 I see the first hand here by the pole. And I see a hand in the center in the back. And I can run my commentary as everybody comes up. So one of my pets that Lee has come up with, I think in health care, one of the things that's not well trained is palliative care, ethics, and communication. I'd invite you to comment on it as everybody lines up their questions. And maybe we can start having hands up so that you can get the mics. I know we have a hand right down here at the front. Thank you very much. Her hand was up very early from the room. Sorry. I'll keep that in mind. So I have three cell phones. Is it my turn? Yes, your question. So apparently I've got a microphone box I speak into. OK, cool. So Claire Mills, sorry, from Paris. I have a question to Robin, really. And I guess reaching the last 10, 20% of people in any intervention is hard work, and usually more expensive than reaching the mass, if you like. But do you feel that it was actually successful? I mean, if you've got an outcome where you've actually identified 19 people out of 1,400 plus, this is a very inefficient way of doing something, I guess. Do you think it's really a successful thing, or do you think that there are going to be other things that will follow? Because feasibility is separate from, I mean, anything's feasible if you put the resources into it. But true feasibility also has to be a workable realistic outcome. Oh, thank you. So we'll take the questions. The one thing I know is that when questions come, they answer, they inspire more questions. So I'll let the originators get their questions out first. There's somebody out there. Hello, I'm Kathleen England, and I'm from the Access Campaign in Geneva. Malawi in the prison scenario. My question is, did you assess any of the loss to adherence once patients were released from the program? Is one question. And for the self-testing for Swaziland, what is the potential of this to be off the shelf in the pharmacy from your experience? I think this is where we would like to see this happen, where people can have autonomy in their testing. And for DRC, NCDs, for diabetes in the HIV, diabetes in the HIV program, was TV assessed at all for the diabetic patients? Since we know there's a comorbidity there. And that's it. And there was one of that. Was there a hand on that right side? The first questioner pretty much asked the same question as me. Same questions? OK, thank you. OK, we'll have one there, and then we'll have the online speakers. You have the bag? Sarah Wookiee. Sarah Wookiee, doctor. You just, I've got a question for the diabetes project, particularly in WESO. You've said that there's a particular group of patients who have a type of diabetes, which isn't clearly classified as one or two, that's associated with current and previous malnutrition. And I'd like to know if there have been any studies looking at what treatment in this particular group is most successful. Thank you. OK, online. Yes, we've had lots of questions online, so I'm just selecting the most popular ones. But for Rinaldo, in Malawi in prisons, did you detect any drug resistance? Do you think there might have been any survival bias introduced in your study design? And then for the self-testing talk, a question, did you analyze whether this approach reached a different population to health facility-based testing? And also, do you think the unassisted testing was a reason for 30% of youngsters having done a test as a hard-to-reach group? And also, were you able to understand the main reasons for not getting confirmed, which I believe was 13 out of 34 HIV self-tested reactive cases? I think that's quite a bit of work for the lineup. Yeah, we can start the answers. And maybe we'll start on the extreme, right? OK, so just in terms of palliative care training needs, I think there's definitely a deficit in terms of curriculums for health care workers when it comes to palliative care. Usually palliative care is a short couple of weeks or a few sessions within curriculums. And it is so vital that health care workers actually understand what palliative care is. Therefore, countries and institutions should prioritize palliative care, not necessarily the advanced palliative care practices, but the principles of palliative care and ethics, which is key to managing and approaching patients in a patient-sated way, should be put as part of every curriculum for health care workers. Thanks. So thanks for the questions about the diabetes program and the DRC. So the first one was about whether patients, if we knew if they had HIV or TB. In Mueso, HIV status was not actually documented in this cohort. And self-reported history or current TB was in 2.7% of the cohort. And just for Swaziland, actually, we only knew the TB status of 11% of the cohort of 800-plus patients. And of the HIV positive patients who were enrolled in the NCD program, it represented only 1% of the total HIV cohort of that clinic. So the idea of having integrated the two types of care and changing some of the protocols for the HIV and TB service to integrate screening for NCDs and vice versa in the NCD part to encourage HIV testing were probably not realized to the extent that it was hoped. So we don't have a lot of data about the kind of dual diagnoses of these groups. The second question was about malnutrition-related diabetes. So actually, very, very little is known about this. And it's quite contentious. There were some studies reported literally just cross-sectional analyses from the 1990s from Ethiopia, for example. But very little is in the literature. And now there seems to be a renewed interest as there is more focus on non-communicable diseases, including diabetes in sub-Saharan Africa. So it is not known at all what is the most ideal treatment for this type of diabetes. Very little is known at all about it. It's very interesting, I think, and should be explored more. Thanks. All right, thank you. OK, thank you for these questions. Is this on? You can hear me? OK. And the first one is a very pointed one. Thank you. Why did we consider this a success? Because we did only find 19 confirmed HIV cases. I wondered this myself. But I think the main goal of this was overarching as a strategy, obviously, is to find the undiagnosed HIV cases. But we consider this a success because so many people accepted the tests. We didn't have any adverse events reported. And actually, also, because the Ministry of Health accepted the idea of HIV self-testing as a strategy in the country, I think there was initially some resistance, which links actually to the next question about the off-the-shelf purchasing of these testing kits that depends on the Ministry of Health at the moment. There's this request that the tests be distributed by trained counselors, HIV testing counselors. I can probably add a comment from our Kenyan experience. So one of the things that happened in Kenya in the National AIDS Control Program was the recognition that as a national program, the government can't provide and pay for everything. But there's a need for guidelines to guide how things are implemented, even in private care. So we have HIV self-testing kits in certain pharmacies. And we have some programs, funded programs, which have subsidized the cost. So at least within the urban areas of Nairobi, there are certain pharmacies where you can walk in and purchase the HIV self-test kits. And we haven't seen any adverse events so far, or even in the research pilots that have been down to explore the same. So it's feasible, I think we can say. It may be different in different populations. If I could then respond to the online community questions, maybe just one. There was a question about whether or not we explored if this approach was different to the health facility testing. And I would say these are not actually separate, as we also distributed the self-tests in facilities. But we have seen from just our routine program data in terms of community testing that the people are different. We do reach more men with the community-based testing than facility-based testing. And this was approximately similar with the blood-based testing in community compared to the self-testing in community. And actually, surprisingly in terms of the youth, we found that there were actually more youth in the facilities. And I think it's because it's the young women who are coming for ANC and PNC. And they were offered self-testing as well. And there are fewer in the community. Thank you. Yeah. Hello? Regarding the rents after the release of the program, actually, we monitor during 2017, during six months, the prisoners that were released for HIV and TB continuation of treatment in the facilities. And we managed to trace them 80% of them that were linked to a care in a facility through phone calls and on-visits. In regards of the DRTB question, fortunately Malawi does not have a high prevalence of drug-resistant TB. So we haven't found any case of drug-resistant TB person with the gene expert that we have found. OK. So you screened for it. You just didn't find any. Yeah, we did. OK. I think that's wonderful. I think we've answered most of the questions. And it looks like we still have time. Yeah, for another round. And I see one, two, three, hands up, four, five. Hi, my name's Jeremy Hill. I'm a TB doctor. I work in the Western Pacific. My question's for Ronaldo. Obviously, a case notification rate of 4%. It's extraordinarily high. So just thinking about control strategies. You didn't mention building design and airspace turnover, which I think has been a key component in evidence from similar settings in mines and hospitals and schools in South Africa. I just wonder if you could talk a little. You showed a picture, but could just talk a little bit more about did you measure airspace turnover or what sort of occupational type strategies you might have assessed or be thinking about implementing? OK, strategies for control. How do I say this? Can I use the clock? Top left on my side. We'll keep coming down. OK, Daryl Stelmack, Manson Unit, MSFUK. Just a question for Lee. What is spiritual counselling in the MSF context? All right. Top right. Yes, the lady on the right. Top right, yes. Yes, hello. Thank you. My name is Mehdi, working with MSF OCA. My question is for Mr. Tarquino, Mozambique. First of all, thank you for your very interesting presentation. My question to you is taking into account that the Pepaterans, the HIV prophylaxis for survivors of sexual violence, is very challenging in any context. I think as an average, you're each about knowing that 50% does manage to complete. Your cascade shows that at 12 months, you managed to keep 25% if I'm not mistaken. And my question is, what do you see as the next step? Because offering this prophylaxis to the key population you are working with, I think is very interesting. But if we learn that we keep 25% on treatment, I'm very interesting to understand what are you going to do with the information you have at this moment? OK, thank you. And we had a question lower down. Who had the lady on the left? Hi, Tamar from the Royal Society of Tropical Medicine and Hygiene. For time, I'll restrict it to three of you. So Robin, him, and then Lee. I'm really interested to know just generally what's happening next steps with the research specifically and whether you have plans in place. And if so, what are they? Thank you. I think you can have a meal, but oh, you've been having your head up for a while, sorry. Thank you. My name is Wale Selami from Drugs for Neglected Diseases Initiative in Nairobi, Kenya. My question goes to Robin on the self-testing. What do you think could be the reason why there's such a low uptake of self-testing by women from the community testing? And the other question is, what do you think is really the benefit of the assistant testing versus the non-assisted testing when you think of the cost perspective? Thank you. All right, the gentleman in the middle. There's no discrimination sitting in the middle seat. Hello, hello. Hi, my name's Jacob. I work for the emergency team. This is a question for Ray Nal, though. I draw a comparison between some of our recent work in Libyan detention centers. And I wonder if you saw any further stigmatization or violence towards the people in detention once they were on treatment? And if that affected their appearance to treatment? Thank you. I think we'll just do one more and then allow the speakers to respond. Do you have any? Hello, Dominique Dieng from MSF OCB. My question is for Robin. You have talked about the involvement of traditional healers. I would like to know more about it. It's an important question. Thank you. I think we can start. You had many questions. Yeah. OK, in regard of the strategies for control, actually, it's quite difficult to establish infection control in regards of isolation, particularly in prison. That's something that we have tried to do in particular sick base cells that we can put prisoners during a short period of time. But unfortunately, because of congestion, it's very difficult to keep them longer than at least one to two weeks. And we have tried to do that in particularly in Maula prison. In GTU prison, we couldn't find a space to do isolation. But it's part of our proposal, actually, it's part of the strategy control. Contact tracing as part of the strategy, we have done a bit of follow up of prisoners and their contacts. But it's very difficult to do so in prison. But as they change every other two weeks or three weeks from one cell to other cells, so 150 prisoners in one cell altogether, it's very difficult to do it inside prison as a part of contact tracing. But we are planning to do it in this new proposal for every prisoner that is having an active TB at entry to at least do contact tracing from their family and trying to see around the closest relative friend. And for sure, what we try to do as well is trying to complete treatment and follow up as much as possible. So treatment success rate is higher than 90% in prisoners inside prison. And the ones that have exceeded, actually, we try to follow as well and to see that they are linked to care. But it's very difficult to follow some of them. Regarding the violence question and adherence to treatment, indeed, it is something that we have seen as a challenge at the beginning of our intervention as violence was produced inside prison cells at the beginning. But with our intervention and the work that we have done, they stopped to do violence inside prison from prison guards themselves. But sometimes we receive prisoners that are in police cells before coming to prison, but they are stopped of their treatment when they are already under ART or TB treatment. And they sometimes are victims of torture. And this is something that we have addressed. We do medical certificates. And we link with partners working with human rights. And yeah, unfortunately, ICRC is not in Malawi, for example. But we work with other organizations that could help us to link and address this situation. Thank you. OK, thank you. Thank you for your questions. I think the first one and the last one are linked, actually. So the first question was about the next steps for HIV self-testing research. So I'll speak just first about the first next step, which is integrating self-testing into our pre-exposure prophylaxis study in Swaziland. So this will happen in two ways. We will provide self-tests to PrEP clients to use in between their visits. We've also seen like the Mozambique study that a lot of clients don't come back for their first month visit. So the hope is that if we give them the self-tests, at least they'll have then a test that they can use even if they don't come back to the clinic for their follow-up visit after they finish PrEP. And then we will also give it to these PrEP clients to distribute to their partners who have unknown HIV status. And so the idea about the traditional healers, this one is a little bit further away in terms of implementation. We're still trying to work out the strategy. But the idea is that in order to optimize the utility of these HIV self-testing, we hope to distribute them through the non-train health care workers. So this was the strategy, including traditional healers, as well as peer educators. And so our community teams in the Chesaweini region are quite linked already with a few traditional healers that are, I would say, maybe more open to a biomedical approach. And the idea would then be to have them undergo a training and be able to provide HIV self-testing to clients that would then come to them for any issues instead of going to the more formal health system. Then there was another question over here from Kenya about the low uptake of self-testing by women in the community. And I actually would rephrase that. I don't think it was a low uptake of self-testing by women. It was actually a rather higher uptake of men. So there's a lot of opportunities for women to test in health facilities, primarily linked to pregnancy. And so the community strategies are rather targeted towards men. They went to workplaces, the forestry industry, where men are working. And so this, I think, would be why the gender distribution was more equal. And then the last point about the benefit of the assisted testing, I think, is to increase knowledge and capacity and understanding of how to use the test. And then eventually one person will then tell another person. And then eventually maybe there's a more clear understanding of how to use the test. So I think the last comment is from Lee. And I'm wondering if, even, you've had a comment at all? So thank you for the question. The next step about PrEP, yes. Actually, we can think about improving PrEP at three different levels. The first one, at community level, as I said, we use peer educators in the recruitment. And this was a very great advantage. So improving behavior change and communication programs in community may lead to be more acceptable. And eventually individuals be more aware about the importance of the program. And also empowering the community, the association of MSM across the country can lead a great help in improving the PrEP intake among this population. At healthcare program, the next step is to include the PrEP in the HIV package at health centers level. And this is a very good discussion we are having with Minister of Health in Mozambique. And we hope that can lead to a positive result. And at national level, offering, this was an observation, a suggestion given by many of our participants, offering PrEP was in pharmacies or in other public places where they can take PrEP without having any kind of stigmatization. So for us, this is the next step in Mozambique. Thank you so much. Salih, you're between the audience and the tea break. OK, sorry. OK, I think a good place to start for clinicians and MSF in terms of spiritual counseling is really acknowledging that pain is not only physical, it can be spiritual. And then making sure that patients engage to their spiritual leaders, healers, pastors, whoever they are, but making sure that that happens for the patient. And then last question, what is the next step? There's been loads of palliative care research, even within drug resistant TB. So the research is out there. There's guidelines, WHO guidelines, South African guidelines, but there's no implementation. So it's time for action. Thanks. I think you've done it. You've been an amazing audience. We've had an amazing group of presenters. And we'll just do three sharp claps of thank you very, very much.