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Adolescent girls and young women (aged 15–24 years; AGYW) continue to carry a disproportionate burden of HIV in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) helps reduce the risk of acquiring HIV for persons at substantial risk, including AGYW. As countries plan for the rollout of PrEP across sub-Saharan Africa, PrEP policies and programs could address the unique needs of AGYW. The purpose of this analysis was to identify policy considerations to improve AGYW access to PrEP. After reviewing the literature, we identified 13 policy considerations that policymakers and stakeholders could evaluate when developing or reviewing PrEP-related policies. We sorted these considerations into five categories, which together comprise an AGYW Access to PrEP Framework: AGYW-friendly delivery systems, clinical eligibility and adherence support, legal barriers and facilitators, affordability, and community and AGYW outreach. We also reviewed policies in three countries (Kenya, South Africa, and Uganda) to explore how PrEP-related policies addressed these considerations. Some of these policies addressed some of the 13 policy considerations, but none of the policies directly addressed the unique needs of AGYW for accessing PrEP. To improve access to PrEP for AGYW, country policies could include specific components that address these 13 considerations. To reach AGYW effectively, each country could use the 13 considerations we have identified to analyze current policies to identify existing programmatic barriers to AGYW accessing HIV services and address these barriers in PrEP-related policies.

Passage of the Affordable Care Act (ACA) in 2010 and subsequent Medicaid expansion has influenced access to HIV treatment and care in the USA. This review aims to evaluate whether the implementation of these policies has impacted progress toward UNAIDS 90-90-90 goals. Preliminary evidence has emerged suggesting that the ACA and Medicaid expansion has increased the likelihood of HIV testing and diagnosis, reduced the number of people unaware of HIV infection, and increased the number of people on antiretroviral therapy (ART) who are virally suppressed. While the ACA is associated with some progress toward 90-90-90 goals, more years of data after policy implementation are needed for robust analysis. Methods including difference-in-differences, instrumental variables, and propensity scores are recommended to minimize bias from unmeasured confounders and make causal inference about non-random Medicaid expansion among states.

Background: With the advancement of imaging technology, focal therapy (FT) has been gaining acceptance for the treatment of select patients with localized prostate cancer (CaP). We aim to provide details of a formal physician consensus on the utilization of FT for patients with CaP who are discontinuing active surveillance (AS). Methods: A 3-stage Delphi consensus on CaP and FT was conducted. Consensus was defined as agreement by >= 80% of physicians. An in-person meeting was attended by 17 panelists to formulate the consensus statement. Results: Fifty-six respondents participated in this interdisciplinary consensus study (82% urologist, 16% radiologist, 2% radiation oncology). The participants confirmed that there is a role for FT in men discontinuing AS (48% strongly agree, 39% agree). The benefit of FT over radical therapy for men coming off AS is: less invasive (91%), has a greater likelihood to preserve erectile function (91%), has a greater likelihood to preserve urinary continence (91%), has fewer side effects (86%), and has early recovery post-treatment (80%). Patients will need to undergo mpMRI of the prostate and/or a saturation biopsy to determine if they are potential candidates for FT. Our limitations include respondent's biases and that the participants of this consensus may not represent the larger medical community. Conclusions: FT can be offered to men coming off AS between the age of 60 to 80 with grade group 2 localized cancer. This consensus from a multidisciplinary, multi-institutional, international expert panel provides a contemporary insight utilizing FT for CaP in select patients who are discontinuing AS. United States Department of Health & Human Services National Institutes of Health (NIH) - USA ; European Urological Scholarship Programme (EUSP)

National health insurance (NHI) is a financing mechanism established by a national government with the goal of covering all or almost all of its citizens. A number of low- and middle-income countries have established NHIs as part of a strategy to progress towards universal health coverage. The establishment of an NHI presents a potentially significant shift in national health sector governance, but little is available in the literature regarding how policymaking authority and health governance is shared between NHIs and ministries of health (MOHs). To answer this question, we conducted a descriptive, qualitative comparative analysis of policies, including legislation, guidelines and webpages, from four sub-Saharan African countries that have established or are in the process of establishing an NHI scheme as of 2019 (Ghana, Kenya, Zambia and South Africa). We developed a novel conceptual framework comprising 16 NHI policy domains and conducted a deductive review of relevant policies. We then extracted and indexed policy elements according to this framework to facilitate comparative analysis. We found substantial variation across countries in the types of policies developed and the decision-making authority around those policies. MOHs in all four countries retained at least some decision-making power over the NHIs through regulations and appointment of board members. However, NHIs were often delegated policymaking authority in key areas including financing mechanisms, provider payments, member payments, benefit schemes, accreditation and relationships with private health insurance schemes. The results of this analysis illustrate many aspects of health regulatory power and oversight that will need to be defined as part of establishing NHIs. The approaches from these four countries and the conceptual framework presented in this manuscript may be helpful for other countries in evaluating differing approaches to shared health governance between NHIs and MOHs.

Background and Purpose: Fiducial marker placement is required in patients undergoing robotic-based Stereotactic Body Radiotherapy (SBRT) or image-guided radiation therapy (IGRT) for prostate cancer. Many patients take antiplatelet or anticoagulant medication due to other medical comorbidities. They are often required to temporarily discontinue these medications prior to invasive medical procedures as they are prone to bleed. Some patients are unable to discontinue therapy due to an elevated risk of thromboembolic events. The purpose of this study is to report this institution's experience placing fiducial markers in prostate cancer patients who are on chronic antiplatelet or anticoagulant medication. Materials and Methods: From August 2015-March 2019 57 patients on chronic antiplatelet or anticoagulation therapy who were not cleared to stop these medications underwent transrectal ultrasound guided (TRUS) fiducial marker placement for SBRT/IGRT. All patients were monitored by a registered nurse during the procedure for prolonged bleeding that required staff to hold pressure to the area with a 4 × 4 gauze until it resolved. All patients were also called the following day to assess for ongoing bleeding events. Treatment planning CT scan confirmed the ideal geometry of the marker placement. Results: All 57 patients on antiplatelet or anticoagulant medication who underwent fiducial marker placement were discharged home the same day of the procedure. Four patients experienced persistent bleeding that required a nurse to hold prolonged pressure to the area. No patient experienced significant bleeding the following day or any untoward cardiovascular event. Conclusions: This series suggests the use of antiplatelet or anticoagulant medication is not an absolute contraindication to fiducial marker placement in patients undergoing SBRT or IGRT for prostate cancer. These patients should be closely monitored after the procedure for bleeding complications. Practitioners may consider the patient's medical comorbidities, risk factors for thromboembolism, and overall functional status as there is no standardized protocol for discontinuing anticoagulant or antiplatelet therapy for fiducial marker placement.

The popularity and the high nicotine content of the American pod e-cigarette JUUL have raised many concerns. To comply with European law, the nicotine concentration in the liquids of the European version, which has been recently released on the market, is limited to below 20 mg/mL. This limit can possibly be circumvented by technological adjustments that increase vaporization and consequently, elevate nicotine delivery. In this study, we compare vapor generation and nicotine delivery of the initial European version, a modified European version, and the original American high-nicotine variant using a machine vaping set-up. Additionally, benzoic acid and carbonyl compounds are quantified in the aerosol. Further, concentrations of nicotine, benzoic acid, propylene glycol, and glycerol, along with the density and pH value of JUUL e-liquids have been assessed. Whereas the initial European version did not compensate for the low nicotine content in the liquid, we provide evidence for an increased vaporization by the modified European version. As a consequence, nicotine delivery per puff approximates the American original. Notably, this is not associated with an increased generation of carbonyl compounds. Our data suggest a similar addictiveness of the enhanced European version and the original American product. Electronic supplementary material The online version of this article (10.1007/s00204-020-02716-3) contains supplementary material, which is available to authorized users.

One barrier to human immunodeficiency virus preexposure prophylaxis (PrEP) is lack or perceived lack of health insurance or financial assistance. We performed a medical records review at a safety-net PrEP clinic in Seattle, Washington, and found that barriers to obtaining financial assistance were commonly recorded in association with initiation and persistence on PrEP.

The development and management of health policies, strategies and guidelines (collectively, policies) in many low- and middle-income countries (LMICs) are often ad hoc and fragmented due to resource constraints a variety of other reasons within ministries of health. The ad hoc nature of these policy processes can undermine the quality of health policy analysis, decision-making and ultimately public health program implementation. To identify potential areas for policy system strengthening, we reviewed the literature to identify potential best practices for ministries and departments of health in LMICs regarding the development and management of health policies. This review led us to identify 34 potential best practices for health policy systems categorized across all five stages of the health policy process. While our review focused on best practices for ministries of health in LMICs, many of these proposed best practices may be applicable to policy processes in high income countries. After presenting these 34 potential best practices, we discuss the potential of operationalizing these potential best practices at ministries of health through the adoption of policy development and management manuals and policy information management systems using the South Africa National Department of Health’s experience as an example.

Driven by the growing importance of situational awareness of bioterrorism threats, the Republic of Korea (ROK) and the United States have constructed a joint military capability, called the Biosurveillance Portal (BSP), to enhance biosecurity. As one component of the BSP, we developed the Military Active Real-time Syndromic Surveillance (MARSS) system to detect and track natural and deliberate disease outbreaks. This article describes the ROK military health data infrastructure and explains how syndromic data are derived and made available to epidemiologists. Queries corresponding to 8 syndromes, based on published clinical effects of weaponized pathogens, were used to classify military hospital patient records to form aggregated daily syndromic counts. A set of ICD-10 codes for each syndrome was defined through literature review and expert panel discussion. A study set of time series of national daily counts for each syndrome was extracted from the Defense Medical Statistical Information System between January 1, 2011, and May 31, 2014. A stratified, adjusted cumulative summation algorithm was implemented for each syndrome group to signal alerts prompting investigation. The algorithm was developed by calculating sensitivity to sets of 1,000 artificial outbreak signals randomly injected in the dataset, with each signal injected in a separate trial. Queries and visualizations were adapted from the Suite for Automated Global bioSurveillance. Findings indicated that early warning of outbreaks affecting fewer than 50 patients will require analysis at subnational levels, especially for common syndrome groups. Developing MARSS to improve sensitivity will require modification of underlying syndromic diagnosis codes, engineering to coordinate alerts among subdivisions, and enhanced algorithms. The bioterrorist threat in the Korean peninsula mandates these efforts.

Background: Gay men and other men who have sex with men are disproportionately burdened by HIV infection. Laws that penalize same-sex intercourse contribute to a cycle of stigma, homonegativity and discrimination. In many African nations, laws criminalizing homosexuality may be fueling the epidemic, as they dissuade key populations from seeking treatment and health care providers from offering it. Objectives: We analyzed the ways in which policies and practices of the US President’s Emergency Plan for AIDS Relief (PEPFAR) program addressed pervasively harsh anti-homosexuality laws across Africa. Given the aim of the US PEPFAR program to reduce stigma surrounding HIV, we explored how PEPFAR may have used its influence to reduce the criminalization of homosexuality in the countries where it operated. Methods: We assessed homosexuality laws in 21 African countries where PEPFAR funding sought to reduce the HIV epidemic. We examined PEPFAR Policy Framework agreements associated with those countries, and other PEPFAR documents, for evidence of attempts to reduce stigma by decriminalizing homosexuality. Results: We found 16 of Africa’s 21 PEPFAR-funded countries had laws characterized as harsh in relation to homosexuality. Among the top eight PEPFAR-funded countries in Africa, seven had harsh anti-homosexuality laws. Most (14) of the 16 African ‘Partnership Framework’ (PEPFAR) policy agreements between African governments and the US State Department call for stigma reduction; however, none call for reducing penalties on individuals who engage in homosexual behavior. Conclusions: We conclude that while PEPFAR has acknowledged the negative role of stigma in fueling the HIV epidemic, it has, so far, missed opportunities to explicitly address the role of the criminalization of homosexuality in feeding stigmatizing attitudes. Our analysis suggests mechanisms like PEPFAR Partnership Framework agreements could be ideal vehicles to call for removal of anti-homosexuality legislation.

Introduction Over the past 3 decades, there has been a substantial shift to the marketisation of government-funded health services. For organisations traditionally buffered from the competitive pressures of for-profit enterprises, such as community-based organisations, this means developing the capacity to adapt to competitive tendering processes, shifting client expectations, and increasing demands for greater accountability. Drawing on ideas of institutional entrepreneurship, we believe that attempts to build adaptive capacity require the transformation of existing institutional arrangements. Key in this may be identifying and fostering institutional entrepreneurs—actors who take the lead in being the impetus for, and giving direction to, structural change. This study focuses on the strategies used by institutional entrepreneurs to build adaptive capacity in the community-based healthcare sector. Methods and analysis The research will use an adapted rapid realist review. The review will find underlying theories that explain the circumstances surrounding the implementation of capacity-building strategies that shape organisational response and generate outcomes by activating causal mechanisms. An early scoping of the literature, and consultations with key stakeholders, will be undertaken to identify an initial programme theory. We will search for relevant journal articles and grey literature. Data will be extracted based on contextual factors, mechanisms and outcomes, and their configurations. The analysis will seek patterns and regularities in these configurations and will focus on confirming, refuting or refining our programme theory. Ethics and dissemination The study does not involve primary research and, therefore, does not require formal ethical approval. However, ethical standards of utility, usefulness, feasibility, propriety, accuracy and accountability will be followed. The results will be written up according to the Realist and Meta-Review Evidence Synthesis: Evolving Standards guidelines. Once completed, findings will be published in a peer-reviewed journal. Trial registration number CRD42015026487.

As a part of the Korea-US joint Biosurveillance Portal project, we have developed the military syndromic surveillance system with electronic medical records from military hospitals for early identification of bio-terror related events among Armed Forces in Korea. Respiratory, Gastrointestinal, Botulism, Dermatologic, Neurologic, Hemorrhagic and Fever syndromes were defined by different ICD-10 codes and their alert thresholds were developed based on the characteristics of time series derived using daily counts of ICD-10 codes for each syndrome.

Objective: Following national trends, Washington State relies heavily on foreign-born workers to provide long-term care. Our study assesses state nursing facility characteristics, quality ratings, and the views of facility administrators about the implications of an increasing number of foreign-born employees. Methods: We used independently available data to supplement a survey of nursing home administrators. Results: Nearly half of the administrators reported difficulty hiring U.S.-born job applicants. Three in four administrators reported problems related to language differences, and just more than a third reported challenges related to cultural and/or religious differences. Nonetheless, the proportion of foreign-born employees was positively associated with independent facility quality ratings. Almost half of the administrators reported discrimination by patients/clients toward their foreign-born workers. Quality ratings were negatively associated with for-profit, chain, or multi-ownership status. Discussion: The proportion of foreign-born employees in nursing facilities may be associated with improved performance.

Achieving an AIDS-free generation will require the adoption and implementation of critical health policy reforms. However, countries with high HIV burden often have low policy development, advocacy, and monitoring capacity. This lack of capacity may be a significant barrier to achieving the AIDS-free generation goals. This manuscript describes the increased focus on policy development and implementation by the United States President's Emergency Plan for AIDS Relief (PEPFAR). It evaluates the curriculum and learning modalities used for two regional policy capacity building workshops organized around the PEPFAR Partnership Framework agreements and the Road Map for Monitoring and Implementing Policy Reforms. A total of 64 participants representing the U.S. Government, partner country governments, and civil society organizations attended the workshops. On average, participants responded that their policy monitoring skills improved and that they felt they were better prepared to monitor policy reforms three months after the workshop. When followed-up regarding utilization of the Road Map action plan, responses were mixed. Reasons cited for not making progress included an inability to meet or a lack of time, personnel, or governmental support. This lack of progress may point to a need for building policy monitoring systems in high HIV burden countries. Because the success of policy reforms cannot be measured by the mere adoption of written policy documents, monitoring the implementation of policy reforms and evaluating their public health impact is essential. In many high HIV burden countries, policy development and monitoring capacity remains weak. This lack of capacity could hinder efforts to achieve the ambitious AIDS-free generation treatment, care and prevention goals. The Road Map appears to be a useful tool for strengthening these critical capacities.

More than four years after September 11, 2001, bioterrorism preparedness remains a high priority for federal, state, and local governments. With reasonably flexible federal funding, communities have strengthened their ability to respond to public health emergencies, according to assessments by stakeholders and market observers. Collaborative relationships developed for bioterrorism preparedness have proved useful in addressing other threats, such as natural disasters and infectious disease outbreaks. Major ongoing challenges include funding constraints, inadequate surge capacity, public health workforce shortages, competing priorities, and jurisdictional issues.

The safety net provides health care to the nation's 20 million low-income uninsured residents1 regardless of their ability to pay for these services. While many providers care for some uninsured people, the safety net consists of the group of hospitals, community health centers and, in some cases, local health departments that provide the bulk of inpatient and outpatient care to this population. A strong safety net is vital for improving both individual health and public health. Given its reliance on external funding to finance care for the uninsured, however, the safety net is vulnerable to the vicissitudes of market and policy forces. Numerous studies have documented the various pressures that challenged the safety net's ability to subsidize care for the uninsured2 during the 1990s and these studies generated pessimistic predictions for the future3. These pressures included the Balanced Budget Act (BBA), movement to Medicaid managed care, and welfare reform. The most comprehensive study of this time period, the 2000 Institute of Medicine report, found that the safety net was largely intact between 1997 and 1999 yet remained fragile. Pressures had not yet converged in all communities, however, and the study recommended ongoing analysis of the status of the safety net (Lewin and Altman 2000). As part of the Community Tracking Study (CTS) site visit research, this analysis examines how market and policy pressures affected the safety net between 1996 and 2001, given the framework that safety net pressures and responses have varied effects due to underlying conditions in the community. This research builds off a baseline CTS safety net assessment (Baxter and Feldman 1999). While many safety net studies focus on a small set of providers or communities at a point in time, the CTS tracks the core safety net providers in 12 nationally representative communities over time. Such a qualitative approach is invaluable to understanding the safety net (Sofaer 1998), particularly due to the lack of quantitative data available (Baxter and Mechanic 1997; Felt-Lisk, McHugh, and Howell 2002). We found that the safety net as a whole expanded and became more financially viable over the last six years. In this paper, we identify the major forces that contributed to stability and growth in the safety net, including policy responses to pressures and safety net strategies. We also explore the variation across communities and the importance of particular conditions to safety net strength. In addition, we discuss how changes in the safety net affected care for low-income uninsured people. Finally, we discuss the lessons to be learned on how to reinforce and further strengthen the safety net for the future.