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When the history of the COVID-19 pandemic is written, the failure of many states to live up to their human rights obligations should be a central narrative. The pandemic began with Wuhan officials in China suppressing information, silencing whistleblowers, and violating the freedom of expression and the right to health. Since then, COVID-19's effects have been profoundly unequal, both nationally and globally. These inequalities have emphatically highlighted how far countries are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously. We propose embedding human rights and equity within a transformed global health architecture as the necessary response to COVID-19's rights violations. This means vastly more funding from high-income countries to support low-income and middle-income countries in rights-based recoveries, plus implementing measures to ensure equitable distribution of COVID-19 medical technologies. We also emphasise structured approaches to funding and equitable distribution going forward, which includes embedding human rights into a new pandemic treaty. Above all, new legal instruments and mechanisms, from a right to health treaty to a fund for civil society right to health advocacy, are required so that the narratives of future health emergencies—and people's daily lives—are ones of equality and human rights.

ABSTRACTBackgroundGlobal prevalence of diabetes is increasing, causing widespread morbidity, mortality and increased healthcare costs. Providing quality care in a timely fashion to people with diabetes in low-resource settings can be challenging. In the underserved state of Chiapas, Mexico, which has some of the lowest diabetes detection and control rates in the country, there is a need to implement strategies that improve care for patients with diabetes. One such strategy is shared medical appointments (SMAs), a patient-centred approach that has proven effective in fostering patient engagement and comprehensive care delivery among underserved populations.ObjectiveThis study aimed to understand the perceptions, experiences and insights of both patients living with diabetes and healthcare providers, who took part in a pilot SMA strategy implemented in five outpatient clinics in rural Chiapas.MethodsFollowing an exploratory qualitative approach, we conducted 50 in-depth interviews with patients and providers involved in diabetes SMAs and five focus group discussions with community health workers providing patient support and education.ResultsThe implementation of an SMA model changed how diabetes care is perceived, structured and delivered. Patients felt sheltered by group interactions based on trust, which allowed for the exchange of experiences, learning and increased engagement in treatment and lifestyle changes. Providers gained insights into their patients’ context and lived experiences, which resulted in improved rapport and quality of care. SMAs also restructured some operational aspects in the clinics and fostered the sharing of power and responsibilities amongst the staff.ConclusionsThe SMAs model transformed care by providing a patient-centred, collaborative approach to diabetes care, education and support. Additionally, it reshaped the health-care team resulting in power-shifting and role-sharing among members of the interdisciplinary team. We therefore encourage decision-makers to expand the use of SMAs to improve care for patients with diabetes in low-resource settings.

Limited treatment data are available for hepatitis C virus (HCV) in sub-Saharan Africa, especially for genotype 4. Our objective was to establish the safety and efficacy of ledipasvir–sofosbuvir for chronic HCV genotype 1 or 4 infection in adults in Rwanda.

ABSTRACTEvaluations of community-based antiretroviral therapy (ART) programmes have demonstrated positive outcomes, but little is known about the impact of tapering community-based ART. The objective of this study was to assess 24-month HIV retention outcomes of a community-based ART programme and its tapered visit frequency in Koidu City, Sierra Leone. This retrospective, quasi-experimental study compared outcomes of 52 HIV-infected persons initiated on community-based ART against 91 HIV-infected persons receiving the standard of care from November 2009 to February 2013. The community-based ART pilot programme was designed to strengthen the standard of care through a comprehensive, patient-centred case management strategy. The strategy included medical, educational, psychological, social, and economic support. Starting in October 2011, the frequency of home visits was tapered from twice daily every day per week to once daily three days per week. Outcomes were retention in care at 12 and 24 months and adherence to ART over a three-month time period. Participants who received community-based ART had significantly higher retention than those receiving standard of care. At 12 months, retention rates for community-based ART and standard of care were 61.5% and 31.9%, respectively (p < .01). At 24 months, retention rates for community-based ART and standard of care were 73.1% and 44.0%, respectively (p < .01). Significant differences in levels of adherence were observed when comparing community-based ART against persons receiving standard of care (p < .05). No differences in adherence levels were observed between groups of people receiving various frequencies of home visits. Our pilot programme in Koidu City provides new evidence that community-based ART has the potential to improve retention and adherence outcomes for HIV-infected persons, regardless of the frequency of home visits. Overcoming the barriers to HIV care requires a comprehensive, patient-centred approach that may include clinic-based and community-based interventions.

ABSTRACTBackgroundThe COVID-19 pandemic has had disproportionate impacts across race, social class, and geography. Insufficient attention has been paid to addressing the massive inequities worsened by COVID-19. In July 2020, Partners In Health (PIH) and the University of Global Health Equity (UGHE) delivered a four-module short course, ‘An Equity Approach to Pandemic Preparedness and Response: Emerging Insights from COVID-19 Global Response Leaders.’ObjectiveWe describe the design and use of a case-based, short-course education model to transfer knowledge and skills in equity approaches to pandemic preparedness and response.MethodsThis course used case studies of Massachusetts and Navajo Nation in the US, and Rwanda to highlight examples of equity-centered pandemic response. Course participants completed a post-session assessment survey after each of the four modules. A mixed-method analysis was conducted to elucidate knowledge acquisition on key topics and assess participants’ experience and satisfaction with the course.ResultsForty-four percent of participants identified, ‘Immediate need for skills and information to address COVID-19’ as their primary reason for attending the course. Participants reported that they are very likely (4.75 out of 5) to use the information, tools, or skills from the course in their work. The average score for content-related questions answered correctly was 82–88% for each session. Participants (~70-90%) said their understanding was Excellent or Very Good for each session. Participants expressed a deepened understanding of the importance of prioritizing vulnerable communities and built global solidarity.ConclusionThe training contributed to a new level of understanding of the social determinants of health and equity issues surrounding pandemic preparedness and response. This course elucidated the intersection of racism and wealth inequality; the role of the social determinants of health in pandemic preparedness and response; and the impacts of neocolonialism on pandemic response in low- and middle-income countries.

Research and clinical experience reliably and repeatedly demonstrate that the determinants of health are most accurately conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. Increased appreciation of biosocial approaches have already driven change in premedical education and focused attention on population health in current U.S. health care reform. Medical education, however, places primary emphasis on biomedicine and often fails to emphasize and educate students and trainees about the social forces that shape disease and illness patterns. The authors of this Commentary argue that medical education requires a comprehensive transformation to incorporate rigorous biosocial training to ensure that all future health professionals are equipped with the knowledge and skills necessary to practice social medicine. Three distinct models for accomplishing such transformation are presented: SocMed’s monthlong, elective courses in Northern Uganda and Haiti; Harvard Medical School’s semester-long, required social medicine course; and the Lebanese American University’s curricular integration of social medicine throughout its entire four-year curriculum. Successful implementation of social medicine training requires the institutionalization of biosocial curricula; the utilization of innovative, engaging pedagogies; and the involvement of health professions students from broad demographic backgrounds and with all career interests. The achievement of such transformational and necessary change to medical education will prepare future health practitioners working in all settings to respond more proactively and comprehensively to the health needs of all populations.

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

Abstract: Background: Over the last decade, the diffusion of ultrasound technology to nontraditional users has been rapid and far-reaching. Much research and effort has been focused on developing an ultrasound curriculum and training and practice guidelines for these users. The potential for this diagnostic tool is not limited to the developed world and in many respects ultrasound is adaptable to limited resource international settings. However, needs-based curriculum development, training guidelines, impact on resource utilization, and sustainability are not well studied in the developing world setting. Aims: We review one method of introducing applicable curriculum, training local providers, and sustaining a comprehensive ultrasound program. Methods: Two rural Rwandan hospitals affiliated with a US nongovernmental organization participated in a pilot ultrasound training program. Prior to introduction of ultrasound, local physicians completed a survey to determine the perceived importance of various ultrasound scan types. Hospital records were also reviewed to determine disease and presenting complaint prevalence as part of an initial needs assessment and to define our curriculum. We hypothesized certain studies would be more utilized and have a greater impact given available treatment resources. Results: We review here the choice of curriculum, the training plan, helpful equipment specifications, and implementation of ongoing measures of quality assessment and sustainability. Our 9-week lecture and practice-based ultrasound curriculum included obstetrics, abdominal, renal, hepatobiliary, cardiac, pleural, vascular, and procedural ultrasound. Conclusions: While ultrasound as a diagnostic modality for resource-poor parts of the world has generated interest for years, recent advances in technology have brought ultrasound again to the forefront as a sustainable and high impact technology for resource-poor developing world nations. From our experience in rural Rwanda, we conclude that ultrasound remains helpful in patient care and the diagnostic impact is enhanced by choosing the correct applications to implement. We also conclude that ultrasound is a teachable skill, with a several week intensive training period involving hands-on practice skills and plans for long-term learning and have begun a second phase of evaluating knowledge retention for this introductory program.

Background: Over the last decade, the diffusion of ultrasound technology to nontraditional users has been rapid and far-reaching. Much research and effort has been focused on developing an ultrasound curriculum and training and practice guidelines for these users. The potential for this diagnostic tool is not limited to the developed world and in many respects ultrasound is adaptable to limited resource international settings. However, needs-based curriculum development, training guidelines, impact on resource utilization, and sustainability are not well studied in the developing world setting. Aims: We review one method of introducing applicable curriculum, training local providers, and sustaining a comprehensive ultrasound program. Methods: Two rural Rwandan hospitals affiliated with a US nongovernmental organization participated in a pilot ultrasound training program. Prior to introduction of ultrasound, local physicians completed a survey to determine the perceived importance of various ultrasound scan types. Hospital records were also reviewed to determine disease and presenting complaint prevalence as part of an initial needs assessment and to define our curriculum. We hypothesized certain studies would be more utilized and have a greater impact given available treatment resources. Results: We review here the choice of curriculum, the training plan, helpful equipment specifications, and implementation of ongoing measures of quality assessment and sustainability. Our 9-week lecture and practice-based ultrasound curriculum included obstetrics, abdominal, renal, hepatobiliary, cardiac, pleural, vascular, and procedural ultrasound. Conclusions: While ultrasound as a diagnostic modality for resource-poor parts of the world has generated interest for years, recent advances in technology have brought ultrasound again to the forefront as a sustainable and high impact technology for resource-poor developing world nations. From our experience in rural Rwanda, we conclude that ultrasound remains helpful in patient care and the diagnostic impact is enhanced by choosing the correct applications to implement. We also conclude that ultrasound is a teachable skill, with a several week intensive training period involving hands-on practice skills and plans for long-term learning and have begun a second phase of evaluating knowledge retention for this introductory program.

Immune responses induced during the early stages of chronic viral infections are thought to influence disease outcome. Using HIV as a model, we examined virus-specific cytotoxic T lymphocytes (CTLs), T helper cells, and viral genetic diversity in relation to duration of infection and subsequent response to antiviral therapy. Individuals with acute HIV-1 infection treated before seroconversion had weaker CTL responses directed at fewer epitopes than persons who were treated after seroconversion. However, treatment-induced control of viremia was associated with the development of strong T helper cell responses in both groups. After 1 yr of antiviral treatment initiated in acute or early infection, all epitope-specific CTL responses persisted despite undetectable viral loads. The breadth and magnitude of CTL responses remained significantly less in treated acute infection than in treated chronic infection, but viral diversity was also significantly less with immediate therapy. We conclude that early treatment of acute HIV infection leads to a more narrowly directed CTL response, stronger T helper cell responses, and a less diverse virus population. Given the need for T helper cells to maintain effective CTL responses and the ability of virus diversification to accommodate immune escape, we hypothesize that early therapy of primary infection may be beneficial despite induction of less robust CTL responses. These data also provide rationale for therapeutic immunization aimed at broadening CTL responses in treated primary HIV infection.

We retrospectively examined infant mortality and human immunodeficiency virus (HIV)-free survival among 211 infants who received a comprehensive package of health services, including breast milk substitution and clean water access, to prevent maternal-to-child transmission of HIV and improve child survival. The cumulative 12-month infant survival probability was 0.97 (95% confidence interval: 0.94–0.99). The cumulative 12- to 18-month HIV-free survival probability was 0.95 (confidence interval: 0.91–0.97).