerns about implementation were related to three programmatic issues: 1) lack of medical staff to prescribe and monitor PrEP, 2) cost of PrEP and third party reimbursement , and 3) securing training for providers on how to educate clients about PrEP. Policymakers interested in the roll-out of PrEP within community based organizations including substance use treatment programs need approaches that take into account issues of cost, capacity and resource allocation so that PrEP treatment can be sustained and managed within these settings. Since most clients receiving treatment services in the locations surveyed are Medicaid recipients, it is important to advocate for Medicaid’s continued coverage of PrEP. Likewise, policymakers may include outcome measures on PrEP uptake for the purposes of reporting program-level data to funders and licensing agencies in order to motivate the use of PrEP as well as develop buy-in among implementers at the program level.Most providers deemed clients that engage in “high risk” sexual behavior , sex workers, clients that inject drugs, and serodiscordant couples as potential candidates for PrEP. However, they also considered stability in housing, mental health, abstinence from illicit drug use, and medical wellness as important criteria. Thus, the very same individuals that are most in need of PrEP according to providers may not be eligible for PrEP based upon the aforementioned criteria. The conflict inherent in targeting PrEP to those that are most chaotic and at-risk while limiting eligibility to individuals that are most stable points to an area of confusion. Providers need guidelines for identifying appropriate substance using clients in community settings so that they may conduct initial screening for PrEP prior to initiating a referral and/or offering to prescribe PrEP. Relatedly, most providers were concerned about adherence to a daily medication for this population in particular and had doubts about clients’ ability to comply with dosing due to forgetting, relapsing with drugs/alcohol, or due to a history of non-compliance with other medications.Currently in development, long-acting injectable PrEP has been shown to be effective in monkeys and will soon be tested in humans . Future Most pronounced were providers’ concerns about drug safety and side effects, particularly in light of the medically compromised clients that are already infected with HCV. Long-term effects of taking antiretrovirals were also noted and providers wanted to know whether it was known how clients’ livers and other organs would be affected over time. Based upon the providers’ focus on this area of concern, we hypothesize that any ambivalence toward PrEP was rooted in being unconvinced of PrEP’s safety and a fear of harming their clients. Thus, training for providers targeting these issues may help to overcome potential barriers to referring clients for PrEP.However, it is worth noting that concerns about confidentiality raise the issue of PrEP stigma and HIV stigma with this population. The concern that clients might identify peers as PrEP recipients, should PrEP trials be conducted on site, and that this may result in stigmatization, points to a need to protect clients’ confidentialities, while at the same time working to educate the substance abuse treatment community about HIV, PrEP, and striving to dispel myths about HIV transmission, reduce homophobia, and assumptions about what constitutes risk.Providers’ overwhelming support of conducting PrEP research trials on site and engaging their clients in trials may be an artifact of the sampling frame being CTN-affiliated programs. All of the programs are currently, or have in the past participated in clinical, behavioral and in many cases, pharmacological research through the CTN. Therefore, these programs in particular have a positive orientation toward research collaboration so this may not represent all substance use treatment programs in New York City or in the United States. This study suggests that more research ought to be done prior to rolling out PrEP in substance abuse treatment programs. PrEP research should focus on testing implementation strategies include structural interventions in order to build agency capacity to sustain PrEP. Interventions aimed at enhancing linkages to PrEP prescribers ought to be leveraged for those programs that lack the capacity to do so.The workforce of substance abuse treatment providers is poised to engage their at-risk clients in PrEP through counseling, referrals, research trials, and may promote sustained use of PrEP by helping clients to maintain adherence to medication regimens through counseling and monitoring. Policymakers and funders will play a critical roll in establishing the structural supports for these initiatives. Structural supports may include trainings for providers in a variety of HIV prevention strategies including PrEP. Trainings may be delivered in-person, through webinars, or through short films depending on budgetary constraints and technological capacity. Likewise, clinics that provide substance abuse treatment services may form collaborative partnerships with primary care providers that are equipped to prescribe PrEP. Such partnerships may be cultivated through policy initiatives aimed at integrating medical and behavioral services, a goal of the Affordable Care Act . This st


Since 2012, rapid diagnostic tests (RDT) for malaria have been in use nationwide in Burkina Faso. The objective is to strengthen health professionals’ diagnostic capabilities and promote good therapeutic practices. A qualitative study was conducted to learn about the adoption of this tool in the natural context of a national scale-up policy.This study involved five health centres in two health districts. Twenty-eight individual interviews were conducted in 2013 with health professionals and members of the health district management teams. Health professionals’ RDT use and drug prescription practices were observed during 278 curative care consultations over 5 weeks.Health professionals assessed the use of RDT positively as it allowed them to reach clear and accurate diagnoses and above all to deliver appropriate, rational care. However, the introduction of RDTs did not really change their diagnostic practices or prescribing practices for artemisinin-based combination therapy (ACT). They continued to rely predominantly on symptoms in establishing their diagnoses because of doubts regarding the reliability of the tests and the occasional stockouts of RDTs experienced by the health centres. Patients with negative RDT results continued to receive anti-malarial treatments. However, the situation remains quite heterogeneous.The use of RDTs points to the co-existence of official standards and different standards applied in practice. Setting up regular supervision activities provided an opportunity to observe and understand the various obstacles encountered by health professionals and to monitor how official directives are put into practice. For efficient use of RDTs and their results, health professionals need information and directives that are up-to-date and standardized. The World Health Organization (WHO) estimated there were 216 million malaria episodes in 2010 . Rapid dIn Burkina Faso, biological testing for malaria treatment is done using two basic techniques, either microscopic diagnosis using thick blood smears or RDT. Official directives stipulate that all suspected cases of malaria must be confirmed by one of these techniques before treatment . RDTs arSince 2010, RDTs have been used throughout Burkina Faso for all patients . This naThe study was conducted in the health districts of Kaya and Zorgho, in Burkina Faso, where research is engaged on the national anti-malaria programme . These tIn the two health districts five primary care health and social promotion centres (CSPS) were selected, of which three were in urban areas and two in rural areas. The selection was aimed at providing a diversity of situations in the two districts and to enable urban–rural comparisons. The field survey was conducted between 19 February and 28 March, 2013. An exploratory visit was conducted in December 2012 in Kaya to learn more about the setting and the status of RDT use, present the study to the clinical teams, and pre-test the data collection tools.Two qualitative data collection tools were used: individual interviews (n = 24) and observations. The individual interviews began with 20 health professionals. In rural health centres, the number of health professionals varied from two to three. Their statuses were different but they all performed the same acts (including RDTs). Given their limited numbers, it was possible to interview all of them. In the urban centres, where there were many more health professionals, the decision was taken to interview only those working in clinics, as that was where curative care consultations occurred. Only those health professionals who were willing to talk with the researchers were interviewed. Nevertheless, every effort was made to obtain a diverse sample of health professionals, in terms not only of their status and function in the health centres, but also of their participation in RDT training sessions. The interviews explored their knowledge about RDTs, what use they made of them, their prescribing practices in relation to the test results, their perceptions of the tool and of how it was received by patients, especially mothers of children under five.In addition, interviews were conducted with four members of the two districts’ management teams (ECD), including the district medical officers (MCD) or their assistants, the managers of the district distribution depots (DRD) who look after RDT stocks, and the managers of the health information and epidemiological surveillance centres (CISSE). A number of curative care consultations were also observed to understand the procedures for medical care of the ill, particularly in cases of fever, and especially the procedures for determining whether or not to use RDTs. In all the CSPSs, a total of 278 curative care consultations in clinics were observed. To conduct these observations, between 4 and 10 days were spent in each of the different CSPSs.All interviews were audio-recorded and fully transcribed into a word-processing program. The transcripts underwent content analysis by site and by topics addressed in the interview guides. Added to these were the four interviews  conducted during the exploratory phase, which were recorded using written notes, bringing to 28 the total number of interviews analysed. Tables The study received ethical approval from the research ethics committees of Burkina Faso and the University of Montreal Hospital Research Centre (CRCHUM). The results of the analyses were presented to the key stakeholders at a workshop held in November 2013.“Before RDTs, there was a lot of investigating, and in the malaria programme there was a dictum to the effect that ‘whenever there’s fever, treat for malaria first,’ so if someone came in with fever, even though we would still investigate the possibility of other things, nevertheless the first line of treatment included an anti-malarial. Even if there’s no scientific evidence there, if it’s based on what the mother or father says, or what the health worker observed, it’s certainly true that, even if he says there’s coughing, that can cause fever, but when there’s fever, we treat for malaria and maybe also pneumonia… And even if that’s not the right diagnosis, to cast a wide net we prefer to include [an anti-malarial].” State certified nurse (IDE), male, urban CSPS, Zorgho.As malaria is the predominant reason for patient visits, clinicians devote considerable time to its diagnosis. According to the clinicians, before the introduction of RDTs, diagnosis was based essentially on the patient’s symptoms. Most cases of fever and symptoms suggestive of malaria were regarded as malaria. Anti-malarials were immediately prescribed, even in cases where the symptoms might suggest other pathologies. The diagnosis was presumptive and anti-malarials were prescribed according to a cautionary logic of making sure the patient was covered.RDTs were introduced following a training process that began with health centre managers. It was carried out using different methods: health professionals received “formal” training, either from the Ministry of Health or from organizations working in their health district.In Zorgho health district, the use of RDTs was preceded in 2011 by an information workshop for CSPS managers.“The scale-up in the district was done in 2012. There was training provided from April 23 to 28, I believe…They trained two health professionals per CSPS. It believes it was the malaria programme. In any case, the implementation was done after the training, around June, I think, and then each CSPS started when it wanted. They didn’t all start at the same time.” District management team (ECD), female, Kaya.In Kaya health district, the scale-up in 2012 was preceded by training on RDT use, provided from April 23–28 to health professionals who were, in turn, mandated to train their colleagues in the CSPSs.Before this, the NGO Save the Children, as part of its malnutrition management programme, had provided some of the Kaya CSPSs with RDTs starting in 2010, for managing children under five, and in that initiative had trained some of the CSPS managers in the use of this tool.The reasoning behind the training provided for the scale-up was that the knowledge acquired would subsequently be transferred to personnel in the health centres who had not attended the training sessions. In both districts, RDTs were introduced into the CSPSs by either the centre managers or their representatives who had undergone training. Those who were trained were expected, in turn, to train their colleagues who had not attended the session. For most health professionals, their first contact with RDTs and their knowledge acquisition occurred in their own health centre through transfer activities  carried out by those who had been trained. In both districts, this was the process by which the majority of health professionals encountered in the study had learned to use RDTs. Transfer activities took several forms, including unit meetings that focused specifically on RDTs or in which information on RDTs was included among other items. For other health professionals, the learning was transferred through practice, that is, during consultations with patients.According to the health professionals, these different methods of teaching RDT use enabled them to perform the test easily but resulted in differences, and even divergences, in how the tool was adopted. These were seen not only in the health professionals’ knowledge, which was inconsistent, but also in their practices that did not necessarily follow official directives.“Just three drops. If the blood is very sticky, you can add a drop because sometimes it congeals. If the blood is sticky, it’s not flowing fast, we can put four drops to dilute the blood even more, it might not work. From what I know, it’s three drops; if it’s four drops, too, then I’m waiting for someone to let me know that…. We can have the results in 10 to 15 min.” Health outreach worker (AIS), female, urban CSPS A, Kaya.While the health professionals were more or less knowledgeable about the objectives for the use of the tool, its actual manipulation was the subject of much discussion and a variety of practices. For example, there were diverse opinions regarding the amount of buffer solution to use and especially the wait time for results. According to one health professional:“In principle, it’s 15 min, but if you had to wait that long—well! It’s just that, right now, there’s no one here, but otherwise there are times when the bench (of the waiting room) is filled to right out the door. If you had to spend 15 min with a patient, oh boy! The patients themselves would come pounce on you here!” Student nurse, female, urban CSPS, Zorgho.In reality, there were different opinions. The number of drops varied from one professional to another, and even for the same professional, from one consultation to another. Likewise, with regard to the wait time for results, observations of curative consultations on all the sites revealed that an average of five to 10 min was spent with each patient, even when an RDT was performed. Yet according to official directives (posted in some consultation rooms), they were supposed to wait at least 15 min before reading and interpreting the results—a time that many health professionals considered overly long. One student nurse at the urban Zorgho CSPS explained what happened during curative consultations carried out under the supervision of a certified health professional:Look, it’s positive, there’s a faint line, and the woman has already left,” the nurse replied, “Oh, well, since there was an anti-malarial in there, it’s okay!”One consequence of these coping strategies is that some patients are mistakenly diagnosed, as was observed in one of the urban CSPSs in Kaya. In a consultation for a 10-month-old child presenting with “hot body and cough with vomiting,” which the mother had treated with paracetamol, a nurse in the urban CSPS A of Kaya decided to perform an RDT. Five minutes later, without the nurse having observed that the control line indicated a negative RDT, she nevertheless reached a diagnosis: “uncomplicated malaria + pneumonia” and prescribed ACT syrup and an antibiotic as treatment. After the mother had left, as the student assisting the nurse was about to dispose of the test in the trash, she noticed that the second line, showing that the test was positive, had appeared, although faintly. When she informed the nurse, “Most of the health professionals in the two districts had learned to use RDTs from transfer activities conducted by others who had been trained. In Zorgho district, the directives on RDT use, posted in the consultation rooms, were also a source of information. This posting of the directives for performing RDTs and of the decision algorithm for suspected cases of malaria was an element that differentiated the health centres in the two districts. In the health centres investigated in Zorgho , these two postings were present in the consultation rooms and were sometimes accompanied by handwritten notes on the use of RDTs. Health professionals referred to them regularly to explain certain points during the interviews to show either what they did, or what they were supposed to do .“In principle, according to the Ministry of Health, AISs shouldn’t be doing them, but on the ground, the CSPSs have staff shortages and so they have to involve the AISs.” ECD, male, Kaya.“Everyone does them. In any case, everyone who carries out consultations does them.” AIS, male, urban CSPS, Zorgho.The use of RDTs was not limited to a single category of health professional. Everyone who saw patients in consultation performed the tests, regardless of their status. However, it was how care was organized that determined who was involved. It was observed that those who conducted the consultations were generally the ones who performed the RDTs. In health centres with staffing shortages, a professional might be working alone. This was the case most often in afternoons or during on-call shifts. Based on the principle that anyone who consults should be able to perform RDTs, it becomes difficult to prohibit anyone from doing it, or to limit it to only one category of health professional. Thus, anyone who received patients in consultation then performed the tests, regardless of their status.However, RDTs were essentially performed by health centre personnel. Community health workers, even though they were involved in the curative management of malaria in patients’ homes, did not perform the tests.The logic that was guiding RDT use varied greatly from one health professional to another and from one health centre to another. Nevertheless, there was an observed tendency to use RDTs routinely whenever they were available. In most health centres, when they were available, RDTs were performed for most patients, but for different reasons. The first had to do with the acceptance of, and compliance with, national directives regarding the management of suspected malaria:“As this is a programme, all we do is follow it; we’re the ones who carry it out. Whatever the decision-makers decide, that’s what we do.” Licensed nurse (IB), male, urban CSPS, Zorgho.Another had to do with the presence of colleagues or students during consultations; these additional human resources were helpful in managing workload, coping with numbers of patients, and improving test accessibility. In certain situations RDTs were not systematically used, for reasons related to service organization (such as when the RDTs were kept in a location that was not accessible to everyone) or to workload.“As for myself, in particular, I don’t systematically do RDTs on every patient who comes in; it depends on the symptoms. If a patient comes in with a cough, I don’t see the need to do an RDT if the patient isn’t reporting any aches and pains, headaches, intermittent fever—no symptoms to suggest malaria. And then there are three or four phases of fever that could lead us to suspect malaria; so if I suspect malaria, I do an RDT to be sure, and even in cases of diarrhoea, if it’s accompanied by fever, I do an RDT because malaria can cause diarrhoea.” IDE, male, urban CSPS B, Kaya.It was mainly the symptoms described or presented by patients that guided the use of RDTs: fever/body heat, headache, diarrhoea and vomiting (in children).is not necessarily synonymous with malaria”, as one health professional noted. Respondents referred to other pathologies, such as typhoid fever or otorhinolaryngological infections  that could cause fever. Conversely, according to the health professionals, “the absence [of fever] does not exclude malaria”. Respondents asserted that, according to this logic, the test should be done systematically for all patients, in the spirit of comprehensive patient management.The most frequent symptom prompting the use of RDT was fever. However, fever was not considered in isolation, as it “However, all these logics clearly only applied when the tests were available. Yet this was not always the case, such that health professionals had to fall back on using clinical symptoms to reach their diagnoses. Thus, the new definition of malaria adopted by the health system in 2010 to incorporate RDT results makes sense only if the RDTs are available. Even when they are, however, presumptive diagnoses continue to have a place in patient care.“To have an uncomplicated case of malaria, the temperature must be equal to or above 37.5° [Celsius] with a positive RDT result for Plasmodium falciparum.” IDE, male, urban CSPS B, Kaya.The introduction of RDTs modified the official definition of malaria and of the therapeutic management of suspected cases. From then on, according to the national policy,“Even when the RDT is negative, if the patient presents malaria symptoms, I treat for malaria. Whether the result is negative or positive, when there are certain symptoms , I do an RDT but I treat according to the symptoms I see.” IB, female, urban CSPS A, Kaya.By the same approach, all drug prescriptions are supposed to be based on evidence of parasite presence obtained through biological diagnosis. However, in the health centres, professionals’ use of RDT results was variable. RDTs had not changed their prescribing practices. This situation was observed more often in Kaya health district, where many patients with negative RDT results continued to receive anti-malarial treatment. The practices were different, however, between urban and rural areas. In urban settings, positive RDT results were never questioned by the health professionals, and those patients received anti-malarial treatment. On the other hand, the same was not true of negative results, which were not always accepted as such, and those patients also often received anti-malarial treatment.Of 90 consultations observed in urban CSPS A, RDTs were performed for 70 patients, of which 59 were negative and 11 positive. Of the 59 patients with negative RDTs, 30 were given prescriptions for anti-malarials. In urban CSPS B, of 46 patients seen when RDTs were available, 28 underwent RDTs, of which 11 were positive and 17 negative; five of the negative cases were interpreted and treated as uncomplicated malaria.In rural areas, only patients with positive RDT results were given anti-malarial treatment. Prescribing anti-malarials for cases with negative RDT results was done less systematically. Anti-malarials were prescribed based on a patient’s symptoms and appeared to be a last resort, after clinical examination of the patient uncovered no other pathology associated with these symptoms.“When it [the RDT result] is positive, we prescribe anti-malarial treatment, he [the patient] picks it up at the depot, brings it back, and we show him the products. If advice is required, we provide the advice. If it’s negative, we also look to see whether there might be another hidden illness. If we find it, we prescribe something else and he goes to get the product. But I’ve told my people [health professionals] here, if it’s negative, no anti-malarials are to be prescribed. We might see it said somewhere that a negative RDT results does not exclude malaria. No! Here, negative RDT means no malaria, look for other symptoms to treat! Here, that’s how it is… That’s in fact what the directives say, that when it’s negative, we don’t give anti-malarials… So, when it’s negative we don’t prescribe [anti-malarials], the person will come back! Even if it’s not allowed, the person will go for a thick blood smear at Zorgho, where things are more sophisticated. In any case, that’s how it is here.” IB, male, rural CSPS, Zorgho.In Zorgho district, anti-malarials were prescribed in most cases with positive RDT results. Unlike in Kaya, negative RDT results were not routinely diagnosed and treated as cases of uncomplicated malaria in Zorgho district. The observations of consultations, the data in the registers, and even the interviews showed that patients with negative RDTs were rarely given anti-malarial prescriptions. Prescriptions for ACT or quinine remained associated, for the most part, with positive RDTs. Here, the official directives played a significant role in malaria diagnosis and prescriptions. The health professionals referred to the decision algorithm for management of suspected cases of malaria in order to decide on the treatment path based on RDT results. The decision algorithm was a significant reference in rural areas, where no negative RDT (both those observed during the survey and those performed before then) had been diagnosed and treated as malaria.In urban settings, health professionals paid attention to the decision algorithm and tried to comply with it as much as possible. However, they expressed their unease in cases where they were convinced certain patients had malaria even though their RDT results were negative. In those situations, they developed strategies to be able to treat them as malaria cases without giving the impression that they had contravened the official directives. A negative RDT result would be entered in the register as a positive result, or the patient would be given a prescription that was different from what was noted in the register and that would include an anti-malarial treatment. This was observed during a morning consultation conducted by a nurse who, in her interview the previous evening, had stressed the fact that she did not provide anti-malarial treatment when the RDT was negative. She had asserted that, when in doubt, she preferred to request that a thick blood smear be done. Even so, the health professionals considered that such situations were exceptional. In most cases, negative RDTs were not diagnosed and treated as cases of uncomplicated malaria.“If the person still has fever but the RDT results continue to be negative, we repeat the clinical exam. If we find nothing else, we might decide to prescribe anti-malarial treatment, since we never know whether the persistent fever might be hiding a case of malaria that could very well get worse if not treated in time.” IDE, female, urban CSPS A, Kaya.“Often we prescribe to prevent the worst-case scenario, to avoid having the person come back with severe malaria.” IB, male, urban CSPS, Zorgho.Generally speaking, RDTs have not modified health professionals’ prescribing practices. In both districts, the professionals offered several explanations for these coping strategies, the main one being anticipation of complications from an underlying malaria. This logic of anticipating a patient’s status was mentioned in both districts.“Because the RDT might often be negative, but if the person was already started on anti-malarial treatment, the RDT could show a negative result. Often, even if the treatment was given a week before, we might think it’s malaria, but because treatment was already started, it doesn’t show up as positive.” AIS, female, urban CSPS B, Kaya.“We’re in a region where Plasmodium falciparum is predominant, but as I said, there are other types of Plasmodium that the RDT doesn’t see, such as vivax, ovale, etc. We might also think of those." IB, male, rural CSPS, Zorgho.Thus, treatments were prescribed based on a cautious logic to protect the patient. Some raised doubts about the test’s reliability, while others pointed to certain elements that could influence the results.The doubts expressed about the reliability of RDTs explain, in part, why anti-malarials are administered even when RDT results are negative. However, in general, the use of RDT results remained correlated with the symptoms presented or described by the patient, and it was those symptoms that guided the health professionals’ prescribing practices. Fever was the reference symptom. When fever was mentioned or observed, anti-malarials were added to the treatment, even if a patient’s symptoms could be due to other pathologies. In using RDTs, the presumptive diagnosis routinely went hand-in-hand with the biological diagnosis.“It made our consultations more specialized! Now, with RDTs, we’re sure of the treatment we’re providing, that’s it! There’s a positive diagnosis, and so the treatment becomes very easy. We’re no longer treating in the dark, but instead, with RDT, we know what we’re doing, where we’re going.” IDE, female, urban CSPS B, Kaya.Even though health professionals varied in how they were trained to use them, and even if prescriptions did not always take into account their results, RDTs were assessed positively in both districts. They were perceived as a tool that was easy to use and helpful for managing patient care. Their utility had to do mainly with the support they provided to diagnosis and decision-making.“For example, if you do a test and it’s positive, you know you’re dealing with a case of malaria; and we can also say that RDTs are helpful because everyone…. From a financial standpoint, not everyone in the population has access to a thick blood smear. Even if you think 500 francs isn’t expensive, it isn’t everyone who can have 500 francs to go have a thick blood smear done, so we can say that RDTs, on one hand, are helpful. They reassure the patients.” IDE, male, urban CSPS, Zorgho.Presumptive diagnosis, for a long time the prevalent approach in malaria management that led to haphazard decisions, resulted in erratic care that patients did not necessarily require. According to the health professionals, RDTs facilitated the diagnosis of malaria. They were helpful in establishing a differential diagnosis of symptoms and providing care that was appropriate and more affordable for patients. The fact that RDTs helped to reduce healthcare costs was mentioned more often by health professionals in Zorgho than in Kaya.Moreover, in helping health professionals to make more appropriate and rational prescriptions, RDTs also provided opportunities for them to strengthen their competencies and improve their credibility among patients.“We were told we need to wear gloves when doing RDTs, but we were never given any gloves to perform RDTs. There you are, handling blood with your bare hands.” AIS, male, rural CSPS, Zorgho.The health professionals mentioned some drawbacks associated with the tool’s use. The lack of gloves for performing the test was mentioned in both districts. This situation exposed them to greater risks, as one respondent explained.RDTs were also seen by the clinicians as adding to their workload and prolonging the consultation time“It takes longer and increases our workload… For example, if you’re alone, you need to write in the ledger, in the booklet, get up to do the RDT, come back and sit around for 10–15 min to wait for the results; it adds to the consultation time.” IB, female, urban CSPS A, Kaya.This constraint was felt most keenly in winter, a period of increased activity in health centres. The fact that services for children under 5 years are free exacerbated this perception in the Kaya health centres, which see large numbers of patients, even outside the winter period . This led them to adopt coping strategies for the use of RDTs by health professionals: involving workers who are not authorized to prescribe RDTs according to official norms; reorganizing the consultation process during periods of high activity , and sometimes prescribing RDTs selectively (such as testing only patients with fever).In this study, the implementation of a public health policy was examined in a natural context . The natmalaria is usually the disease that generates a lot of revenue” [The introduction of RDTs for malaria is part of a movement to improve health professionals’ diagnostic capacities and promote good therapeutic practices. It involves moving away from presumptive diagnoses in favour of biological diagnoses, such that prescriptions are based on evidence of parasite infection . Clinicirevenue” . The resrevenue” . In Burkrevenue” . In CSPSrevenue” , which irevenue” . These prevenue” , 29.The health professionals in Zorgho paid more attention to official directives and took test results into account when prescribing drug treatments, more than the professionals in Kaya health district, who pointed out the financial benefits to patients of using RDTs. They perceived the utility of the tool as a means of bringing some relief to their populations. Other studies in Burkina Faso have shown that contextual factors can explain health professionals’ practices . In thisThe problem does not appear to be related so much to using RDTs as routine work tools, since they are perceived as offering health centres more advantages than disadvantages . Rather,These factors were assessed in a variety of ways, because, of the diversity of information sources and the means by which health professionals had learned to use the tool. To improve health professionals’ compliance with test results, it is essential that information and knowledge be standardized. Most of the health professionals had not received any formal training, and this need came up repeatedly in their statements. Knowledge was transmitted by means of a cascade (top-down) training strategy implemented over a short period (2–5 days) by people with different interests and profiles. While this approach may have reduced training costs and made it possible to reach many people in a short time, it was seriously limited in terms of effective knowledge dissemination . It entaBesides the observed heterogeneity of care practices around RDT use, which impaired the proper implementation of the policy, this study highlighted a problem of supply shortages, a recurrent feature of health interventions in Burkina Faso , 39 and In the national directives on the use of RDTs, wearing gloves is one of the steps in carrying out the tests. Yet no gloves were provided in the parcels of tests sent to CSPS health professionals, who were left to their own devices in performing the tests. For some, the lack of gloves becomes their justification for not performing RDTs . HoweverWhile every effort has been made to ensure the rigorous conduct of this study, nevertheless it has certain limitations. To strengthen the external validity of the results, several other sites could have been studied; but, this was not the fundamental objective of the qualitative methodology used, which was more focused on understanding the phenomena in their complexity. The rigour of the process used  helped tThe health problem created by malaria has mobilized decision-makers and researchers around issues related to its management. The value of this study is that it was conducted in an uncontrolled context, in contrast to previous studies in Burkina Faso. Health professionals’ adherence to national guidelines is crucial to the successful implementation of a disease management policy, although there are many parameters that influence prescribing behaviours besides health professionals’ command of the technical subject matter. A discrepancy between official norms and practice norms of public actors leads to the question of how health professionals’ practices can be improved .In the absence of other tools to confirm diagnoses, RDTs could be helpful for optimizing care quality and population health status, in that while they do not supplant clinical diagnosis, they can significantly support health professionals’ rapid management of patients. However, in the settings studied here, the prescribing of anti-malarials to patients who had tested negative remained widespread. Efficient use of RDTs will require several improvements in the management of suspected malaria cases: (1) reinforcement of supervision and training practices in order to observe and understand the problems and obstacles that health professionals encounter, as well as any facilitating factors, and to help them to comply with official directives of health programmes; (2) ensure a steady supply of RDTs in health centres; and, (3) update and standardize information and national guidelines provided to health professionals.


Since the initial reports of a link between Zika and microcephaly, researchers across the world began working toward understanding the virus. In a short amount of time, Zika has become a household name, prompting worldwide concern. The virus is spread rapidly by mosquito bites. We currently do not have a vaccine for Zika. But with the recent findings, vaccine companies are mobilizing their resources to expedite efforts to shave years off the typical decade-long process of vaccine development. The World Health Organization (WHO) has confirmed recently in a scientific consensus that the Zika virus is linked with microcephaly as well as Guillain-Barré syndrome . PreviouUntil recently, Zika was labeled “non-threatening”, “rare” and “relatively benign” and there was little incentive for companies to fund research and development of a vaccine. In addition, vaccine manufacturers are usually not keen to spend millions of dollars needed to bring a vaccine candidate from animal testing to human trials unless a market is guaranteed. Now, researchers all over the world have started the process. Currently, 60 companies and research institutions are working on Zika - this includes 18 vaccine candidates targeted to women of childbearing age . The But


Multiple nerve branches were created during the regeneration procedure after a nerve injury and such multiple branches are suggested to be used to control, for example, prosthesis with many degrees of freedom. Transected rat sciatic nerve stumps were inserted into a nine mm long silicone tube, which contained four, five mm long, smaller tubes, thus leaving a five mm gap for regenerating nerve fibers. Six weeks later, several new nerve structures were formed not only in the four smaller tubes, but also in the spaces in-between. The 7–9 new continuous nerve structures, which were isolated as individual free nerves after removal of the tubes, were delineated by a perineurium and contained both myelinated and unmyelinated nerve fibers as well as blood vessels. Stimulation of the proximal nerve elicited contractions in distal muscles. Thin metal electrodes, inserted initially into the smaller tubes in some experiments, became embedded in the new nerve structures and when stimulated contractions of the distal muscles were observed. The “tubes within a tube” technique, creating multiple new nerves from a single “mother” nerve, can be used to record multiple signals for prosthetic device control or as sources for supply of multiple denervated targets. The clinical treatment of nerve injuries is complex and the outcome depends on a variety of factors; one of them is performing an optimal reconstruction of the severed nerve trunk. In some of these situations, multiplication of the proximal nerve trunk would be advantageous, like in encountering extensive traumatic brachial plexus injuries and/or when multiple targets, supplied by a single nerve, are denervated, as well as when multiple signals for prosthetic arm/hand device control are required.An artificial limb, in particular arm/hand prosthesis, must be endowed with several motors for the control of the movements of individual fingers, the wrist, the elbow, and the shoulder . Today, For invasive electrodes, one possibility would be to increase the number of fascicles in a severed nerve. Assume that a nerve can be divided into two, three, or more parts. Then, one would be able to selectively address two, three, or more individual nerve trunks or even fascicles. We hypothesize that splitting of a nerve into multiple parts can offer a solution to increase the number of signals required for an advanced arm/hand prosthesis. Interestingly, it has been demonstrated that a severed nerve can be redirected to several new muscles, thus creating a platform for EMG control of a prosthetic device –13. ThisIf the continuity of a peripheral nerve is disrupted, then it too can be repaired by joining the severed ends via a tube –18. A neIn the present study, we tested if smaller tubes, inserted within a larger tube, could be used to create multiple new nerves or “fascicles,” thus offering the possibility to obtain multiple signals from one and the same nerve. Such a “Matruschka” or Russian doll approach could be used for bidirectional interfacing of a nerve or as a supply for multiple denervated end organs as in traumatic brachial plexus injuries. To test this possibility, we repaired the rat sciatic nerve by one large tube containing four smaller ones. This setting resulted in the formation of up to nine new fascicles , each of which was surrounded by a perineurial-like structure. We could also show that these new nerves could be stimulated to induce muscle contraction distal to the site of nerve reconstruction.μm thick  Pt (90)/Ir (10) electrodes . The isolation was removed from 3 mm of the electrode within the small tubes.Two variations of silicone tubes were used: one without Figures  and one Female Sprague-Dawley rats, weighing around 200 g, were used. The Ethical Committee at Lund University, Sweden, approved the study. A total of 10 rats were used. Four of these received implanted electrodes. The animals were anesthetized using a mixture of diazepam and pentobarbital as described  and the At the day of evaluation, the animals were reanesthetized and the tube, with the attached sciatic nerve, was exposed. Needle electrodes were used for stimulation, providing square pulses of 10 Hz, 1 ms duration with an amplitude of 0.2 V to 1 V. The stimulation was delivered either proximal to the chamber or via the leads to the internal electrodes of the smaller tubes . Visual μm) were either processed for conventional histology, using toluidine blue, or stained by immunocytochemistry for neurofilaments to visualize axons. The primary antibody (dilution 1/200) used was a rabbit anti-Neurofilament M , which has a high specificity, followed by a goat anti-rabbit Alexa 488 antibody . Counterstaining with bisbenzimide was used to visualize nuclei in the sections. The procedure has been described in detail elsewhere  and The regenerative capability of the peripheral nervous system is truly remarkable. Even in mammals, it is sufficient to supply a piece of a nerve or muscle distally in the tube to induce formation of a nerve trunk. Furthermore, even if two degenerating pieces of a nerve are attached to both ends of a tube, a new nerve-like structure is formed in the tube; the nerve-like structure is being used as a nerve graft . Here, wThe finding that the new nerve structures were surrounded by a perineurial-like structure is an advantage. The perineurium offers isolation and should prevent overhearing between electrodes as compared to an array of multiple electrodes inserted into one and the same fascicle. In another technique, where longitudinal sutures are used as guidance, a perineurial-like structure is also formed, but it encloses the whole new nerve structure . Another


Creativity refers to the capability to catch original and valuable ideas and solutions. It involves different processes. In this study the extent to which visual creativity is related to cognitive processes underlying visual mental imagery was investigated. Fifty college students (25 women) carried out: the Creative Synthesis Task, which measures the ability to produce creative objects belonging to a given category ; an adaptation of Clark’s Drawing Ability Test, which measures the ability to produce actual creative artworks  and three mental imagery tasks that investigate the three main cognitive processes involved in visual mental imagery: generation, inspection and transformation. Vividness of imagery and verbalizer–visualizer cognitive style were also measured using questionnaires. Correlation analysis revealed that all measures of the creativity tasks positively correlated with the image transformation imagery ability; practicality of inventions negatively correlated with vividness of imagery; originality of inventions positively correlated with the visualization cognitive style. However, regression analysis confirmed the predictive role of the transformation imagery ability only for the originality score of inventions and for the graphic ability and esthetic scores of artistic drawings; on the other hand, the visualization cognitive style predicted the originality of inventions, whereas the vividness of imagery predicted practicality of inventions. These results are consistent with the notion that visual creativity is domain- and task-specific. Creativity is a mysterious aspect of human thinking. The general characteristics shared by the creative products are hard to recognize. There is wide agreement on the notion that creativity involves the ability to produce a work that is both original and appropriate , leadingIn the present paper, the extent to which visual creativity is related to visual mental imagery was explored considering the product-oriented approach. Firstly, the creative cognition approach  was usedSecondly, the visual creative behavior approach was used. The actual creative behavior involving performance in visual arts and drawing is assumed to be related to vividness of imagery, which refers to the pictorial dimension of imagery, given that previous studies revealed that vividness of imagery  and the The relationship between visual creativity products and visual mental imagery was investigated within The research involved 50 College students from the “Department of Life, Health and Environmental Sciences,” University of L’Aquila, Italy: 25 women (mean age = 20.64 ± 1.32—age range = 19–24) and 25 men (mean age = 23.4 ± 4.20—age range = 19–31). All participants were healthy and without neurological and/or psychiatric disorders; no problem with alcohol or drug addiction was reported. None of the participants had a background in art or creative activities in general. In order to exclude those with significant visuo-spatial working memory problems, the Corsi Block-tapping Test  was admiParticipants took part in the study individually. The experiment lasted approximately 2 h. The following tasks and questionnaires were administered in random order.The creative synthesis taskThe Creative Synthesis Task  aimed toParticipants were first introduced to the task with a practical example. Following Clark’s drawing ability testClark’s Drawing Ability Test  aimed toVividness and cognitive style tasksThe vividness of visual imagery questionnaire. The Vividness of Visual Imagery Questionnaire , “synthesis” , and “transformation” .The pre-inventive forms of the Creative Synthesis Task were evaluated in terms of: “originality,” defined as a form being new and not derived from something else, from 1  to 5 ; “synthesis,” defined as the extent to which components were well assembled together, from 1 (very poor synthesis) to 5 (very high synthesis); “transformation,” defined as the extent to which components were changed in position, orientation and size when assembled into the final form, from 1 (very poorly transformed) to 5 (very highly transformed). The inter-rater correlations (intra-class correlation coefficient—absolute agreement) were significant for both “originality”  and “practicality” .Inventions were evaluated in terms of: “originality,” defined as an invention being new and not derived from something else, from 1  to 5 ; “practicality,” defined as an invention involving an actual use in a specific context, rather than a hypothetical use, from 1  to 5 . The inter-rater correlations (intra-class correlation coefficient—absolute agreement) were significant for both “originality” , “esthetic” , “creativity” .The creative drawings were evaluated in terms of: “graphic ability,” defined as the extent to which drawings were performed accurately in terms of pictorial aspects, such as colors, shades, details provided, as well as in terms of spatial aspects, such as spatial relations among elements; “esthetic,” defined as the extent to which drawings involved beauty, giving pleasure and satisfaction viewing them; “creativity,” defined as drawings involving different new ideas, perspective, colourfulness. The inter-rater correlations (intra-class correlation coefficient—absolute agreement) were significant for “graphic ability” , in order to obtain one independent variable for each cognitive process involved in visual mental imagery: generation, inspection and transformation, respectively.The vividness score was computed by summing the scores of each item; the VVQ was scored according to Richardson’ norms. The score was treated as a continuous independent variable, assuming that the higher the VVQ score was, the higher the degree of imagery ability.In order to explore the relationship between visual creativity and visual mental imagery abilities Pearson correlations between different variables were performed , whereas the VVQ score was positively correlated with the “originality” score of inventions . The PFT score was found to be positively correlated with all measures of creativity tasks, as follows: “originality” , “synthesis” , and “transformation”  scores of pre-inventive forms; “originality”  and “practicality”  scores of inventions; “graphic ability” , “esthetic” , and “creativity”  scores of Clark’s Drawing Ability Test.The VVIQ score was found to be negatively correlated with the “practicality” score of inventions  = 1.423, p > 0.05], “synthesis”  and “transformation” scores  of pre-inventive forms were not significant.The analysis showed that the overall model of the “originality” . After introducing the VVIQ and VVQ scores, the second model explained 17.7% of variance , that is an additional 15% . After introducing the accuracy score of the generation, inspection and transformation processes of visual mental imagery, the third model explained 31.5% of variance , that is an additional 13.8%, . In the model as a whole, the VVQ score  and the PFT score  were significant.Regarding the “originality” score of inventions, the analysis demonstrated that the first model was not significant . After introducing the VVIQ and VVQ scores, the second model explained 17.1% of variance , that is an additional 17.1% . After introducing the accuracy score of the generation, inspection and transformation processes of visual mental imagery, the third model explained 29.2% of variance , that is an additional 12.1% . In the model as a whole, only the VVIQ score  was significant.Regarding the “practicality” score of inventions, the analysis showed that the first model was not significant  and the second  model were not significant. After introducing the accuracy score of the generation, inspection and transformation processes of visual mental imagery, the third model explained 30.5% of variance , that is an additional 23.7%, . In the model as a whole, only the PFT score  was significant.Regarding the “graphic ability” score of Clark’s Drawing Ability Test, the first  and the second  model were not significant. After introducing the accuracy score of the generation, inspection and transformation processes of visual mental imagery, the third model explained 28.9% of variance , that is an additional 23%, . In the model as a whole, only the PFT score  was significant.Regarding the “esthetic” score of Clark’s Drawing Ability Test, the first  was not significant.Regarding the “creativity” score of Clark’s Drawing Ability Test, the analysis showed that the overall model [This study was aimed at investigating the extent to which dimensions of visual creativity, measured in terms of creative objects production and artistic drawings making, and imagery components, such as vividness of imagery, the strategy to use preferentially images and cognitive processes involved in imagery  are related. The correlation analysis revealed that all dimensions of pre-inventive forms, inventions and artistic drawings positively correlated with the transformation imagery ability measured by means of the PFT, meaning that the higher the ability to construct pre-inventive forms, original and practical inventions and to make creative artistic drawings, the higher the ability to mentally manipulate spatial forms. According to our results only the high capability to mentally transform an image predicts dimensions of visual creativity products. Among the three cognitive components of visual mental imagery, transformation is the only one that requires a high cognitive load also involving working memory. All participants enrolled in the study showed a working memory capability above the cut-off reported by the two most recent Italian validation studies  of the CFocusing on the Creative Synthesis Task, the construction of pre-inventive forms, based on mental transformations and syntheses of visual elements, as well as the interpretation of pre-inventive forms were supported by the spatial imagery ability. These results confirm and extend The regression analysis partially confirmed these results, given that the transformation imagery ability only predicted the originality score of inventions. Interestingly, the originality score of inventions positively correlated with the Visualizer-Verbalizer score: the higher the ability to use images, the more original were the inventions in the Creative Synthesis Task. This result was also confirmed by the regression analysis. Therefore, both the spatial imagery ability and the strategy to use images to process information play a key role when interpreting pre-inventive meaningless forms. In other words, while searching for a creative object in the category, participants probably mentally visualized possible objects of the same shape as the pre-inventive form and used spatial imagery to compare shapes.In addition, the practicality score of inventions was found to be negatively correlated with the vividness of imagery, meaning that the more participants imagine vividly the less practical were their inventions. These results were also confirmed by the regression analysis. This apparently contradicts Moving to Clark’s Drawing Ability Test, the graphic ability, the esthetic and creativity scores of drawings correlated only with the transformation imagery ability. The regression analysis confirmed the predictive role of the PFT for the graphic ability and esthetic scores of the artistic drawing. No relationship was found between dimensions of the artistic drawing and processes supporting object imagery, such as vividness of imagery. Although these results partially confirm In conclusion, this study underlines that the relationship between visual creativity and visual mental imagery is rather problematic and hard to predict. Visual creativity is definitively supported by specific visual imagery processes, and this would led one to suppose that it is enabled by abilities that fall in the visual domain of knowledge, but the extent to which visual imagery processes play a key role seems to be task- and expertise-dependent. Results might change depending on the tasks used both to measure visual creativity and visual imagery proficiencies, as well as the individual differences in visual creativity and visual imagery processing. In the present study visual creativity was assessed in light of two different product-oriented tasks, and scores obtained were related to specific visual imagery abilities scores. Of course, given the complexity of the visual domain, the methodology used does not encompass the variety of possibilities that the relationships between visual creativity and visual imagery can take on. In this direction, it would be interesting to better consider the spatial domain. According to The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.