The Republic of South Sudan (RSS) is the newest state in the world which earned its independence on the 9th July 2011, following a peaceful secession from Sudan through a referendum in January 2011. In barely about 2.5 years after independence, the country ran into civil crisis starting on 15th December 2013, and refreshed in July 2016. The situation caused massive displacement and health systems disruption. The aim is to reflect on the HIV response in South Sudan despite the challenges of continued conflicts, displacement, and system disruption. Published data, as well as unpublished data available at the HIV Directorate in the Ministry of Health have been reviewed, including the HIV National Strategic plans, ANC sentinel Surveillance data, surveys and special studies, annual Health Management Information System cumulative reports from routine programmatic data (HTS, PMTCT, ART, TB/HIV, retention on care) and the UNAIDS spectrum data. The HIV epidemic in South Sudan is categorized as low and generalized (2.7%), with pockets of HIV concentration among key and vulnerable populations; who have a prevalence of 5% or more. The epidemic is thought to be widely variable across the country and geographically concentrated in the southern states of the greater Equatorial region formerly known as Western Equatoria with HIV prevalence of 6.8%, Central Equatoria 3.1%, and Eastern Equatoria 4.0%. The primary mode of infection is heterosexual exposure followed by mother-to-child transmission during pregnancy, at birth, and through breastfeeding. About 42% of the new HIV infections occurred mainly in clients of sex workers, while men and women involved in casual sexual relationships accounted for 14.5% of new infections. Female sex workers (FSWs) themselves only contributed to 11.2% of new HIV infections. Children born by HIV infected mothers accounted for 15.7%. In post conflict era in South Sudan, there is an urgent need for global initiative to conduct epidemiological studies about HIV. This will not only help peoples of South Sudan but will also increase our knowledge about how conflict and war can contribute in the spread of infectious diseases. Importantly, there are valuable lessons to learn from the South Sudan experience in terms of persistence and resilience during war and peace as HIV interventions continued to be implemented in a challenging context. Unless a strong health system is developed and sustained, building a sustainable HIV response will continue to be a challenge, and a lot more will be required.

Background: The gallstones are common health problem across the world with huge financial burden on health authorities. Obesity and insulin resistance are associated with risk of gallstones disease (GSD). The aim of this study was to assess the prevalence of metabolic syndrome (MetS) and diabetes and associated risk factors in Sudanese patients with gallstones.Methods: A prospective cross-sectional study, enrolled patients with gallstones attending Ibn Sina Specialized Teaching Hospital for gastrointestinal and hepatobiliary diseases. A structured questionnaire was applied, anthropometric measures were taken, and blood tested for HbA1c, fasting glucose and lipid profile. Data was analysed using SPSS version 23.Results: A total number of 151 participants were recruited in the study, 71 of them were ultrasound confirmed GSD patients, and the other 80 were controls without GSD over a period of six months. The prevalence of the MetS and diabetes was 30% and 23.9% respectively. Borderline diabetes was 16.9% and overweight and obesity constituted more than half of the sample 59.6%. Using Chi-Square test, a statistically significant association was found between MetS and HDL, TG, LDL level, waist circumference and blood pressure (BP). Absolute predictors and the risk factors for gallstone disease were waist circumference, age, HbA1c and LDL. Conclusions:The prevalence of MetS and diabetes among gallstone patients was 30% and 23.9% respectively. Absolute predictors and the risk factors for gallstone disease were waist circumference, age, HbA1c and LDL.

3 4 Introduction 3 5Gallstone disease (Cholelithiasis) affects 10 to 15% of the population of developed countries. Our 3 6 study aimed to determine the risk factors associated to different types of gallstone in patients 3 7 diagnosed in Khartoum State Ibnsina Gastroenterology Center. 3 8 Methods 3 9 A facility-based prospective cross-sectional study was implemented on a convenient sample of 47 4 0 participants diagnosed with gallstone through ultrasonography in Ibnsina Gastroenterology center 4 1 and who underwent surgical interventions for gallstone removal. A standardized interviewer-4 2 administrated research tool comprising three parts was used to collect data related to the 4 3 characteristics of the participants, their medical presentation and examination as well as 4 4 information on types of gallstone, surgical interventions and outcomes. The data were 4 5 computerized through Epi-info 7 and analyzed through SPSS 23. Descriptive statistics were firstly 4 6 performed and association was tested through Chi square tests and ANOVA. A multinomial 4 7 regression analysis established the relationship between types of gallstone and their associated risk 4 8 factors. All statistical tests were considered as significant when p < 0.05. 4 9 Results 5 0The risk factors statistically associated to gallstone types were family history (p = 0.011) and 5 1 duration of living in the residence area (p= 0.043) in pigment-cholesterol gallstone model vs 5 2 mixed-cholesterol gallstone model. Other four risk factors contributing to the pathogenesis of 5 3 gallstone were parity (OR = 1.623 [95% CI: 0.795-3.315]) vs (OR = 1.426, [95% CI: 0.729-5 4 2.790]), waist circumference (OR= 1.014 [95% CI: 0.948-1.085]) vs (OR = 1.001 [95% CI: 0.942-5 5 1.065]), chronic disease (OR = 0.698, [95% CI: 0.028 -17.445]) vs (OR = 0.354, [95% CI: 0.021-5 6 6.087]) and serum triglyceride (OR = 0.985, [95% CI: 0.950-1.022]) vs (OR= 0.980, [95% CI: 5 7 0.949-1.012]). 5 8 Conclusion 5 9 Our finding indicated six risk factors related to types of gallstone. Further multicenter research in 6 0Sudan on risk factors is needed to calibrate and validate our model. 6 1 Keyword: Cholelithiasis, Gallstone disease, Risk factors, Types of gallstone, Ultrasonography.6 2 6 3 9 1gallstone as well as between types of gallstone and positive history of type 2 diabetes (p=0.035). 2The other risk factors assessed were family history of GSD, history of dyslipedemia, total 9 3 cholesterol, triglycerides, high density lipoprotein cholesterol, low density lipoprotein cholesterol, 9 4 fasting blood glucose, parity and use of exogenous oestrogen in female patients, smoking and 9 5 alcohol consumption in males were not statistically associated (p >0.05) to the types of gallstone. 6Another study [29] on a sample of 100 patients investigated the association between gallstone 9 7 characteristics and 23 patient parameters. A statistically significant association was found between 9 8 both mean diastolic (p=0.012) and systolic blood pressure and types of gallstone (p=0.027).