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28 January 2021 where to buy ventolin pills The "NHS at 70. NHS Voices of asthma treatment" initiative is creating where to buy ventolin pills a national collection of personal testimonies The NHS at 70. NHS Voices of asthma treatment initiative, directed by Dr Stephanie Snow, at the University of Manchester received funding from the National Lottery Heritage Fund and the UKRI asthma treatment Urgency Call through the Arts and Humanities Research Council to document the impact of the global health ventolin on the lives of people across the four nations of the UK. The project builds on the NHS at 70 collection and you can see a number of stories online on their website.In partnership with the British Library they are currently creating a unique national archive of personal testimonies that will capture the complex social where to buy ventolin pills dimensions of this crisis. The archive will be preserved at the British Library as a permanent public resource and will contribute to the knowledge of future health ventolins.

In contrast to the 1918 Spanish flu ventolin, they aim to leave an important historical footprint and a legacy that consists of diverse voices, experiences and opinions.Our members' work in where to buy ventolin pills pathology constitutes a significant intervention in the evolving oral testimonies of the ventolin in ‘real time’. This matters as it allows the project to capture for both current and future generations including policy makers, the significance of the wider political, social and scientific context of the current situation.The NHS Voices of asthma treatment project appreciates the constraints you will have on your time during this extraordinary period and says that even a short interview would be hugely valuable for the project – they can accommodate any time to suit you including weekends and evenings.Please also note that you are able to close all or parts of the interview for a period of years if this is something that might enable you to speak more frankly.If you would like to make an informal enquiry or you are interested in contributing towards this project, please take the time to read the attached Participant Information Sheet and Recording Agreement (which you would be asked to complete after the interview) before contacting the project manager Angela Whitecross on angela.whitecross@manchester.ac.uk.

Ventolin pump

About This TrackerThis ventolin pump tracker provides the number of confirmed cases and deaths from novel asthma by country, the trend in confirmed case and death counts by country, and a global map showing which countries have confirmed cases and deaths http://jeffreymetcalfe.com/commercial/lukes-liquors/. The data are drawn from the Johns Hopkins University (JHU) asthma Resource Center’s asthma treatment Map and the World Health Organization’s (WHO) asthma Disease (asthma treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About asthma treatment asthmaIn late 2019, a new asthma emerged in central China to cause disease in humans ventolin pump. Cases of this disease, known as asthma treatment, have since been reported across around the globe. On January 30, 2020, the World Health Organization (WHO) declared the ventolin represents a public health emergency of international concern, and on January 31, 2020, the U.S.

Department of Health and Human Services declared it to be a health emergency for the United States.As of July 7, 2021, of the estimated 3.3 billion asthma treatment doses administered ventolin pump globally, most had been provided in a small number of countries only. For much of the world, particularly for those living in low- and middle-income countries, asthma treatments remain out of reach. While international efforts, such as COVAX and additional treatment donations are seeking to increase global treatment access, several estimates suggest that many countries may not achieve substantial levels of vaccination until at least 2023.Drawing on and complementing existing efforts that track global treatment access, such as Our World in Data, the Launch and Scale Speedometer, ventolin pump and Bloomberg’s treatment Tracker, we examine several measures of global treatment equity in an effort to assess where the biggest gaps are and whether they are narrowing or getting worse. Specifically, we group countries by income and by region and look at:Share of the total population having received at least one treatment doseRate of first treatment doses administered (Using the 7-day rolling average per 1,000,000 people)Based on the current rate of treatment doses administered, we also estimate how much the pace would need to increase in order to reach global treatment coverage goals set by the World Health Organization, World Trade Organization, International Monetary Fund, and World Bank. 40% coverage by the end of 2021 and 60% by mid-2022.

We do this at the country-level, and for countries by income group and regional classification.As we find here, there are wide disparities in access by income and by region (especially where these overlap), with low-income countries (LICs) in particular lagging far behind, followed ventolin pump closely by lower middle-income countries (LMICs), and Africa lagging behind all other regions. If current rates continue, most low-income countries and most countries in Africa are not on track to meet global vaccination targets.asthma treatment Vaccinations by Country Income There are large differences in the share of the population that has received at least one treatment dose by country income, with LMICs lagging significantly behind. As of July 7, whereas more than half of individuals (51%) have received at least one dose in high-income countries (HICs), only 1% of the population in LICs, 14% in LMICs, and 31% in upper middle-income countries (UMICs) have received at least one dose (see Figure 1 and Figure 2). Three countries (China, India and the United States) ventolin pump account for the majority (57%) of all first doses administered globally. When removed, the difference between HICs and middle-income countries becomes even starker, with HICs still well ahead of other income groups in share of population that has received at least one dose (see Figure 3).

See Table 1 for the full list of countries in each income ventolin pump group by share of population that has received at least one dose. Similarly, there is also a large gulf in the rate at which treatments are being administered by country income. While the daily rate of first doses administered varies by country (see Figure 4), HICs were administering first doses at a rate nearly 2 times the rate in LMICs and in UMICs, and nearly 30 times the rate in LICs. See Table ventolin pump 2 for a breakdown of top countries in each income group by coverage and daily administration rates. If current trends continue, these disparities are likely to grow, and LICs are unlikely to meet vaccination targets.

Based on current vaccination rates (using rates of first doses administered), HICs and UMICs are on track to have 40% or more of their populations having received at least one dose by the end of the year, whereas LMICs would need to increase their daily rate by 1.03 times and LICs would need to increase their daily rate by nearly 19 times in order to meet the same goal. HICs, UMICs, and LMICs are on track to have ventolin pump 60% or more of their populations having received at least one dose by mid-2022, while LICs would need to increase their daily rate by 14 times (see Figure 5). Certain countries, primarily HICs, have already met some of these vaccination targets. asthma treatment Vaccinations by ventolin pump RegionAs with country income, there are large differences in the share of the population that has received at least one treatment dose among regions, with the highest coverage in Europe and smallest in Africa. As of July 7, the region with the highest coverage is Europe (40%) followed by the Americas (39%) and the Western Pacific (37%).

Africa has the lowest coverage (2%) (see Figure 6 and Figure 7). Similar to income level, China, India and ventolin pump the U.S. Are driving trends in vaccination coverage in their respective regions. For instance, China accounts for 87% of first doses administered in Western Pacific, the US accounts for 46% in the Americas, and India accounts for 84% in South-East Asia. When removing these countries, the differences between Europe and the Americas, Western Pacific, and South-East Asia are larger (see Figure ventolin pump next page 8).

See Table 3 for a breakdown of top countries in each region by coverage and daily administration rates. The rate of treatment administration is highest in Europe and the ventolin pump Americas and lowest in Africa. While rates of first doses administered vary by country (see Figure 9), Europe and the Americas currently have the highest rate of daily doses administered. These regions are vaccinating at a rate approximately 1.5 times that of South-East Asia, nearly 3 times that of Eastern Mediterranean, 4 times that of the Western Pacific, and more than 13 times higher that of Africa. See Table 4 for a ventolin pump breakdown of top countries in each region by coverage and daily administration rates.

These disparities are likely to grow based on current vaccination trends. Western Pacific, Europe, the Americas, and South-East Asia are all ahead of schedule toward reaching 40% by the end of 2021 while Eastern Mediterranean would need to increase its rate of daily first doses ventolin pump administered by nearly 1.6 times the current rate, and Africa by approximately 11 times the current rate. They are also ahead of schedule to reach 60% by mid-2022, while Eastern Mediterranean would need to increase its rate of daily first doses administered by approximately 1.4 times the current rate, and Africa by approximately 8 times the current rate (see Figure 10). Certain countries, primarily those in Europe, have already met some of these vaccination targets. ImplicationsThese findings underscore an ongoing equity gap in access to asthma treatment vaccinations around the world, particularly for those living in the poorest countries and in ventolin pump countries in Africa.

Furthermore, they suggest that if current rates continue, some of these disparities may grow and many low-income countries will not meet global targets of vaccinating 40% of each countries’ population by end of 2021 and 60% by mid-2022. Increasing treatment supplies and stepping up the pace of vaccinations in those countries lagging furthest behind can narrow the equity gap and help all countries achieve asthma treatment vaccination coverage goals. Vaccination Data ventolin pump. We used country-level vaccination data on doses administered, provided by Our World in Data (OWID), to assess global vaccination trends at the income and regional level. Totals for some entities were combined (Taiwan, Hong Kong, and Macao included as part of China, and Jersey and ventolin pump Guernsey were combined and reported as the Channel Islands).

Where missing data in the daily doses provided existed between two dates for a country, we estimated the number of doses administered each day between the two reported dates assuming a linear distribution. For countries that have stopped reporting data, we assumed no change in new doses administered. For countries that report total doses administered but not share of population that has received at least one dose, we use OWID’s suggested ventolin pump methodology and calculated a lower-bound estimate. As a result, our estimates are conservative and the actual share of the population receiving one dose is likely higher. For data on daily administration of first doses, we calculated the rolling 7-day average in daily change of the number of people who have received at least one dose.

For projecting increased rate needed for groupings to reach certain benchmarks (40% by end of 2021 and 60% by July ventolin pump 1, 2022), we calculated the rate needed to reach these benchmarks for each grouping, based on number of first doses already administered and population, and calculated the percentage change from the current daily rate in first doses being administered to the increased rate needed to reach these targets. Lastly, for all data, to account for any lag in country reporting, we use data up to one week prior (July 7, 2021).Population Data. Population data were obtained from the United Nations World Population Prospects using 2020 estimates for total population (and the CIA World Factbook for ventolin pump Serbia and Kosovo). Totals for some entities were combined (Taiwan, Hong Kong, and Macao included as part of China), while others were separated (separating Kosovo from Serbia).Income Data. Income classifications were obtained using World Bank data.

Entities lacking an income classification were ventolin pump excluded from the income-level analysis.Regional Data. Region classifications were obtained using World Health Organization data. Entities lacking a region classification were excluded from the region-level analysis..

About This TrackerThis tracker provides the number of confirmed cases and deaths from novel asthma by country, the trend in confirmed case and death counts by country, and a global where to buy ventolin pills map showing which countries have confirmed cases and http://www.ec-cath-ernolsheim-bruche.ac-strasbourg.fr/?tribe_events=rencontre-badminton-cm1cm2 deaths. The data are drawn from the Johns Hopkins University (JHU) asthma Resource Center’s asthma treatment Map and the World Health Organization’s (WHO) asthma Disease (asthma treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About asthma treatment asthmaIn late 2019, a new asthma emerged in central China to cause disease in humans where to buy ventolin pills. Cases of this disease, known as asthma treatment, have since been reported across around the globe.

On January 30, 2020, the World Health Organization (WHO) declared the ventolin represents a public health emergency of international concern, and on January 31, 2020, the U.S. Department of Health and Human Services declared it to be a health emergency for the United States.As of July 7, 2021, of the estimated 3.3 billion asthma treatment doses administered globally, most had been provided in a small number where to buy ventolin pills of countries only. For much of the world, particularly for those living in low- and middle-income countries, asthma treatments remain out of reach. While international efforts, such as COVAX and additional treatment donations are seeking to increase global treatment access, several estimates suggest that many countries may not achieve substantial levels of vaccination until at least 2023.Drawing on and complementing existing efforts that track global treatment access, such as Our World in Data, the Launch and Scale Speedometer, and Bloomberg’s treatment Tracker, we examine several measures of global treatment equity in an effort to assess where the biggest gaps are and whether they where to buy ventolin pills are narrowing or getting worse.

Specifically, we group countries by income and by region and look at:Share of the total population having received at least one treatment doseRate of first treatment doses administered (Using the 7-day rolling average per 1,000,000 people)Based on the current rate of treatment doses administered, we also estimate how much the pace would need to increase in order to reach global treatment coverage goals set by the World Health Organization, World Trade Organization, International Monetary Fund, and World Bank. 40% coverage by the end of 2021 and 60% by mid-2022. We do this at the country-level, and for countries by income group and regional classification.As we where to buy ventolin pills find here, there are wide disparities in access by income and by region (especially where these overlap), with low-income countries (LICs) in particular lagging far behind, followed closely by lower middle-income countries (LMICs), and Africa lagging behind all other regions. If current rates continue, most low-income countries and most countries in Africa are not on track to meet global vaccination targets.asthma treatment Vaccinations by Country Income There are large differences in the share of the population that has received at least one treatment dose by country income, with LMICs lagging significantly behind.

As of July 7, whereas more than half of individuals (51%) have received at least one dose in high-income countries (HICs), only 1% of the population in LICs, 14% in LMICs, and 31% in upper middle-income countries (UMICs) have received at least one dose (see Figure 1 and Figure 2). Three countries (China, India and the United States) account for the majority where to buy ventolin pills (57%) of all first doses administered globally. When removed, the difference between HICs and middle-income countries becomes even starker, with HICs still well ahead of other income groups in share of population that has received at least one dose (see Figure 3). See Table 1 for the where to buy ventolin pills full list of countries in each income group by share of population that has received at least one dose.

Similarly, there is also a large gulf in the rate at which treatments are being administered by country income. While the daily rate of first doses administered varies by country (see Figure 4), HICs were administering first doses at a rate nearly 2 times the rate in LMICs and in UMICs, and nearly 30 times the rate in LICs. See Table 2 for a breakdown of top countries where to buy ventolin pills in each income group by coverage and daily administration rates. If current trends continue, these disparities are likely to grow, and LICs are unlikely to meet vaccination targets.

Based on current vaccination rates (using rates of first doses administered), HICs and UMICs are on track to have 40% or more of their populations having received at least one dose by the end of the year, whereas LMICs would need to increase their daily rate by 1.03 times and LICs would need to increase their daily rate by nearly 19 times in order to meet the same goal. HICs, UMICs, and where to buy ventolin pills LMICs are on track to have 60% or more of their populations having received at least one dose by mid-2022, while LICs would need to increase their daily rate by 14 times (see Figure 5). Certain countries, primarily HICs, have already met some of these vaccination targets. asthma treatment Vaccinations by RegionAs with country income, there are large differences in the share of the population that has received at least one where to buy ventolin pills treatment dose among regions, with the highest coverage in Europe and smallest in Africa.

As of July 7, the region with the highest coverage is Europe (40%) followed by the Americas (39%) and the Western Pacific (37%). Africa has the lowest coverage (2%) (see Figure 6 and Figure 7). Similar to income level, China, India where to buy ventolin pills and the U.S. Are driving trends in vaccination coverage in their respective regions.

For instance, China accounts for 87% of first doses administered in Western Pacific, the US accounts for 46% in the Americas, and India accounts for 84% in South-East Asia. When removing these countries, the differences find out this here between Europe and the Americas, Western Pacific, and South-East Asia are larger (see Figure where to buy ventolin pills 8). See Table 3 for a breakdown of top countries in each region by coverage and daily administration rates. The rate where to buy ventolin pills of treatment administration is highest in Europe and the Americas and lowest in Africa.

While rates of first doses administered vary by country (see Figure 9), Europe and the Americas currently have the highest rate of daily doses administered. These regions are vaccinating at a rate approximately 1.5 times that of South-East Asia, nearly 3 times that of Eastern Mediterranean, 4 times that of the Western Pacific, and more than 13 times higher that of Africa. See Table 4 for a breakdown of top countries in where to buy ventolin pills each region by coverage and daily administration rates. These disparities are likely to grow based on current vaccination trends.

Western Pacific, Europe, the Americas, and South-East Asia are all ahead of schedule toward reaching 40% by the end of 2021 while Eastern Mediterranean would need to increase its rate of daily first doses administered by nearly 1.6 times the current rate, and Africa by approximately 11 times where to buy ventolin pills the current rate. They are also ahead of schedule to reach 60% by mid-2022, while Eastern Mediterranean would need to increase its rate of daily first doses administered by approximately 1.4 times the current rate, and Africa by approximately 8 times the current rate (see Figure 10). Certain countries, primarily those in Europe, have already met some of these vaccination targets. ImplicationsThese findings underscore an ongoing equity gap in access to where to buy ventolin pills asthma treatment vaccinations around the world, particularly for those living in the poorest countries and in countries in Africa.

Furthermore, they suggest that if current rates continue, some of these disparities may grow and many low-income countries will not meet global targets of vaccinating 40% of each countries’ population by end of 2021 and 60% by mid-2022. Increasing treatment supplies and stepping up the pace of vaccinations in those countries lagging furthest behind can narrow the equity gap and help all countries achieve asthma treatment vaccination coverage goals. Vaccination Data where to buy ventolin pills. We used country-level vaccination data on doses administered, provided by Our World in Data (OWID), to assess global vaccination trends at the income and regional level.

Totals for some entities were combined (Taiwan, Hong Kong, and Macao included as part of China, and Jersey and Guernsey were combined and reported as where to buy ventolin pills the Channel Islands). Where missing data in the daily doses provided existed between two dates for a country, we estimated the number of doses administered each day between the two reported dates assuming a linear distribution. For countries that have stopped reporting data, we assumed no change in new doses administered. For countries that report total doses administered but not share of population that has received at least one dose, where to buy ventolin pills we use OWID’s suggested methodology and calculated a lower-bound estimate.

As a result, our estimates are conservative and the actual share of the population receiving one dose is likely higher. For data on daily administration of first doses, we calculated the rolling 7-day average in daily change of the number of people who have received at least one dose. For projecting increased rate needed for groupings to reach certain benchmarks (40% by end of 2021 and 60% by July 1, 2022), we calculated the rate needed to reach these benchmarks for each grouping, based on number of first doses already administered and population, and calculated the percentage where to buy ventolin pills change from the current daily rate in first doses being administered to the increased rate needed to reach these targets. Lastly, for all data, to account for any lag in country reporting, we use data up to one week prior (July 7, 2021).Population Data.

Population data were obtained where to buy ventolin pills from the United Nations World Population Prospects using 2020 estimates for total population (and the CIA World Factbook for Serbia and Kosovo). Totals for some entities were combined (Taiwan, Hong Kong, and Macao included as part of China), while others were separated (separating Kosovo from Serbia).Income Data. Income classifications were obtained using World Bank data. Entities lacking an income where to buy ventolin pills classification were excluded from the income-level analysis.Regional Data.

Region classifications were obtained using World Health Organization data. Entities lacking a region classification were excluded from the region-level analysis..

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses.

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Games and sports of all kind, have always helped reduce anxieties, improve is there a generic version of ventolin http://yohoho.co.uk/ods-n-ends/ mental health, and survive times of crisis. Over the past few months, the overall interest in chess has reportedly doubled with more players than ever playing in events online. A combination of strategic and scientific thinking, combined with elements of pure art, is there a generic version of ventolin chess is one of the most cultural of games handed down over generations, the UN recognizes. Crossing barriersAffordable and inclusive, chess can be played anywhere and played by all – across the barriers of language, age, gender, physical ability and social status.

Because it is a global game that promotes fairness and mutual respect, it can contribute to an atmosphere of tolerance and understanding among peoples and nations, according to the UN. And chess also offers important opportunities in the implementation of the 2030 Agenda for Sustainable is there a generic version of ventolin Development and the Sustainable Development Goals (SDGs), including by strengthening education, realizing gender equality and the empowerment of women and girls. Multiplying values With the start of the Olympics in Tokyo just days away, the UN credits sport, arts and physical activity with the power to change perceptions and prejudices. The world body also sees them as inspiring people, breaking down racial and political barriers, combating discrimination and defusing conflict.

Therefore, according to the Organization, they contribute to peace, cooperation, solidarity and health at local, regional and international levels.Designating the dayOn 12 December 2019, to mark the date of the establishment of the International Chess Federation (FIDE) in Paris in 1924, the General Assembly proclaimed 20 July as is there a generic version of ventolin World Chess Day.The UN’s designation of the day will not only recognize the important role of the FIDE in supporting international cooperation for chess activity and aiming to improve friendly harmony among all peoples of the world, but also to provide an important platform to foster dialogue, solidarity and culture of peace.Interesting chess facts Some 605 million adults play chess regularly. Mathematically, there are more possible outcomes in a chess game, than there are atoms in the universe, as observed from earth. About 70 per cent of adults in is there a generic version of ventolin Germany, India, Russia, United Kingdom and United States have played chess at some point. Despite the complexity of the game, it is possible to checkmate an opponent in chess, in just two moves.Briefing on behalf of the UN chief, Deputy Secretary-General Amina Mohammed, painted a grim picture of civilian executions, arbitrary arrests, detentions, forced displacement and sexual violence against children, on a massive scale, in the Tigray region of Ethiopia.

She also spoke of “brutal attacks” in Afghanistan, Syria and Yemen, where 20 million people are living “face-to-face” with hunger. “We are in uncharted waters”, she is there a generic version of ventolin said, with the “sheer scale of humanitarian needs” never greater. This year the UN and its partners are seeking to assist 160 million people – its highest number ever. €˜Relentless’ attacks The “hurricane of humanitarian crises” is compounded by a “relentless wave of attacks” on humanitarian and medical workers, and the imposition of ever narrower constraints on humanitarian space, according to is there a generic version of ventolin the deputy UN chief.

€œThe Secretary-General urges this Council to take strong and immediate action to support its numerous resolutions on the protection of civilians, humanitarian and healthcare workers, and humanitarian space”, she told ministers and ambassadors. Surge in incidents Shootings, bodily and sexual assault, kidnappings and other attacks affecting humanitarian organizations, have increased tenfold since 2001, according to Ms. Mohammed. “In the five years since this Council’s landmark resolution calling for an end to impunity for attacks on healthcare systems, workers and patients have suffered thousands of attacks”, she said.

Meanwhile, it is becoming ever more difficult to provide vital humanitarian aid to people in need. Delaying tactics Some authorities impose restrictions on the movements of humanitarian staff and supplies, long visa and customs procedures and delays at checkpoints. Other obstacles include high taxes and fees on humanitarian supplies. And while every country needs to act against terrorism, each also has a responsibility to make sure its counter-terrorism efforts do not undermine humanitarian operations.  As Governments create systems around humanitarian aid delivery, the deputy chief reminded, “it is essential” that they support, rather than block aid.

Protect humanitarian space Because the best way to protect humanitarian space is by ending violence and conflict, the Secretary-General had called for a global ceasefire to focus on the common enemy. The asthma treatment ventolin. And on Thursday, the UN chief issued a call for silencing the guns in the run up to the Olympic and Paralympic Games in Tokyo. €œPeople and nations can build on this temporary respite to establish lasting ceasefires and find paths towards sustainable peace”, he said.

“Turbo-charged” by asthma treatment, humanitarian needs are outpacing the capacity to meet them, said Ms. Mohammed.  While the UN engages in difficult negotiations to create lasting ceasefires and build sustainable peace, the delivery of life-saving humanitarian aid must continue and that requires the necessary humanitarian space. Member States and the Security Council have “a responsibility to do everything in their power” to end attacks on humanitarians and assets, and seek accountability for serious violations, she underscored. [embedded content] Key steps She said there needed to be greater respect for international humanitarian law that does not “blur the lines” between military operations, political objectives and humanitarian efforts.   “Upholding the principles of humanitarian action…is essential to building trust with political, military, security, non-State armed groups and others”.

Secondly, “investigation and accountability” are essential to prevent attacks on aid workers, which she said was “completely unacceptable and may constitute war crimes” adding that “what goes unpunished will be repeated”. Thirdly, governments need to protect the ability of humanitarian organizations to engage with conflict parties, including non-State armed groups, because when humanitarian agencies are perceived as part of a political agenda, it puts workers in danger “and reduces their effectiveness”.   Principles of humanitarian action…essential to building trust with political, military, security, non-State armed groups and others -- UN deputy chiefCounter-terrorism measures should include clear provisions to preserve humanitarian space, she said, minimizing the impact on humanitarian operations and ensuring that humanitarian and healthcare personnel are not punished for doing their jobs. Finally, the Council must use its influence to immediately stop attacks against schools and hospitals. €œThe unprecedented healthcare emergency cause by the asthma treatment ventolin makes the protection of medical facilities and workers more critical than ever”.

Calls to action Member States were urged to endorse and implement the Safe Schools Declaration, which aims to protect all educational institutions from the worst effects of armed conflict and support the Health Care in Danger initiative. Due to the enormous challenges faced by humanitarian agencies, the Secretary-General has asked his incoming Humanitarian Affairs chief to appoint a Special Adviser on the preservation of humanitarian space and access, and to strengthen humanitarian negotiations. €œThe international community owes humanitarian aid agencies and healthcare and humanitarian workers its full and unwavering support in their difficult and often dangerous work”, Ms. Mohammed concluded..

Games and where to buy ventolin pills sports of all kind, have always helped http://www.edwardandsons.org/?p=1141 reduce anxieties, improve mental health, and survive times of crisis. Over the past few months, the overall interest in chess has reportedly doubled with more players than ever playing in events online. A combination of strategic and scientific thinking, combined with elements of pure art, chess is one of the most cultural of games handed down over generations, the where to buy ventolin pills UN recognizes. Crossing barriersAffordable and inclusive, chess can be played anywhere and played by all – across the barriers of language, age, gender, physical ability and social status.

Because it is a global game that promotes fairness and mutual respect, it can contribute to an atmosphere of tolerance and understanding among peoples and nations, according to the UN. And chess also offers important opportunities in the implementation of the 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs), including by strengthening education, realizing where to buy ventolin pills gender equality and the empowerment of women and girls. Multiplying values With the start of the Olympics in Tokyo just days away, the UN credits sport, arts and physical activity with the power to change perceptions and prejudices. The world body also sees them as inspiring people, breaking down racial and political barriers, combating discrimination and defusing conflict.

Therefore, according to the Organization, they contribute to peace, cooperation, solidarity and health at local, regional and international levels.Designating the dayOn 12 December 2019, to mark the date of the establishment of the International Chess Federation (FIDE) in Paris in 1924, where to buy ventolin pills the General Assembly proclaimed 20 July as World Chess Day.The UN’s designation of the day will not only recognize the important role of the FIDE in supporting international cooperation for chess activity and aiming to improve friendly harmony among all peoples of the world, but also to provide an important platform to foster dialogue, solidarity and culture of peace.Interesting chess facts Some 605 million adults play chess regularly. Mathematically, there are more possible outcomes in a chess game, than there are atoms in the universe, as observed from earth. About 70 per cent of adults in Germany, India, Russia, United Kingdom where to buy ventolin pills and United States have played chess at some point. Despite the complexity of the game, it is possible to checkmate an opponent in chess, in just two moves.Briefing on behalf of the UN chief, Deputy Secretary-General Amina Mohammed, painted a grim picture of civilian executions, arbitrary arrests, detentions, forced displacement and sexual violence against children, on a massive scale, in the Tigray region of Ethiopia.

She also spoke of “brutal attacks” in Afghanistan, Syria and Yemen, where 20 million people are living “face-to-face” with hunger. “We are where to buy ventolin pills in uncharted waters”, she said, with the “sheer scale of humanitarian needs” never greater. This year the UN and its partners are seeking to assist 160 million people – its highest number ever. €˜Relentless’ attacks The “hurricane of humanitarian crises” is compounded by a “relentless wave of attacks” on humanitarian and medical workers, and the imposition where to buy ventolin pills of ever narrower constraints on humanitarian space, according to the deputy UN chief.

€œThe Secretary-General urges this Council to take strong and immediate action to support its numerous resolutions on the protection of civilians, humanitarian and healthcare workers, and humanitarian space”, she told ministers and ambassadors. Surge in incidents Shootings, bodily and sexual assault, kidnappings and other attacks affecting humanitarian organizations, have increased tenfold since 2001, according to Ms. Mohammed. “In the five years since this Council’s landmark resolution calling for an end to impunity for attacks on healthcare systems, workers and patients have suffered thousands of attacks”, she said.

Meanwhile, it is becoming ever more difficult to provide vital humanitarian aid to people can i buy ventolin over the counter uk in need. Delaying tactics Some authorities impose restrictions on the movements of humanitarian staff and supplies, long visa and customs procedures and delays at checkpoints. Other obstacles include high taxes and fees on humanitarian supplies. And while every country needs to act against terrorism, each also has a responsibility to make sure its counter-terrorism efforts do not undermine humanitarian operations.  As Governments create systems around humanitarian aid delivery, the deputy chief reminded, “it is essential” that they support, rather than block aid.

Protect humanitarian space Because the best way to protect humanitarian space is by ending violence and conflict, the Secretary-General had called for a global ceasefire to focus on the common enemy. The asthma treatment ventolin. And on Thursday, the UN chief issued a call for silencing the guns in the run up to the Olympic and Paralympic Games in Tokyo. €œPeople and nations can build on this temporary respite to establish lasting ceasefires and find paths towards sustainable peace”, he said.

“Turbo-charged” by asthma treatment, humanitarian needs are outpacing the capacity to meet them, said Ms. Mohammed.  While the UN engages in difficult negotiations to create lasting ceasefires and build sustainable peace, the delivery of life-saving humanitarian aid must continue and that requires the necessary humanitarian space. Member States and the Security Council have “a responsibility to do everything in their power” to end attacks on humanitarians and assets, and seek accountability for serious violations, she underscored. [embedded content] Key steps She said there needed to be greater respect for international humanitarian law that does not “blur the lines” between military operations, political objectives and humanitarian efforts.   “Upholding the principles of humanitarian action…is essential to building trust with political, military, security, non-State armed groups and others”.

Secondly, “investigation and accountability” are essential to prevent attacks on aid workers, which she said was “completely unacceptable and may constitute war crimes” adding that “what goes unpunished will be repeated”. Thirdly, governments need to protect the ability of humanitarian organizations to engage with conflict parties, including non-State armed groups, because when humanitarian agencies are perceived as part of a political agenda, it puts workers in danger “and reduces their effectiveness”.   Principles of humanitarian action…essential to building trust with political, military, security, non-State armed groups and others -- UN deputy chiefCounter-terrorism measures should include clear provisions to preserve humanitarian space, she said, minimizing the impact on humanitarian operations and ensuring that humanitarian and healthcare personnel are not punished for doing their jobs. Finally, the Council must use its influence to immediately stop attacks against schools and hospitals. €œThe unprecedented healthcare emergency cause by the asthma treatment ventolin makes the protection of medical facilities and workers more critical than ever”.

Calls to action Member States were urged to endorse and implement the Safe Schools Declaration, which aims to protect all educational institutions from the worst effects of armed conflict and support the Health Care in Danger initiative. Due to the enormous challenges faced by humanitarian agencies, the Secretary-General has asked his incoming Humanitarian Affairs chief to appoint a Special Adviser on the preservation of humanitarian space and access, and to strengthen humanitarian negotiations. €œThe international community owes humanitarian aid agencies and healthcare and humanitarian workers its full and unwavering support in their difficult and often dangerous work”, Ms. Mohammed concluded..

Difference between proair and ventolin

A broadly neutralising antibody to prevent HIV transmissionTwo difference between proair and ventolin HIV prevention How to buy generic levitra online trials (HVTN 704/HPTN 085. HVTN 703/HPTN 081) enrolled 2699 at-risk cisgender men and transgender persons in the Americas and Europe and 1924 at-risk women in sub-Saharan Africa who were randomly assigned to receive the broadly neutralising antibody (bnAb) VRC01 or placebo (10 infusions at an interval of 8 weeks). Moderate-to-severe adverse events related to VRC01 were difference between proair and ventolin uncommon. In a prespecified pooled analysis, over 20 months, VRC01 offered an estimated prevention efficacy of ~75% against VRC01-sensitive isolates (30% of ventolines circulating in the trial regions). However, VRC01 did not prevent with other difference between proair and ventolin HIV isolates and overall HIV acquisition compared with placebo.

The data provide proof of concept that bnAb can prevent HIV acquisition, although the approach is limited by viral diversity and potential selection of resistant isolates.Corey L, Gilbert PB, Juraska M, et al. Two randomized trials of neutralizing antibodies difference between proair and ventolin to prevent HIV-1 acquisition. N Engl J Med. 2021;384:1003–1014.Seminal cytokine difference between proair and ventolin profiles are associated with the risk of HIV transmissionInvestigators analysed a panel of 34 cytokines/chemokines in blood and semen of men (predominantly men who have sex with men) with HIV, comparing 21 who transmitted HIV to their partners and 22 who did not. Overall, 47% of men had a recent HIV , 19% were on antiretroviral therapy and 84% were viraemic.

The cytokine profile in seminal fluid, but not in blood, differed significantly between transmitters and non-transmitters, with transmitters showing higher difference between proair and ventolin seminal concentrations of interleukin 13 (IL-13), IL-15 and IL-33, and lower concentrations of interferon‐gamma, IL-15, macrophage colony-stimulating factor (M-CSF), IL-17, granulocyte-macrophage CSF (GM-CSF), IL-4, IL-16 and eotaxin. Although limited, the findings suggest that the seminal milieu modulates the risk of HIV transmission, providing a potential development opportunity for HIV prevention strategies.Vanpouille C, Frick A, Rawlings SA, et al. Cytokine network difference between proair and ventolin and sexual HIV transmission in men who have sex with men. Clin Infect Dis. 2020;71:2655–2662.The challenge of estimating global treatment eligibility for chronic hepatitis B from incomplete datasetsWorldwide, over 250 million people are estimated to live with chronic hepatitis B difference between proair and ventolin (CHB), although only ~11% is diagnosed and a minority receives antiviral therapy.

An estimate of the global proportion eligible for treatment was not previously available. A systematic review analysed studies of difference between proair and ventolin CHB populations done between 2007 and 2018 to estimate the prevalence of cirrhosis, abnormal alanine aminotransferase, hepatitis B ventolin DNA >2000 or >20 000 IU/mL, hepatitis B e-antigen, and overall eligibility for treatment as per WHO and other guidelines. The pooled treatment eligibility estimate was 19% (95% CI 18% to 20%), with about 10% requiring urgent treatment due to cirrhosis. However, the estimate should difference between proair and ventolin be interpreted with caution due to incomplete data acquisition and reporting in available studies. Standardised reporting is needed to improve global and regional estimates of CHB treatment eligibility and guide effective policy formulation.Tan M, Bhadoria AS, Cui F, et al.

Estimating the proportion of people with chronic hepatitis B ventolin eligible difference between proair and ventolin for hepatitis B antiviral treatment worldwide. A systematic review and meta-analysis. Lancet Gastroenterol Hepatol, difference between proair and ventolin 2021. 6:106–119.Broad geographical disparity in the contribution of HIV to the burden of cervical cancerThis systematic review and meta-analysis estimated the contribution of HIV to the global and regional burden of cervical cancer using data from 24 studies which included 236 127 women with HIV. HIV difference between proair and ventolin markedly increased the risk of cervical cancer (pooled relative risk 6.07.

95% CI 4.40 to 8.37). In 2018, 4.9% (95% CI 3.6% to 6.4%) of cervical cancers were attributable to HIV globally, although the population-attributable fraction for HIV difference between proair and ventolin varied geographically, reaching 21% (95% CI 15.6% to 26.8%) in the African region. Cervical cancer is preventable and treatable. Efforts are needed to expand access to HPV difference between proair and ventolin vaccination in sub-Saharan Africa. More immediately, there is an urgent need to integrate cervical cancer screening within HIV services.Stelzle D, Tanaka LF, Lee KK, et al.

Estimates of the global burden of cervical difference between proair and ventolin cancer associated with HIV. Lancet Glob Health. 2020. 9:e161–69.The complex relationship between serum vitamin D and persistence of high-risk human papilloma ventolin Most cervical high-risk human papilloma ventolin (hrHPV) s are transient and those that persist are more likely to progress to cancer. Based on the proposed immunomodulatory properties of vitamin D, a longitudinal study examined the association between serum concentrations of five vitamin D biomarkers and short-term persistent (vs transient or sporadic) detection of hrHPV in 72 women who collected monthly cervicovaginal swabs over 6 months.

No significant associations were detected in the primary analysis. In sensitivity analyses, after multiple adjustments, serum concentrations of multiple vitamin D biomarkers were positively associated with the short-term persistence of 14 selected hrHPV types. The relationship between vitamin D and hrHPV warrants closer examination. Studies should have longer follow-up, include populations with more diverse vitamin D concentrations and account for vitamin D supplementation.Troja C, Hoofnagle AN, Szpiro A, et al. Understanding the role of emerging vitamin D biomarkers on short-term persistence of high-risk HPV among mid-adult women.

J Infect Dis 2020. Online ahead of printPublished in STI—the editor’s choice. One in five cases of with Neisseria gonorrhoeae clear spontaneouslyStudies have indicated that Neisseria gonorrhoeae (NG) s can resolve spontaneously without antibiotic therapy. A substudy of a randomised trial investigated 405 untreated subjects (71% men) who underwent both pretrial and enrolment NG testing at the same anatomical site (genital, pharyngeal and rectal). Based on nuclear acid amplification tests, 83 subjects (20.5%) showed clearance of the anatomical site within a median of 10 days (IQR 7–15) between tests.

Those with spontaneous clearance were less likely to have concurrent chlamydia (p=0.029) and dysuria (p=0.035), but there were no differences in age, gender, sexual orientation, HIV status, number of previous NG episodes, and symptoms other than dysuria between those with and without clearance. Given the high rate of spontaneous resolution, point-of-care NG testing should be considered to reduce unnecessary antibiotic treatment.Mensforth S, Ayinde OC, Ross J. Spontaneous clearance of genital and extragenital Neisseria gonorrhoeae. Data from GToG. STI 2020.

96:556–561.BackgroundReproductive aged women are at risk of both pregnancy and sexually transmitted s (STI). The modern contraceptive prevalence among married and unmarried women in South Africa is 54% and 64%, respectively, with injectable progestins being most widely used.1 Moreover, current global efforts aim towards all women having access to a range of reliable contraceptives options.2 The prevalences of chlamydia and gonorrhoea are high among women in Africa, particularly among younger women. A recent meta-analysis of over 37 000 women estimated prevalences for chlamydia and gonorrhoea by region and population type (South Africa clinic/community-based, Eastern Africa higher-risk and Southern/Eastern Africa clinic community-based). High chlamydia and gonorrhoea prevalences were found among 15–24 year-old South African women and high risk populations in East Africa.3 Both chlamydia and gonorrhoea are associated with numerous comorbidities including pelvic inflammatory disease (PID), ectopic pregnancy, infertility, increased risk of HIV and other STIs, as well as significant social harm.4While STIs are a significant global health burden, data on STI prevalence by gender and drivers of are limited, hindering an effective public health response.5 Moreover, data on the association between contraceptive use and risk of non-HIV STIs are limited. The WHO recently reported stagnation in efforts to decrease global STI incidence.5 Understanding drivers of STI acquisition, including any possible associations with widely used contraceptive methods, is necessary to effectively target public health responses that reduce STI incidence and associated comorbidities.The ECHO Trial (ClinicalTrials.gov Identifier.

NCT02550067) was a multicentre, open-label randomised trial of 7829 HIV-seronegative women seeking effective contraception in Eswatini, Kenya, South Africa and Zambia. Detailed trial methods and results have been published.6 7 We conducted a secondary analysis of ECHO trial data to evaluate absolute and relative chlamydia and gonorrhoea final visit prevalences among women randomised to intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUD) and a levonorgestrel (LNG) implant.MethodsStudy design, participants and ethicsWomen were enrolled in the ECHO trial from December 2015 through September 2017. Institutional review boards at each site approved the study protocol and women provided written informed consent before any study procedures. In brief, women who were not pregnant, HIV-seronegative, aged 16–35 years, seeking effective contraception, without medical contraindications, willing to use the assigned method for 18 months, reported not using injectable, intrauterine or implantable contraception for the previous 6 months and reported being sexually active, were enrolled. At every visit, participants received HIV risk reduction counselling, HIV testing and STI management, condoms and, as it became a part of national standard of care, HIV pre-exposure prophylaxis.

Counselling messages related to HIV risk were implemented consistently across the three groups throughout the trial.6The trial was implemented in accordance with the Declaration of Helsinki and Good Clinical Practice. Informed consent was obtained from participants or their parents/guardians and human experimentation guidelines of the United States Department of Health and Human Services and those of the authors' institution(s) were followed.Contraceptive exposureAt enrolment, women were randomly assigned (1:1:1) to DMPA-IM, copper IUD or LNG implant.6 Participants received an injection of 150 mg/mL DMPA-IM (Depo Provera. Pfizer, Puurs, Belgium) at enrolment and every 3 months until the final visit at 18 months after enrolment, a copper IUD (Optima TCu380A. Injeflex, Sao Paolo, Brazil) or a LNG implant (Jadelle. Bayer, Turku, Finland) at enrolment.

Women returned for follow-up visits at 1 month after enrolment to address initial contraceptive side-effects and every 3 months thereafter, for up to 18 months with later enrolling participants contributing 12 to 18 months of follow-up. Visits included HIV serological testing, contraceptive counselling, syndromic STI management and safety monitoring.STI outcomesThe primary outcomes of this secondary analysis were prevalent chlamydia and gonorrhoea at the final visit. Syndromic STI management was provided at screening and all follow-up visits. Nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae was conducted at screening and final visits, at the visit of HIV detection for participants who became HIV infected and at clinical discretion. Any untreated participants with positive NAAT results were contacted to return to the study clinic for treatment.CovariatesAt baseline (inclusive of screening and enrolment visits), we collected demographic, sexual and reproductive risk behaviour and reproductive and contraceptive history data.

Baseline risk factors evaluated as covariates included age, whether the participant earned her own income, chlamydia and gonorrhoea status, herpes simplex ventolin type 2 (HSV-2) sero-status and suspected PID. Final visit factors evaluated as covariates included number of sex partners in the past 3 months, number of new sex partners in the past 3 months, HIV serostatus, HSV-2 serostatus, condom use in the past 3 months, sex exchanged for money/gifts, sex during vaginal bleeding, follow-up time and number of pelvic examinations during follow-up. Age and HSV-2 serostatus were evaluated for effect measure modification.Statistical analysisWe conducted analyses using R V.3.5.3 (Vienna, Austria), and log-binomial regression to estimate chlamydia and gonorrhoea prevalences within each contraceptive group and pairwise prevalence ratios (PR) between each arm in as-randomised and consistent use analyses.In the as-randomised analysis, we analysed participants by the contraceptive method assigned at randomisation independent of method adherence. We estimated crude point prevalences by arm and study site and pairwise adjusted PRs.In the consistent use analysis, we only included women who initiated use of their randomised contraceptive method and maintained randomised method adherence throughout follow-up. We estimated crude point prevalences by arm and pairwise adjusted PRs, with evaluation of age and HSV-2 status first as potential effect measure modifiers, and all covariates above as potential confounders.

Study site and age were retained in the final model. Other covariates were retained if their inclusion in the base model led to a 10% change in the effect estimate through backwards selection.Supplementary analysesAdditional supporting analyses to assess postrandomisation potential sources of bias were conducted to inform interpretation of results. These include evaluation of recent sexual behaviour at enrolment, month 9 and the final visit. Cohort participation (ie, follow-up time, early discontinuation and timing of randomised method discontinuation) and health outcomes (ie, final visit HIV and HSV-2 status) and frequency and results of pelvic examinations by STI status, site and visit month by randomised arm.ResultsA total of 7829 women were randomly assigned as follows. 2609 to the DMPA-IM group, 2607 to the copper IUD group and 2613 to the LNG implant group (figure 1).

Participants were excluded if they were HIV positive at enrolment, did not have at least one HIV test or did not have chlamydia and gonorrhoea test results at the final visit. Overall, 90%, 94% and 93% from the DMPA-IM, copper IUD and LNG implant groups, respectively, were included in analyses.Study profile. DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device. LNG, levonorgestrel." data-icon-position data-hide-link-title="0">Figure 1 Study profile.

DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device. LNG, levonorgestrel.Participant characteristicsBaseline characteristics were similar across groups (table 1). Nearly two-third of enrolled women (63%) were aged 24 and younger and 5768 (74%) of the study population resided in South Africa.View this table:Table 1 Participant baseline and final visit characteristicsThe duration of participation averaged 16 months with no differences between randomised groups (table 1). A total of 1468 (19%) women either did not receive their randomised method or discontinued use during follow-up.

Overall method continuation rates were high with minimal differences between randomised groups when measured by person-years.6 The proportion, however, of method non-adherence as defined in this analysis (ie, did not receive randomised method at baseline or discontinued randomised method at any point during follow-up), was greater in the DMPA-IM group (26%), followed by the copper IUD (18%) and LNG implant (12%) groups. Timing of discontinuation also differed across methods. During the first 6 months, method discontinuation was highest in the copper IUD group (7%) followed closely by DMPA-IM (6%) and LNG implant (4%) groups. Between 7 and 12 months of follow-up, it was highest in DMPA-IM group (15%), with equivalent proportions in the LNG implant (5%) and copper IUD (5%) groups.Point prevalences of chlamydia and gonorrhoea at baseline and final visitsIn total, 18% of women had chlamydia at baseline (figure 2A) and 15% at the final visit. Among women 24 years and younger, 22% and 20% had chlamydia at baseline and final visits, respectively.

Women aged 25–35 at baseline were less likely to have chlamydia at both baseline (12%) and final visits (8%) compared with younger women. Baseline chlamydia prevalence ranged from 5% in Zambia to 28% in the Western Cape, South Africa (figure 2B).Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures." data-icon-position data-hide-link-title="0">Figure 2 Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures.Among all women, 5% had gonorrhoea at baseline and the final visit (figure 2C). Women aged 24 and younger were more likely to have gonorrhoea compared with women aged 25 and older at both baseline (5% vs 4%, respectively) and the final visit (6% vs 3%, respectively).

Baseline gonorrhoea prevalence ranged from 3% in Zambia and Kenya to 9% in the Western Cape, South Africa (figure 2D). Similar prevalences were observed at the final visit.Point prevalences of chlamydia and gonorrhoea at final visit by randomised contraceptive methodFourteen per cent of women randomised to DMPA-IM, 15% to copper IUD and 17% to LNG implant had chlamydia at the final visit (table 2).View this table:Table 2 Chlamydia trachomatis and Neisseria gonorrhoeae prevalence at final visitThe prevalence of chlamydia did not significantly differ between DMPA-IM and copper IUD groups (PR 0.90, 95% CI (0.79 to 1.04)) or between copper IUD and LNG implant groups (PR 0.92, 95% CI (0.81 to 1.04)). Women in the DMPA-IM group, however, had a significantly lower risk of chlamydia compared with the LNG implant group (PR. 0.83, 95% CI (0.72 to 0.95)). Findings from the consistent use analysis were similar, and neither age nor HSV-2 status modified the observed associations.Four per cent of women randomised to DMPA-IM, 6% to copper IUD and 5% to LNG implant had gonorrhoea at the final visit (table 2).

Gonorrhoea prevalence did not significantly differ between DMPA-IM and LNG implant groups (PR. 0.79, 95% CI (0.61 to 1.03)) or between copper IUD and LNG implant groups (PR. 1.18, 95% CI (0.93 to 1.49)). Women in the DMPA-IM group had a significantly lower risk of gonorrhoea compared with women in the copper IUD group (PR. 0.67, 95% CI (0.52 to 0.87)).

Results from as randomised and continuous use analyses did not differ. And again, neither age nor HSV-2 status modified the observed associations.Clinical assessment by randomised contraceptive methodTo assess the potential for outcome ascertainment bias, we evaluated the frequency of pelvic examinations and abdominal/pelvic pain and discharge by study arm. Women in the copper IUD group were generally more likely to receive a pelvic examination during follow-up as compared with women in the DMPA-IM and LNG implant groups (online supplemental appendix 1). Similarly, abdominal/pelvic pain on examination or abnormal discharge was observed most frequently in the copper IUD group. The number of pelvic examinations met the prespecified criteria for retention in the adjusted gonorrhoea model but not in the chlamydia model.Supplemental materialFrequency of syndromic symptoms and potential reAmong women who had chlamydia at baseline, 23% were also positive at the final visit (online supplemental appendix 2, figure 3A).

Nine per cent of gonorrhoea-positive women at baseline were also positive at the final visit (online supplemental appendix 2, figure 3B). Across both baseline and final visits, a minority of women with chlamydia or gonorrhoea presented with signs and/or symptoms. Among chlamydia-positive women, only 12% presented with either abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3C). Similarly, only 15% of gonorrhoea-positive women presented with abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3D).Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D).

Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain. Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment." data-icon-position data-hide-link-title="0">Figure 3 Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D). Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain. Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment.DiscussionWe observed differences in final prevalences of chlamydia and gonorrhoea by contraceptive group in both as-randomised and consistent-use analyses.

The DMPA-IM group had lower final visit chlamydia and gonorrhoea prevalences as compared with copper IUD and LNG implant groups, though only the DMPA-IM versus the copper IUD comparison of gonorrhoea and DMPA-IM versus LNG implant comparison of chlamydia reached statistical significance. These are novel findings that have not previously been reported to our knowledge and were determined in a randomised trial setting with high participant retention, robust biomarker testing and high randomised method adherence. Interestingly, the copper IUD group had higher gonorrhoea and lower chlamydia prevalence compared with the LNG implant group, though neither finding was statistically significant.Two recent systematic reviews of the association between contraceptives and STIs found inconsistent and insufficient evidence on the association between the contraceptive methods under study in ECHO and chlamydia and gonorrhoea.8 9 Neither systematic review identified any randomised studies or any direct comparative evidence for DMPA-IM, copper IUD and LNG implant, thus enabling a unique scientific contribution from this secondary trial analysis. Nonetheless, these findings should be interpreted in light of biological plausibility, as well as the design strengths and limitations of this analysis.The emerging science on the biological mechanisms underlying HIV susceptibility demonstrates the complex relationship between the infectious pathogen, the host innate and adaptive immune response and the interaction of both with the vaginal microbiome and other -omes. Data on these factors in relationship to chlamydia and gonorrhoea acquisition are much more limited but can be assumed to be equally complex.

Vaginal microbiome composition, including microbial metabolic by-products, have been shown to significantly modify risk of HIV acquisition and to vary with exogenous hormone exposure, menstrual cycle phase, ethnicity and geography.10–12 These same biological principles likely apply to chlamydia and gonorrhoea susceptibility. While DMPA-IM has been associated with decreased bacterial vaginosis (BV), initiation of the copper IUD has been associated with increased BV prevalence, and BV is associated with chlamydia and gonorrhoea acquisition.13 14 Moreover, Lactobacillus crispatus, which is less abundant in BV, has been shown to inhibit HeLa cell by Chlamydia trachomatis and inhibits growth of Neisseria gonorrhoeae in animal models.15 16 In addition, microbial community state types that are deficient in Lactobacillus crispatus and/or dominated by dysbiotic species are associated with inflammation, which is a driver of both STI and HIV susceptibility. Thus, while the exact mechanisms of chlamydia and gonorrhoea in the presence of exogenous hormones and varying host microbiomes are unknown, it is biologically plausible that these complex factors may result in differential susceptibility to chlamydia and gonorrhoea among DMPA-IM, copper IUD and LNG implant users.An alternative explanation for these findings may be postrandomisation differences in clinical care and/or sexual behaviour. Participants in the copper IUD arm were more likely to have pelvic examinations and more likely to have discharge compared with women in the DMPA-IM and LNG implant groups. While interim STI testing and/or treatment were not documented, women in the copper IUD arm may have been more likely to receive syndromic STI treatment during follow-up due to more examination and observed discharge.

More frequent STI treatment in the copper IUD group would theoretically lower the final visit point prevalence relative to women in the DMPA-IM and LNG implant arms, suggesting that the observed lower risk of STI in the DMPA-IM arm is not due to differential examination, testing and treatment. Differential sexual risk behaviour may also have influenced the results. As reported previously, women in the DMPA-IM group less frequently reported condomless sex and multiple partners than women in the other groups, and both DMPA-IM and LNG implant users less frequently reported new partners and sex during menses than copper IUD users.6 Statistical control of self-reported sexual risk behaviour in the consistent-use analysis may have been inadequate if self-reported sexual behaviour was inaccurately or insufficiently reported.A second alternative explanation may be differences in randomised method non-adherence, which was greater in the DMPA-IM group, compared with copper IUD and LNG implant groups. Yet, the consistency of findings in the as-randomised and continuous use analyses suggests that method non-adherence had minimal effect on study outcomes. Taken as a whole, these findings indicate that there may be real differences in chlamydia and gonorrhoea risk associated with use of DMPA-IM, the copper IUD and LNG implant.

However, any true differential risk by method must be evaluated in light of the holistic benefits and risks of each method.The high observed chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among women ages 24 years and younger and among women in South Africa and Eswatini. While the ECHO study was conducted in settings of high HIV/STI incidence, enrolment criteria did not purposefully target women at highest risk of HIV/STI in the trial communities, suggesting that the observed prevalences may be broadly applicable to women seeking effective contraception in those settings. Improved approaches are needed to prevent STIs, including options for expedited partner treatment, to prevent re.As expected, few women testing positive for chlamydia or gonorrhoea presented with symptoms (12% and 15%, respectively), and a substantial proportion of women who were positive and treated at baseline were infected at the final visit despite syndromic management during the follow-up. Given that syndromic management is the standard of care within primary health facilities in most trial settings, these data suggest that a large proportion of among reproductive aged women is missed, exacerbating the burden of curable STIs and associated morbidities. Routine access to more reliable diagnostics, like NAAT and novel point-of-care diagnostic tests, will be key to managing asymptomatic STIs and reducing STI prevalence and related morbidities in these settings.17This secondary analysis of the ECHO trial has strengths and limitations.

Strengths include the randomised design with comparator groups of equal STI baseline risk. Participants had high adherence to their randomised contraceptive method.6 While all participants received standardised clinical care and counselling, the unblinded randomisation may have allowed postrandomisation differences in STI risk over time by method. It is possible that participants modified their risk-taking behaviour based on study counselling messages regarding the potential association between DMPA-IM and HIV.In conclusion, our analyses suggest that DMPA-IM users may have lower risk of chlamydia and gonorrhoea compared with LNG implant and copper IUD users, respectively. Further investigation is warranted to better understand the mechanisms of chlamydia and gonorrhoea susceptibility in the context of contraceptive use. Moreover, the high chlamydia and gonorrhoea prevalences in this population, independent of contraceptive method, warrants urgent attention.Key messagesThe prevalence of chlamydia and gonorrhoea varied by contraceptive method in this randomised trial.High chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among young women in South Africa and Eswatini.Most chlamydia and gonorrhoea s were asymptomatic.

Therefore, routine access to reliable diagnostics are needed to effectively manage and prevent STIs in African women..

A broadly neutralising antibody to prevent where to buy ventolin pills HIV transmissionTwo HIV prevention trials (HVTN 704/HPTN How to buy generic levitra online 085. HVTN 703/HPTN 081) enrolled 2699 at-risk cisgender men and transgender persons in the Americas and Europe and 1924 at-risk women in sub-Saharan Africa who were randomly assigned to receive the broadly neutralising antibody (bnAb) VRC01 or placebo (10 infusions at an interval of 8 weeks). Moderate-to-severe adverse events related to VRC01 were where to buy ventolin pills uncommon. In a prespecified pooled analysis, over 20 months, VRC01 offered an estimated prevention efficacy of ~75% against VRC01-sensitive isolates (30% of ventolines circulating in the trial regions).

However, VRC01 where to buy ventolin pills did not prevent with other HIV isolates and overall HIV acquisition compared with placebo. The data provide proof of concept that bnAb can prevent HIV acquisition, although the approach is limited by viral diversity and potential selection of resistant isolates.Corey L, Gilbert PB, Juraska M, et al. Two randomized trials of neutralizing antibodies where to buy ventolin pills to prevent HIV-1 acquisition. N Engl J Med.

2021;384:1003–1014.Seminal cytokine profiles are associated with the risk of HIV transmissionInvestigators analysed a panel of 34 cytokines/chemokines where to buy ventolin pills in blood and semen of men (predominantly men who have sex with men) with HIV, comparing 21 who transmitted HIV to their partners and 22 who did not. Overall, 47% of men had a recent HIV , 19% were on antiretroviral therapy and 84% were viraemic. The cytokine profile in seminal fluid, but not in blood, differed significantly between transmitters and non-transmitters, with transmitters showing higher seminal concentrations of interleukin 13 (IL-13), IL-15 and IL-33, and lower concentrations of interferon‐gamma, IL-15, macrophage where to buy ventolin pills colony-stimulating factor (M-CSF), IL-17, granulocyte-macrophage CSF (GM-CSF), IL-4, IL-16 and eotaxin. Although limited, the findings suggest that the seminal milieu modulates the risk of HIV transmission, providing a potential development opportunity for HIV prevention strategies.Vanpouille C, Frick A, Rawlings SA, et al.

Cytokine network and sexual HIV transmission where to buy ventolin pills in men who have sex with men. Clin Infect Dis. 2020;71:2655–2662.The challenge of estimating global treatment eligibility for chronic hepatitis B from incomplete datasetsWorldwide, over 250 million people are estimated to live with chronic hepatitis B (CHB), although where to buy ventolin pills only ~11% is diagnosed and a minority receives antiviral therapy. An estimate of the global proportion eligible for treatment was not previously available.

A systematic review analysed studies of CHB populations done between 2007 and 2018 to estimate the prevalence of cirrhosis, abnormal alanine aminotransferase, hepatitis B ventolin DNA >2000 or >20 000 IU/mL, hepatitis B e-antigen, and overall eligibility for treatment as per WHO and where to buy ventolin pills other guidelines. The pooled treatment eligibility estimate was 19% (95% CI 18% to 20%), with about 10% requiring urgent treatment due to cirrhosis. However, the estimate should be where to buy ventolin pills interpreted with caution due to incomplete data acquisition and reporting in available studies. Standardised reporting is needed to improve global and regional estimates of CHB treatment eligibility and guide effective policy formulation.Tan M, Bhadoria AS, Cui F, et al.

Estimating the proportion of people with where to buy ventolin pills chronic hepatitis B ventolin eligible for hepatitis B antiviral treatment worldwide. A systematic review and meta-analysis. Lancet Gastroenterol where to buy ventolin pills Hepatol, 2021. 6:106–119.Broad geographical disparity in the contribution of HIV to the burden of cervical cancerThis systematic review and meta-analysis estimated the contribution of HIV to the global and regional burden of cervical cancer using data from 24 studies which included 236 127 women with HIV.

HIV markedly increased the risk of cervical cancer (pooled where to buy ventolin pills relative risk 6.07. 95% CI 4.40 to 8.37). In 2018, 4.9% (95% CI 3.6% to 6.4%) of cervical cancers were attributable to HIV globally, although the population-attributable fraction for HIV varied where to buy ventolin pills geographically, reaching 21% (95% CI 15.6% to 26.8%) in the African region. Cervical cancer is preventable and treatable.

Efforts are where to buy ventolin pills needed to expand access to HPV vaccination in sub-Saharan Africa. More immediately, there is an urgent need to integrate cervical cancer screening within HIV services.Stelzle D, Tanaka LF, Lee KK, et al. Estimates of the global burden of cervical where to buy ventolin pills cancer associated with HIV. Lancet Glob Health.

2020. 9:e161–69.The complex relationship between serum vitamin D and persistence of high-risk human papilloma ventolin Most cervical high-risk human papilloma ventolin (hrHPV) s are transient and those that persist are more likely to progress to cancer. Based on the proposed immunomodulatory properties of vitamin D, a longitudinal study examined the association between serum concentrations of five vitamin D biomarkers and short-term persistent (vs transient or sporadic) detection of hrHPV in 72 women who collected monthly cervicovaginal swabs over 6 months. No significant associations were detected in the primary analysis.

In sensitivity analyses, after multiple adjustments, serum concentrations of multiple vitamin D biomarkers were positively associated with the short-term persistence of 14 selected hrHPV types. The relationship between vitamin D and hrHPV warrants closer examination. Studies should have longer follow-up, include populations with more diverse vitamin D concentrations and account for vitamin D supplementation.Troja C, Hoofnagle AN, Szpiro A, et al. Understanding the role of emerging vitamin D biomarkers on short-term persistence of high-risk HPV among mid-adult women.

J Infect Dis 2020. Online ahead of printPublished in STI—the editor’s choice. One in five cases of with Neisseria gonorrhoeae clear spontaneouslyStudies have indicated that Neisseria gonorrhoeae (NG) s can resolve spontaneously without antibiotic therapy. A substudy of a randomised trial investigated 405 untreated subjects (71% men) who underwent both pretrial and enrolment NG testing at the same anatomical site (genital, pharyngeal and rectal).

Based on nuclear acid amplification tests, 83 subjects (20.5%) showed clearance of the anatomical site within a median of 10 days (IQR 7–15) between tests. Those with spontaneous clearance were less likely to have concurrent chlamydia (p=0.029) and dysuria (p=0.035), but there were no differences in age, gender, sexual orientation, HIV status, number of previous NG episodes, and symptoms other than dysuria between those with and without clearance. Given the high rate of spontaneous resolution, point-of-care NG testing should be considered to reduce unnecessary antibiotic treatment.Mensforth S, Ayinde OC, Ross J. Spontaneous clearance of genital and extragenital Neisseria gonorrhoeae.

Data from GToG. STI 2020. 96:556–561.BackgroundReproductive aged women are at risk of both pregnancy and sexually transmitted s (STI). The modern contraceptive prevalence among married and unmarried women in South Africa is 54% and 64%, respectively, with injectable progestins being most widely used.1 Moreover, current global efforts aim towards all women having access to a range of reliable contraceptives options.2 The prevalences of chlamydia and gonorrhoea are high among women in Africa, particularly among younger women.

A recent meta-analysis of over 37 000 women estimated prevalences for chlamydia and gonorrhoea by region and population type (South Africa clinic/community-based, Eastern Africa higher-risk and Southern/Eastern Africa clinic community-based). High chlamydia and gonorrhoea prevalences were found among 15–24 year-old South African women and high risk populations in East Africa.3 Both chlamydia and gonorrhoea are associated with numerous comorbidities including pelvic inflammatory disease (PID), ectopic pregnancy, infertility, increased risk of HIV and other STIs, as well as significant social harm.4While STIs are a significant global health burden, data on STI prevalence by gender and drivers of are limited, hindering an effective public health response.5 Moreover, data on the association between contraceptive use and risk of non-HIV STIs are limited. The WHO recently reported stagnation in efforts to decrease global STI incidence.5 Understanding drivers of STI acquisition, including any possible associations with widely used contraceptive methods, is necessary to effectively target public health responses that reduce STI incidence and associated comorbidities.The ECHO Trial (ClinicalTrials.gov Identifier. NCT02550067) was a multicentre, open-label randomised trial of 7829 HIV-seronegative women seeking effective contraception in Eswatini, Kenya, South Africa and Zambia.

Detailed trial methods and results have been published.6 7 We conducted a secondary analysis of ECHO trial data to evaluate absolute and relative chlamydia and gonorrhoea final visit prevalences among women randomised to intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUD) and a levonorgestrel (LNG) implant.MethodsStudy design, participants and ethicsWomen were enrolled in the ECHO trial from December 2015 through September 2017. Institutional review boards at each site approved the study protocol and women provided written informed consent before any study procedures. In brief, women who were not pregnant, HIV-seronegative, aged 16–35 years, seeking effective contraception, without medical contraindications, willing to use the assigned method for 18 months, reported not using injectable, intrauterine or implantable contraception for the previous 6 months and reported being sexually active, were enrolled. At every visit, participants received HIV risk reduction counselling, HIV testing and STI management, condoms and, as it became a part of national standard of care, HIV pre-exposure prophylaxis.

Counselling messages related to HIV risk were implemented consistently across the three groups throughout the trial.6The trial was implemented in accordance with the Declaration of Helsinki and Good Clinical Practice. Informed consent was obtained from participants or their parents/guardians and human experimentation guidelines of the United States Department of Health and Human Services and those of the authors' institution(s) were followed.Contraceptive exposureAt enrolment, women were randomly assigned (1:1:1) to DMPA-IM, copper IUD or LNG implant.6 Participants received an injection of 150 mg/mL DMPA-IM (Depo Provera. Pfizer, Puurs, Belgium) at enrolment and every 3 months until the final visit at 18 months after enrolment, a copper IUD (Optima TCu380A. Injeflex, Sao Paolo, Brazil) or a LNG implant (Jadelle.

Bayer, Turku, Finland) at enrolment. Women returned for follow-up visits at 1 month after enrolment to address initial contraceptive side-effects and every 3 months thereafter, for up to 18 months with later enrolling participants contributing 12 to 18 months of follow-up. Visits included HIV serological testing, contraceptive counselling, syndromic STI management and safety monitoring.STI outcomesThe primary outcomes of this secondary analysis were prevalent chlamydia and gonorrhoea at the final visit. Syndromic STI management was provided at screening and all follow-up visits.

Nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae was conducted at screening and final visits, at the visit of HIV detection for participants who became HIV infected and at clinical discretion. Any untreated participants with positive NAAT results were contacted to return to the study clinic for treatment.CovariatesAt baseline (inclusive of screening and enrolment visits), we collected demographic, sexual and reproductive risk behaviour and reproductive and contraceptive history data. Baseline risk factors evaluated as covariates included age, whether the participant earned her own income, chlamydia and gonorrhoea status, herpes simplex ventolin type 2 (HSV-2) sero-status and suspected PID. Final visit factors evaluated as covariates included number of sex partners in the past 3 months, number of new sex partners in the past 3 months, HIV serostatus, HSV-2 serostatus, condom use in the past 3 months, sex exchanged for money/gifts, sex during vaginal bleeding, follow-up time and number of pelvic examinations during follow-up.

Age and HSV-2 serostatus were evaluated for effect measure modification.Statistical analysisWe conducted analyses using R V.3.5.3 (Vienna, Austria), and log-binomial regression to estimate chlamydia and gonorrhoea prevalences within each contraceptive group and pairwise prevalence ratios (PR) between each arm in as-randomised and consistent use analyses.In the as-randomised analysis, we analysed participants by the contraceptive method assigned at randomisation independent of method adherence. We estimated crude point prevalences by arm and study site and pairwise adjusted PRs.In the consistent use analysis, we only included women who initiated use of their randomised contraceptive method and maintained randomised method adherence throughout follow-up. We estimated crude point prevalences by arm and pairwise adjusted PRs, with evaluation of age and HSV-2 status first as potential effect measure modifiers, and all covariates above as potential confounders. Study site and age were retained in the final model.

Other covariates were retained if their inclusion in the base model led to a 10% change in the effect estimate through backwards selection.Supplementary analysesAdditional supporting analyses to assess postrandomisation potential sources of bias were conducted to inform interpretation of results. These include evaluation of recent sexual behaviour at enrolment, month 9 and the final visit. Cohort participation (ie, follow-up time, early discontinuation and timing of randomised method discontinuation) and health outcomes (ie, final visit HIV and HSV-2 status) and frequency and results of pelvic examinations by STI status, site and visit month by randomised arm.ResultsA total of 7829 women were randomly assigned as follows. 2609 to the DMPA-IM group, 2607 to the copper IUD group and 2613 to the LNG implant group (figure 1).

Participants were excluded if they were HIV positive at enrolment, did not have at least one HIV test or did not have chlamydia and gonorrhoea test results at the final visit. Overall, 90%, 94% and 93% from the DMPA-IM, copper IUD and LNG implant groups, respectively, were included in analyses.Study profile. DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device.

LNG, levonorgestrel." data-icon-position data-hide-link-title="0">Figure 1 Study profile. DMPA-IM, depot medroxy progesterone acetate. IUD, intrauterine device. LNG, levonorgestrel.Participant characteristicsBaseline characteristics were similar across groups (table 1).

Nearly two-third of enrolled women (63%) were aged 24 and younger and 5768 (74%) of the study population resided in South Africa.View this table:Table 1 Participant baseline and final visit characteristicsThe duration of participation averaged 16 months with no differences between randomised groups (table 1). A total of 1468 (19%) women either did not receive their randomised method or discontinued use during follow-up. Overall method continuation rates were high with minimal differences between randomised groups when measured by person-years.6 The proportion, however, of method non-adherence as defined in this analysis (ie, did not receive randomised method at baseline or discontinued randomised method at any point during follow-up), was greater in the DMPA-IM group (26%), followed by the copper IUD (18%) and LNG implant (12%) groups. Timing of discontinuation also differed across methods.

During the first 6 months, method discontinuation was highest in the copper IUD group (7%) followed closely by DMPA-IM (6%) and LNG implant (4%) groups. Between 7 and 12 months of follow-up, it was highest in DMPA-IM group (15%), with equivalent proportions in the LNG implant (5%) and copper IUD (5%) groups.Point prevalences of chlamydia and gonorrhoea at baseline and final visitsIn total, 18% of women had chlamydia at baseline (figure 2A) and 15% at the final visit. Among women 24 years and younger, 22% and 20% had chlamydia at baseline and final visits, respectively. Women aged 25–35 at baseline were less likely to have chlamydia at both baseline (12%) and final visits (8%) compared with younger women.

Baseline chlamydia prevalence ranged from 5% in Zambia to 28% in the Western Cape, South Africa (figure 2B).Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures." data-icon-position data-hide-link-title="0">Figure 2 Point prevalence (per 100 persons) of chlamydia and gonorrhoea at baseline and final visit by age category and study site region. Y-axis scale differs for chlamydia and gonorrhoea figures.Among all women, 5% had gonorrhoea at baseline and the final visit (figure 2C). Women aged 24 and younger were more likely to have gonorrhoea compared with women aged 25 and older at both baseline (5% vs 4%, respectively) and the final visit (6% vs 3%, respectively).

Baseline gonorrhoea prevalence ranged from 3% in Zambia and Kenya to 9% in the Western Cape, South Africa (figure 2D). Similar prevalences were observed at the final visit.Point prevalences of chlamydia and gonorrhoea at final visit by randomised contraceptive methodFourteen per cent of women randomised to DMPA-IM, 15% to copper IUD and 17% to LNG implant had chlamydia at the final visit (table 2).View this table:Table 2 Chlamydia trachomatis and Neisseria gonorrhoeae prevalence at final visitThe prevalence of chlamydia did not significantly differ between DMPA-IM and copper IUD groups (PR 0.90, 95% CI (0.79 to 1.04)) or between copper IUD and LNG implant groups (PR 0.92, 95% CI (0.81 to 1.04)). Women in the DMPA-IM group, however, had a significantly lower risk of chlamydia compared with the LNG implant group (PR. 0.83, 95% CI (0.72 to 0.95)).

Findings from the consistent use analysis were similar, and neither age nor HSV-2 status modified the observed associations.Four per cent of women randomised to DMPA-IM, 6% to copper IUD and 5% to LNG implant had gonorrhoea at the final visit (table 2). Gonorrhoea prevalence did not significantly differ between DMPA-IM and LNG implant groups (PR. 0.79, 95% CI (0.61 to 1.03)) or between copper IUD and LNG implant groups (PR. 1.18, 95% CI (0.93 to 1.49)).

Women in the DMPA-IM group had a significantly lower risk of gonorrhoea compared with women in the copper IUD group (PR. 0.67, 95% CI (0.52 to 0.87)). Results from as randomised and continuous use analyses did not differ. And again, neither age nor HSV-2 status modified the observed associations.Clinical assessment by randomised contraceptive methodTo assess the potential for outcome ascertainment bias, we evaluated the frequency of pelvic examinations and abdominal/pelvic pain and discharge by study arm.

Women in the copper IUD group were generally more likely to receive a pelvic examination during follow-up as compared with women in the DMPA-IM and LNG implant groups (online supplemental appendix 1). Similarly, abdominal/pelvic pain on examination or abnormal discharge was observed most frequently in the copper IUD group. The number of pelvic examinations met the prespecified criteria for retention in the adjusted gonorrhoea model but not in the chlamydia model.Supplemental materialFrequency of syndromic symptoms and potential reAmong women who had chlamydia at baseline, 23% were also positive at the final visit (online supplemental appendix 2, figure 3A). Nine per cent of gonorrhoea-positive women at baseline were also positive at the final visit (online supplemental appendix 2, figure 3B).

Across both baseline and final visits, a minority of women with chlamydia or gonorrhoea presented with signs and/or symptoms. Among chlamydia-positive women, only 12% presented with either abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3C). Similarly, only 15% of gonorrhoea-positive women presented with abnormal vaginal discharge and/or abdominal/pelvic pain at their test-positive visit (online supplemental appendix 2, figure 3D).Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D).

Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain. Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment." data-icon-position data-hide-link-title="0">Figure 3 Potential re and symptoms among women with chlamydia or gonorrhoea. Data are pooled across the screening and final visits in figures (C) and (D). Symptomatic is defined as presenting with abnormal vaginal discharge and/or abdominal/pelvic pain.

Final visit is described as potential re because test of cure was not conducted following baseline diagnosis and treatment.DiscussionWe observed differences in final prevalences of chlamydia and gonorrhoea by contraceptive group in both as-randomised and consistent-use analyses. The DMPA-IM group had lower final visit chlamydia and gonorrhoea prevalences as compared with copper IUD and LNG implant groups, though only the DMPA-IM versus the copper IUD comparison of gonorrhoea and DMPA-IM versus LNG implant comparison of chlamydia reached statistical significance. These are novel findings that have not previously been reported to our knowledge and were determined in a randomised trial setting with high participant retention, robust biomarker testing and high randomised method adherence. Interestingly, the copper IUD group had higher gonorrhoea and lower chlamydia prevalence compared with the LNG implant group, though neither finding was statistically significant.Two recent systematic reviews of the association between contraceptives and STIs found inconsistent and insufficient evidence on the association between the contraceptive methods under study in ECHO and chlamydia and gonorrhoea.8 9 Neither systematic review identified any randomised studies or any direct comparative evidence for DMPA-IM, copper IUD and LNG implant, thus enabling a unique scientific contribution from this secondary trial analysis.

Nonetheless, these findings should be interpreted in light of biological plausibility, as well as the design strengths and limitations of this analysis.The emerging science on the biological mechanisms underlying HIV susceptibility demonstrates the complex relationship between the infectious pathogen, the host innate and adaptive immune response and the interaction of both with the vaginal microbiome and other -omes. Data on these factors in relationship to chlamydia and gonorrhoea acquisition are much more limited but can be assumed to be equally complex. Vaginal microbiome composition, including microbial metabolic by-products, have been shown to significantly modify risk of HIV acquisition and to vary with exogenous hormone exposure, menstrual cycle phase, ethnicity and geography.10–12 These same biological principles likely apply to chlamydia and gonorrhoea susceptibility. While DMPA-IM has been associated with decreased bacterial vaginosis (BV), initiation of the copper IUD has been associated with increased BV prevalence, and BV is associated with chlamydia and gonorrhoea acquisition.13 14 Moreover, Lactobacillus crispatus, which is less abundant in BV, has been shown to inhibit HeLa cell by Chlamydia trachomatis and inhibits growth of Neisseria gonorrhoeae in animal models.15 16 In addition, microbial community state types that are deficient in Lactobacillus crispatus and/or dominated by dysbiotic species are associated with inflammation, which is a driver of both STI and HIV susceptibility.

Thus, while the exact mechanisms of chlamydia and gonorrhoea in the presence of exogenous hormones and varying host microbiomes are unknown, it is biologically plausible that these complex factors may result in differential susceptibility to chlamydia and gonorrhoea among DMPA-IM, copper IUD and LNG implant users.An alternative explanation for these findings may be postrandomisation differences in clinical care and/or sexual behaviour. Participants in the copper IUD arm were more likely to have pelvic examinations and more likely to have discharge compared with women in the DMPA-IM and LNG implant groups. While interim STI testing and/or treatment were not documented, women in the copper IUD arm may have been more likely to receive syndromic STI treatment during follow-up due to more examination and observed discharge. More frequent STI treatment in the copper IUD group would theoretically lower the final visit point prevalence relative to women in the DMPA-IM and LNG implant arms, suggesting that the observed lower risk of STI in the DMPA-IM arm is not due to differential examination, testing and treatment.

Differential sexual risk behaviour may also have influenced the results. As reported previously, women in the DMPA-IM group less frequently reported condomless sex and multiple partners than women in the other groups, and both DMPA-IM and LNG implant users less frequently reported new partners and sex during menses than copper IUD users.6 Statistical control of self-reported sexual risk behaviour in the consistent-use analysis may have been inadequate if self-reported sexual behaviour was inaccurately or insufficiently reported.A second alternative explanation may be differences in randomised method non-adherence, which was greater in the DMPA-IM group, compared with copper IUD and LNG implant groups. Yet, the consistency of findings in the as-randomised and continuous use analyses suggests that method non-adherence had minimal effect on study outcomes. Taken as a whole, these findings indicate that there may be real differences in chlamydia and gonorrhoea risk associated with use of DMPA-IM, the copper IUD and LNG implant.

However, any true differential risk by method must be evaluated in light of the holistic benefits and risks of each method.The high observed chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among women ages 24 years and younger and among women in South Africa and Eswatini. While the ECHO study was conducted in settings of high HIV/STI incidence, enrolment criteria did not purposefully target women at highest risk of HIV/STI in the trial communities, suggesting that the observed prevalences may be broadly applicable to women seeking effective contraception in those settings. Improved approaches are needed to prevent STIs, including options for expedited partner treatment, to prevent re.As expected, few women testing positive for chlamydia or gonorrhoea presented with symptoms (12% and 15%, respectively), and a substantial proportion of women who were positive and treated at baseline were infected at the final visit despite syndromic management during the follow-up. Given that syndromic management is the standard of care within primary health facilities in most trial settings, these data suggest that a large proportion of among reproductive aged women is missed, exacerbating the burden of curable STIs and associated morbidities.

Routine access to more reliable diagnostics, like NAAT and novel point-of-care diagnostic tests, will be key to managing asymptomatic STIs and reducing STI prevalence and related morbidities in these settings.17This secondary analysis of the ECHO trial has strengths and limitations. Strengths include the randomised design with comparator groups of equal STI baseline risk. Participants had high adherence to their randomised contraceptive method.6 While all participants received standardised clinical care and counselling, the unblinded randomisation may have allowed postrandomisation differences in STI risk over time by method. It is possible that participants modified their risk-taking behaviour based on study counselling messages regarding the potential association between DMPA-IM and HIV.In conclusion, our analyses suggest that DMPA-IM users may have lower risk of chlamydia and gonorrhoea compared with LNG implant and copper IUD users, respectively.

Further investigation is warranted to better understand the mechanisms of chlamydia and gonorrhoea susceptibility in the context of contraceptive use. Moreover, the high chlamydia and gonorrhoea prevalences in this population, independent of contraceptive method, warrants urgent attention.Key messagesThe prevalence of chlamydia and gonorrhoea varied by contraceptive method in this randomised trial.High chlamydia and gonorrhoea prevalences, despite intensive counselling and condom provision, warrants attention, particularly among young women in South Africa and Eswatini.Most chlamydia and gonorrhoea s were asymptomatic. Therefore, routine access to reliable diagnostics are needed to effectively manage and prevent STIs in African women..