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IntroductionWomen in sub-Saharan Africa (SSA) experience the world's highest rates of both HIV infection and unintended pregnancy. The Dual Prevention Pill (DPP) is a novel multipurpose prevention technology (MPT) that co-formulates HIV pre-exposure prophylaxis (PrEP) and combined hormonal oral contraception into a single daily pill. As a dual indication product, the DPP may be preferred by women facing these overlapping health risks. However, most SSA countries face severe healthcare resource constraints. Research is needed to assess whether, in what populations, and in what use cases the DPP would be cost-effective.MethodsWe augmented an agent-based SSA HIV model with maternal health parameters including unintended pregnancy, abortion, and maternal mortality. Based on a previous market analysis, we assumed a primary DPP user population of current oral contraceptive users ages 25–49, and alternative user populations in different risk groups (age 15–24, sex workers, HIV-serodiscordant couples) and baseline product use profiles (unmet need for contraception, oral PrEP use, condom use). In three geographies (western Kenya, Zimbabwe, South Africa), we estimated HIV infections averted, pregnancies averted, disability-adjusted life-years (DALYs) averted, and the incremental cost-effectiveness ratio (ICER) over a 30-year time horizon, assuming equivalent adherence to the DPP as to oral contraceptives, higher adherence, or lower adherence.ResultsThe DPP is likely to be a cost-effective alternative to oral PrEP among users in need of contraception. Among women not already using PrEP, the DPP is likely to be cost-saving in sex workers and serodiscordant couples. The DPP is unlikely to be cost-effective in oral contraceptive users in the general population. Switching from oral contraception to the DPP could be net harmful in some settings and populations if it were to substantially reduces adherence to oral contraception. Results were robust to a range of time horizons or discount rates.ConclusionThe DPP has the potential to be cost-effective and cost-saving in populations at substantial HIV risk. Outcomes are sensitive to adherence, implying that effective counseling and decision-making tools for users considering the DPP will be essential. More research is needed to understand real-life adherence patterns and ensure health benefits achieved from contraception alone are not lost.

Coatings of metal specimens are known to have an impact on hydrogen gettering (hydrogen absorption). The coating can have one or more functions, such as enhancing gettering, preventing gettering and/or preventing oxidation of the metal substrate. It is known that contaminants and surface texture can impact hydrogen gettering/absorption performance, but has not previously been thoroughly explored. This study evaluated the role of different post-plating heat treatments of nickel-plated zircaloy-4 getters (NPGs) and the role of the heat treatments on gettering rates, surface composition and texture. Nickel plating is applied to prevent oxidation of the Zircaloy-4 surface and also enhances gettering. The nickel plating must be heat treated before desirable gettering can occur. Our NPG getters with historically known satisfying performance were pre-heat treated in air followed by activation heat treatment in a vacuum at a higher temperature. In this study, we were interested in finding out if both heat treatment steps were necessary to obtain a desirable gettering performance, or if one step could be omitted. XPS analysis showed that if the nickel surface is not heat treated before bonding the nickel to the zirconium in the activation step, there will be carbon contaminants on the surface, which significantly reduces gettering. We studied the texture of Zircaloy-4 using SEM/EBSD to compare NPGs with both heat treatment steps with NPGs that had no post-plating heat treatment to learn if the degree of cold work could be impacted by the heat treatment steps. We did not observe any differences in texture between them. We measured gettering rates of both pretreated and activated NPGs and NPGs that had been activated without first being pre-heat treated. We found that the NPGs without the first post-plating heating step had up to a seven times slower gettering rate and obtained higher plateau pressures due to the contaminated surface. Thus, the pre-heat treatment in air before activation is necessary to avoid slower gettering rates and higher plateau pressures.

Background Two billion people worldwide, predominantly in low- and middle-income countries, cannot consistently access required essential medications, thus affecting their ability to attain optimal health outcomes. Access to appropriate medicines may be compromised due to issues involving cost, availability, quality, and prescribing practices, and system-wide factors such as a lack of transparency and accountability. Pharmaceutical promotional practices impact many of these issues, thus influencing the use of appropriate medicines,. Good governance is ultimately the responsibility of national governments through strong health systems with transparent and accountable practices that facilitate appropriate medicine use. We designed a structured set of indicators, based on existing tools, to assess the strength of the national governance of pharmaceutical promotion. In this exploratory study, we trialed the indicators in Ghana. Methods Two existing tools, one developed by the World Health Organization and the other by Health Action International with the Medicines Transparency Alliance, were adapted to examine the governance of pharmaceutical promotion, resulting in a hybrid framework of 45 indicators of system strength, grouped into four categories: a) Governance of prescription medicines, b) Health care professional codes and regulations, c) Anti-corruption governance, and d) Indexes. Evidence was gathered via desk-based research to establish whether indicator requirements were met. Results Our desk-based research discovered the following: a) 21 of 45 indicators for the governance of prescription medicines were met in Ghana, including the existence of a national medicines policy, national medicines list, medicines regulatory authority and a national guide for the promotion of prescription pharmaceuticals; b) pharmacists have a code of conduct specific to ethical promotion though co-development with the pharmaceutical industry should be further examined; and c) anti-corruption indicators were met for 10 of 12 criteria; and d) two indexes were available that were relevant to Ghana. Conclusion Our set of indicators identified gaps and opportunities for the governance of medicines promotion in Ghana. These indicators have the potential to highlight areas requiring improved governance and could therefore form a useful diagnostic tool for identifying key discussion points for policy strengthening within low- and middle-income countries.