Suchergebnisse

OBJECTIVES: To evaluate the implementation progress and contextual influences of Malaysia's five-year national salt reduction program at midpoint, with a view to generating lessons on adapting the World Health Organization's salt reduction 'best buys' to suit the local context. METHODS: The Malaysian Government's multi-faceted strategy includes three of four salt-related 'best buys'; reduce salt intake through 1) behavior change communication, 2) reformulation of food products to contain less salt and 3) implementation of front-of-pack labeling, as well as a strategy to monitor population salt intake and sodium levels in foods. Based on the UK Medical Research Council's guidance on process evaluation, routinely-collected administrative data, 12 semi-structured interviews and public information were used and synthesized in NVivo to evaluate the reach, dose, adoption, fidelity and contextual influences of implementation. This was supplemented with data from three focus groups (43 participants) conducted using the nominal group technique to understand the priority barriers and facilitators of lowering salt intake in Malaysia. RESULTS: In the first 3 years, there was high progress in accurately monitoring population salt intake and developing culturally-specific education resources. However, a major barrier to implementing the other interventions was the absence of mandatory sodium content declaration on packaged foods. A lack of packaged foods with sodium content labeling hindered the program implementers' ability to identify and engage high-salt food producers in reformulation, identify low-salt foods eligible for the Healthy Choice Logo front-of-pack label, educate consumers to identify high or lower-salt foods and monitor the sodium content of packaged foods. This aligns with the perceived challenges of reducing salt consumption in Malaysia being poor consumer knowledge and attitudes around salt reduction, and the absence of low-salt alternatives. CONCLUSIONS: Countries without mandatory sodium or salt labeling ...

Introduction: Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery. Methods: We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes. Results: We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers' access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers' control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection. Conclusions: There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services - including peer interventions, condom promotion and STI screening - would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV

IntroductionVirtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery.MethodsWe systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub‐Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non‐indexed journals were searched for studies with quantitative study outcomes.ResultsWe located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer‐mediated condom promotion, risk‐reduction counselling and skills‐building for safer sex. One study found that interventions to counter hazardous alcohol‐use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers' access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers' control over working conditions and impedes their access to health services. It also obstructs health‐service provision and legal protection.ConclusionsThere is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.

IntroductionHIV epidemics in the Asia‐Pacific region are concentrated among men who have sex with men (MSM) and other key populations. Pre‐exposure prophylaxis (PrEP) is an effective HIV prevention intervention and could be a potential game changer in the region. We discuss the progress towards PrEP implementation in the Asia‐Pacific region, including opportunities and barriers.DiscussionAwareness about PrEP in the Asia‐Pacific is still low and so are its levels of use. A high proportion of MSM who are aware of PrEP are willing to use it. Key PrEP implementation barriers include poor knowledge about PrEP, limited access to PrEP, weak or non‐existent HIV prevention programmes for MSM and other key populations, high cost of PrEP, stigma and discrimination against key populations and restrictive laws in some countries. Only several clinical trials, demonstration projects and a few larger‐scale implementation studies have been implemented so far in Thailand and Australia. However, novel approaches to PrEP implementation have emerged: researcher‐, facility‐ and community‐led models of care, with PrEP services for fee and for free. The WHO consolidated guidelines on HIV testing, treatment and prevention call for an expanded access to PrEP worldwide and have provided guidance on PrEP implementation in the region. Some countries like Australia have released national PrEP guidelines. There are growing community leadership and consultation processes to initiate PrEP implementation in Asia and the Pacific.ConclusionsCountries of the Asia‐Pacific region will benefit from adding PrEP to their HIV prevention packages, but for many this is a critical step that requires resourcing. Having an impact on the HIV epidemic requires investment. The next years should see the region transitioning from limited PrEP implementation projects to growing access to PrEP and expansion of HIV prevention programmes.

In 2007 an estimated 33 million people were living with HIV; 67% resided in sub‐Saharan Africa, with 35% in eight countries alone. In 2007, there were about 1.4 million HIV‐positive tuberculosis cases. Globally, approximately 4 million people had been given highly active antiretroviral therapy (HAART) by the end of 2008, but in 2007, an estimated 6.7 million were still in need of HAART and 2.7 million more became infected with HIV.Although there has been unprecedented investment in confronting HIV/AIDS ‐ the Joint United Nations Programme on HIV/AIDS estimates $13.8 billion was spent in 2008 ‐ a key challenge is how to address the HIV/AIDS epidemic given limited and potentially shrinking resources. Economic disparities may further exacerbate human rights issues and widen the increasingly divergent approaches to HIV prevention, care and treatment.HIV transmission only occurs from people with HIV, and viral load is the single greatest risk factor for all modes of transmission. HAART can lower viral load to nearly undetectable levels. Prevention of mother to child transmission offers proof of the concept of HAART interrupting transmission, and observational studies and previous modelling work support using HAART for prevention. Although knowing one's HIV status is key for prevention efforts, it is not known with certainty when to start HAART.Building on previous modelling work, we used an HIV/AIDS epidemic of South African intensity to explore the impact of testing all adults annually and starting persons on HAART immediately after they are diagnosed as HIV positive. This theoretical strategy would reduce annual HIV incidence and mortality to less than one case per 1000 people within 10 years and it would reduce the prevalence of HIV to less than 1% within 50 years. To explore HAART as a prevention strategy, we recommend further discussions to explore human rights and ethical considerations, clarify research priorities and review feasibility and acceptability issues.

IntroductionHIV testing is the entry point for the elimination of mother‐to‐child transmission of HIV. Decreasing external funding for the HIV response in some low‐ and middle‐income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high‐burden areas should be considered. This study aimed at determining and comparing the cost‐effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings.MethodsWe conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country‐based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high‐, medium‐ and low‐burden areas, and modelled different antenatal and testing coverage in each.ResultsWhen HIV testing services were only focused in high‐burden areas within a country, mother‐to‐child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost‐effective compared to focused approaches, with $ 125 per quality‐adjusted life years gained in the Viet Nam‐based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings.ConclusionsUniversal approach to antenatal HIV testing achieves the best health outcomes and is cost‐saving or cost‐effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother‐to‐child transmission of HIV.

There are currently several ongoing or planned trials evaluating the efficacy of pre‐exposure prophylaxis (PrEP) as a preventative approach to reducing the transmission of HIV. PrEP may prove ineffective, demonstrate partial efficacy, or show high efficacy and have the potential to reduce HIV infection in a significant way. However, in addition to the trial results, it is important that issues related to delivery, implementation and further research are also discussed. As a part of the ongoing discussion, in June 2009, the Bill & Melinda Gates Foundation sponsored a Planning for PrEP conference with stakeholders to review expected trial results, outline responsible educational approaches, and develop potential delivery and implementation strategies. The conference reinforced the need for continued and sustained dialogue to identify where PrEP implementation may fit best within an integrated HIV prevention package. This paper identifies the key action points that emerged from the Planning for PrEP meeting.

AbstractIntroductionModelling suggests that early diagnosis and immediate antiretroviral therapy (ART) among key populations would have a substantial impact in reducing HIV transmission and mortality in Vietnam. An implementation research project of "test‐and‐treat" among people who inject drugs (PWID) was developed to inform effective roll‐out of such interventions.Methods"Test‐and‐treat" was offered to PWID in two high burden provinces, Thai Nguyen and Thanh Hoa. The interventions comprised the offer of biannual HIV testing and immediate ART, irrespective of CD4 count. PWID were enrolled between April 2014 and July 2015 and followed up for 12 months, and retention, HIV viral load (VL) and risk behaviours were assessed. Retention in care of this prospective cohort was compared with the retention among men enrolled in care in the preceding period (April 2012 to March 2013) at the same clinics when ART was initiated at CD4 cell count ≤350 cells/mm3.ResultsIn total, 287 HIV positive PWID started immediate ART. The majority (98%) were men; median age was 34; and median (interquartile range) CD4 count was 199 (50 to 402) cells/mm3. After 12 months, 238 participants (83%) were retained on ART, and 205 achieved viral suppression (<1000 copies/mL) (92% among those in whom VL was measured, 71% overall). Baseline CD4 count ≤100 cells/mm3 and history of imprisonment were associated with lower retention and viral suppression, while engagement in methadone maintenance was associated with higher retention. Retention in care was higher in the "test‐and‐treat" cohort (83%) compared with men enrolled in care in the preceding period (78%), primarily because lost‐to‐follow‐up during pre‐ART care was eliminated. No decline in consistent condom use and clean needle use was observed.ConclusionsEarly ART initiation resulted in successful treatment outcomes among PWID, with no observed increase in self‐reported risk behaviours, suggesting feasibility and potential effectiveness of "test‐and‐treat" approach. The results also call for differentiated care for PWID, including promoting early diagnosis and engagement in methadone maintenance therapy while enhancing care for those with advanced HIV disease and history of imprisonment.