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University students usually consist of young people from culturally and linguistically diverse backgrounds, and a group recognised as being at increased risk of STI. This study found lower levels of STI knowledge and STI testing among international students and to a lesser extent, domestic overseas-born students, compared with domestic Australian-born students. International students exhibited lower risk sexual behaviour but were more likely to have had a HIV test than domestic students. This diversity in sexual health knowledge, sexual health services utilisation and sexual experience indicates the need for a variety of public health approaches to improve sexual health.

Despite increases in treatment uptake for hepatitis C viral infection (HCV) in Australia since the introduction of direct acting antiviral (DAA) therapy, a large proportion of HCV-infected people who inject drugs (PWID) have not sought treatment.

The Pacific region faces a significant and growing burden of noncommunicable diseases and mental disorders. An emerging issue is the increasing overlap between physical and mental health conditions, which are often the result of interactive effects and lead to more severe consequences. In addition, climate change is amplifying health risks, as it poses both physical and existential threats to Pacific Island communities. The sustainable development agenda provides a holistic opportunity to address these issues; key elements include improving health surveillance and strengthening health systems, within a multisectoral approach, in order to work towards achieving Healthy Islands.

The uptake and implementation of universal health coverage (UHC) is primarily a political, rather than a technical, exercise, with contested ideas and diverse stakeholders capable of facilitation or resistance—even veto—of the policy uptake. This narrative systematic review, undertaken in 2018, sought to identify all peer-reviewed publications dealing with concepts relating to UHC through a political economy framing. Of the 627 papers originally identified, 55 papers were directly relevant, with an additional eight papers added manually on referral from colleagues. The thematic analysis adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions to organize the analysis. The results identified a literature strong in its exploration of the ideologies and ideas that underpin UHC, but with an apparent bias in authorship towards more rights-based, left-leaning perspectives. Despite this, political economy analyses of country case studies suggested a more diverse political framing for UHC, with the interests and institutions engaged in implementation drawing on pragmatic and market-based mechanisms to achieve outcomes. Case studies offered limited detail on the role played by specific interests, though the influence of global development trends was evident, as was the role of donor organizations. Most country case studies, however, framed the development of UHC within a narrative of national ownership, with steps in implementation often critical political milestones. The development of institutions for UHC implementation was predicated largely on available infrastructure, with elements of that infrastructure—federal systems, user fees, pre-existing insurance schemes—needing to be accommodated in the incremental progress towards UHC. The need for technical competence to deliver ideological promises was underlined. The review concludes that, despite the disparate sources for the analyses, there is an emerging shared narrative in the growing literature around the political economy of UHC that offers an increasing awareness of the political dimensions to UHC uptake and implementation.

HIV self-testing (HIVST) introduces opportunities for screening in non-conventional settings, and addresses known testing barriers. This study involved the development and evaluation of a free online HIVST dissemination service hosted by a peer-led, community-based organisation with on-site, peer-facilitated HIV testing, and established referral and support programs for people newly diagnosed with HIV to determine whether this model was feasible and acceptable for engaging MSM, particularly among infrequent and naive HIV-testers, or those living in remote and rural areas. Between December 2016 and April 2018, 927 kits were ordered by 794 individuals, the majority of whom were men who have sex with men (MSM) (62%; 494), having condomless sex (50%; 392), or living outside a major city (38%; 305). Very few (5%; 39) sought the available pre-test peer contact, despite 45% (353) being naive HIV-testers. This study demonstrates that online HIVST dissemination is acceptable and feasible for engaging at-risk suboptimal testers, including those unwilling to test elsewhere (19%; 47/225). With half (50%; 403) unwilling to buy a kit, our study suggests that HIVST will need to be subsidized (cost-neutral to users) to enhance population coverage and access.

This introduction to the special issue aims to conceptualize the structural and super-structural relations between global capitalism and health, incorporating both historical and contemporary capit...

In this article, we seek to intervene on the global health security debate and attendant literatures to argue that the primary focus of global health security–that infectious disease is an existential security threat to both humans and vital infrastructures–only tells one part of the story about the meaning and significance of biological danger in the contemporary context. While important, this perspective fails to grapple with the ways that our conception of what biology is and what it can do have been altered through advances in science and technology, particularly through the intermingling of computer science and molecular biology. Starting from the premise that biology has been informationalized, we argue that biological exchange is not only a threat to humans and the institutional structures they create, it is also, importantly, a political and economic opportunity for firms and core states involved in global health security, and one of the key bases for an emergent global political economy of health security. We forward the idea of a somatic-security industrial complex to capture this dynamic.

Background The study aimed to estimate the comparative costs per positive diagnosis of previously undetected HIV in three testing regimes: conventional; parallel and point of care (POC) testing. The regimes are analysed in six testing settings in Australia where infection is concentrated but with low prevalence. Methods A cost model was developed to highlight the trade-offs between test and economic efficiency from a provider perspective. First, an estimate of the number of tests needed to find a true (previously undiagnosed) positive diagnosis was made. Second, estimates of the average cost per positive diagnosis in whole of population (WoP) and men who have sex with men (MSM) was made, then third, aggregated to the total cost for diagnosis of all undetected infections. Results Parallel testing is as effective as conventional testing, but more economically efficient. POC testing provide two significant advantages over conventional testing: they screen out negatives effectively at comparatively lower cost and, with confirmatory testing of reactive results, there is no loss in efficiency. The average and total costs per detection in WoP are prohibitive, except for Home Self Testing. The diagnosis in MSM is cost effective in all settings, but especially using Home Self Testing when the individual assumes the cost of testing. Conclusions This study illustrates the trade-offs between economic and test efficiency and their interactions with population(s) prevalence. The efficient testing regimes and settings are presently under or not funded in Australia. Home Self Testing has the potential to dramatically increase testing rates at very little cost.

For populations at risk of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), regular testing of multiple anatomical sites is recommended. Pooling methods that combine one patient’s anatomical site specimens can reduce cost and workflow burdens.1 2 The feasibility of such methods within a community setting is well established3 4; however, sensitivities of pooling are inferior to methodologies that test anatomical sites separately.1 5 Our group sought to improve pooling performance near the point of care within a peer-led, community-based STI testing service. Adapting a protocol described by Speers et al ,5 we previously reported3 sensitivities of 90% (95% CI 77.4% to 96.3%) and 89.7% (95% CI 74.8% to 96.7%) for the pooled detection of CT and NG, respectively, when using the Xpert CT/NG assay (Cepheid, Sunnyvale, California, USA). The Xpert CT/NG assay has not been listed by any regulatory body …

Background The addition of pre-exposure prophylaxis (PrEP) for HIV prevention to the Australian Government-subsidised Pharmaceutical Benefits Scheme (PBS) enables any doctor or nurse practitioner to prescribe it and has increased accessibility options. However, understanding of Australian healthcare providers’ (HCP) knowledge and preparedness to prescribe PrEP remains limited. Methods: Semistructured interviews, conducted before PBS listing (October 2016–April 2017), explored PrEP knowledge and prescription experiences of 51 multidisciplinary HCPs involved with the Queensland Pre-Exposure Prophylaxis Demonstration study. Results: Thematic analysis revealed that participants viewed PrEP as a necessary HIV prevention option, but there was concern about confusing prevention messages and potential risk compensation. Clinical capacity, stigma, cultural norms, rural access and PrEP-associated costs were identified as barriers to access and uptake. Some of these barriers may be addressed by the PBS listing; nonetheless, there was strong specialist concern about the preparedness of general practitioners without sexual health experience to prescribe PrEP. Participants identified a need to educate all HCPs, implement multidisciplinary supply models and provide timely access to PrEP for vulnerable populations and those ineligible for Medicare (Australia’s universal healthcare insurance system). Conclusions: Although PrEP listing on the PBS addressed structural barriers to access, this study highlights the role of nurses and other interdisciplinary healthcare workers in the provision of PrEP in addressing the sociocultural barriers that still affect the access of certain populations to HIV prevention measures. These findings will inform further professional training as PrEP is more widely accessed and requested outside specialist sexual health services. Future work is needed to ensure that the primary healthcare workforce is prepared to provide competent and safe access to PrEP across diverse locations and population groups.

Abstract Background The advent of fully automated nucleic acid amplification test (NAAT) technology brings new public health opportunities to provide Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) point-of-care testing (POCT) in non-traditional settings. Methods: This pilot study evaluated the integration of the CT/NG Xpert diagnostic assay into an urban peer-led community setting providing HIV and syphilis POCT. A comprehensive protocol of testing, result notification, referral and follow up, managed by peer test facilitators, was undertaken. Results: Over 67 weeks, there were 4523 occasions of CT/NG testing using urine, oropharyngeal and anorectal samples with 25.7% (803) of the 3123 unique participants returning for repeat testing. The prevalence of CT and NG was 9.5% and 5.4% respectively. Where CT and or NG infection was detected, 98.4% (604/614) of participants were successfully notified of detected infection and referred for treatment. Evaluation Survey responses (11.4%, 516/4523) indicated a substantial proportion of respondents (27.1%, 140/516) ‘would not have tested anywhere else’. Of note, 17.8% (92/516) of participants reported no previous CT/NG test and an additional 17.8% (92/516) reported testing more than 12 months ago. A total of 95.9% (495/516) of participants ‘Strongly agreed’ or ‘Agreed’ to being satisfied with the service. Conclusion: The project successfully demonstrated an acceptable and feasible model for a peer-delivered community-led service to provide targeted molecular CT/NG POCT. This model offers capacity to move beyond the traditional pathology and STI testing services and establish community-led models that build trust and increase testing rates for key populations of epidemiological significance.

This paper explores the willingness to use and pay for HIV Self-testing (HIVST) among Australian gay and bisexual men (GBM). Bivariate and univariate multinominal logistic regression of data from an online survey was performed. Thirty-one (13%) had never HIV tested and 41.9% (88) were testing sub-optimally by Australian guidelines. Half (58.4%, 136) had never heard of HIVST, however, 56.2% (131) reported willingness to use HIVST, with sub-optimal (OR=2.13; p

Objective To examine the hepatitis C virus (HCV) cascade of care at a community-based integrated harm reduction and treatment facility for people who inject drugs (PWID). Methods Queensland Injectors' Health Network is a community-based agency providing integrated harm reduction and treatment services, including HCV treatment. Program data were analyzed from program commencement (early 2015) up to December 2017. Results By December 2017, 476 participants with confirmed HCV infection had enrolled in treatment, of whom 72% had commenced treatment, 65% had completed treatment, and 44% had a confirmed sustained virologic response at 12-weeks post-treatment. Participants who commenced treatment tended to be older (ref 18–34 years; 35–49 years OR = 1.84, p = 0.037, 50+ years OR = 3.19, p = 0.002) and to feel safe and stable in their housing (OR = 2.36, p = 0.021). Participants who completed treatment were less likely to report legal issues (OR = 0.23, p = 0.009). Conclusions Integrated community-based services can successfully engage PWID throughout the HCV treatment journey. Additional social support, including linkage with housing and legal navigation services, may improve treatment uptake and completion. Point-of-care testing, including same-day scripting, could improve treatment uptake.

Background Ethiopia is one of the countries which has scaled up antiretroviral treatment (ART) over the past decade. This study reviews the performance of the ART program in Ethiopia during the past decade, and identifies successes and weaknesses toward ending AIDS in the country. Methods A review and synthesis of data was conducted using multiple data sources: reports from all health facilities in Ethiopia to the Federal Ministry of Health, HIV/AIDS estimates and projections, and retrospective cohort and cross-sectional studies conducted between 2005/6 and 2014/15. Findings The ART program has been successful over several critical areas: (1) ART coverage improved from 4% to 54%; (2) the median CD4 count/mm 3 at the time of ART initiation increased from 125 in 2005/6 to 231 in 2012/13; (3) retention in care after 12 months on ART has increased from 82% to 92%. In spite of these successes, important challenges also remain: (1) ART coverage is not equitable: among regions (5.6%-93%), between children (25%) and adults (60%), and between female (54%) and male patients (69%); (2) retention in care is variable among regions (83%-94%); and, (3) the shift to second-line ART is slow and low (0·58%). Interpretation The findings suggest that the ART program should sustain the successes and reflect on the shortcomings toward the goal of ending AIDS. It is important to capitalize on and calibrate the interventions and approaches utilized to scale up ART in the past. Analysis of the treatment cascade, in order to pinpoint the gaps and identify appropriate solutions, is commendable in this regard.

Self-Testing for HIV (HIVST) is widely recognised as a feasible and effective means of increasing rates of testing and detection of HIV, particularly in non-testing and infrequent testing populations. Currently in Australia, the only means of accessing this technology is to purchase unregulated products on-line. A search of available on-line distributers was purposefully performed from the perspective of an English-speaking individual, with no clinical background or specific understanding of HIV testing practices, seeking to determine their HIV status. Purchased kits were assessed against a structured extraction tool based on the Australian Therapeutic Goods Administration (TGA) HIV testing clinical performance guidelines. In total, eight HIVST kits were purchased from seven different distributers. Analysis of the purchased kits and linked websites revealed that none met the TGA's requirements for HIV testing kits intended for home use; none also conformed to the additional recommendations for information, quality and links to services developed from this study's review of HIVST associated literature. People seeking HIVST kits are able to purchase sub-standard products that ill-serve their needs, and do so at a time of great personal vulnerability. The fact that Australians are willing to purchase and use these sub-standard products indicates HIVST is in demand. Health policy and models of service are needed in order to ensure people have access to a safe and effective registered device at prices that enable equity of access to all Australians, particularly those most at risk of HIV. Other countries awaiting access to regulated HIVST devices also need to consider the potential implications. Collaboration between manufacturers, distributers, regulatory bodies, service providers and the community is needed globally in order to ensure HIVST is embedded into testing methods in a manner that does not disrupt but rather safely and effectively increases HIV testing rates.

Background The aim of this study was to compare the performance of pooled self-collected urogenital, pharyngeal and anorectal specimens to that of individual specimen results for the molecular detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) near the point of care (POC) for diagnostic sensitivity. Methods: Clients (mostly men who have sex with men) attending an urban community testing service and three sex-on-premises venues in Brisbane, Australia, were offered CT and NG testing by trained lay providers. Participants provided three self-collected specimens (urine, pharyngeal and rectal) for testing by GeneXpert (Cepheid, Sunnyvale, CA, USA). If any of the individual specimens from a participant were positive, all three specimens were pooled and retested. Results: Of the 388 participants who provided three individual anatomical specimens, 76 (19.6%) were found to be positive for CT and/or NG at one or more sites. The pooling approach failed to detect five CT rectal and four NG pharyngeal infections. The overall performance (sensitivity) of the pooling approach compared with individual specimen testing and Cohen’s κ were 90.0% and 0.86 respectively for CT and 89.7% and 0.89 respectively for NG. Conclusions: Reduced sensitivity was observed when using pooled specimens for the detection of CT and NG using GeneXpert near the POC, similar to results reported in laboratory-based CT and NG pooling studies. These data suggest specimen pooling is feasible near to the POC, potentially saving time and costs when screening at-risk populations for CT and NG. Our data also suggest a reduction in pooled urine could improve overall test sensitivity.

This study aims to pilot and evaluate an integrated model for HIV self-testing (HIVST) service delivery in a peer-led Queensland community setting to increase access to HIVST, particularly for men who have sex with men (MSM) living in regional, remote and rural areas. It seeks to provide evidence that would overcome some of the key objections previously raised to HIVST. Recruitment strategies have been designed to engage hard to reach MSM populations in testing. Awareness of the trial will be generated through advertising on social media platforms, including dating applications, word of mouth and HIV related websites. Participants will access an HIVST online ordering system hosted by a HIV community organisation. This system: (1) enables on-line informed consent; 2) gives clients the choice to accept verbal pre-test information from a trained peer test facilitator or not; and (3) allows for ordering of the HIVST kit after completion of an online survey (with demographic information and testing history etc.). Clients receive the kits via the post; and at 2 weeks receive a follow-up phone-call and SMS link to a post-test survey. If the test is non-reactive, clients can opt for test reminders. If reactive, referral to clinical services, peer navigation and support systems are provided. This study addresses important gaps in understanding of acceptable and feasible methods to integrate HIVST into an existing peer-led testing service and into the broader suite of HIV testing options and services. The findings will inform the actions needed to enhance access to HIVST for MSM wishing to use this technology in Australia and elsewhere, especially those who have never tested and infrequent testers.

At September’s 2017 United Nations General Assembly, a state-of-the-art HIV medicine was announced to be made available at just $75 per person per year. There have been a number of strategies that the global AIDS community and countries have utilized to reduce prices and make antiretrovirals (ARVs) accessible for people living with HIV/AIDS. There appears to be an opportunity for the treatment of hepatitis C virus infection using direct-acting antivirals (DAAs) to benefit from the often painful and laboured history of driving down the prices of ARVs. In general, the success of lowering prices for ARVs has stemmed from the politics needed to initially support generic entry into the on-patent market. The use of flexibilities present in the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) have been used to overcome patent barriers, with the use of compulsory licenses and/or the threat of their use as instruments for strengthening the bargaining power in price negotiations.These strategies have been combined with new financing mechanisms that have promoted more effective procurement and price negotiations. Partnership among the different stakeholders has also been critical in this regard. Countries have also invested in their health systems and implemented several strategies to reduce stigma and discrimination to increase access to and improve utilization of ARVs. This article suggests that any future international initiatives to increase access to DAAs can learn from these lessons surrounding price reduction, improved financing, advocacy, as well as health systems strengthening and stigma reduction. Adopting and reconfiguring these strategies will also incur substantial savings in time, money and lives. Keywords: Acces to medicines, Hepatitis C virus, HIV, Antiretrovirals, Direct-acting antivirals

Recently, there has been a policy momentum toward creating a global tiered pricing framework, which would provide differentiated prices for medicines globally, based on each country’s capacity to pay. We studied the most influential proposals for a tiered pricing framework since the 1995 World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights. We synthesized 6 critical questions to be addressed for a global framework to function and explored the many challenges of implementation. Although we acknowledge that there is the potential for an exceptional global commitment that would benefit both producers and those in developing countries in need of wider access to medicines, our greatest concern is to ensure that a global framework does not price out the poor from pharmaceutical markets nor threaten current flexibilities within the international patent regime.

The study of global health governance has developed rapidly over recent years. That literature has identified a range of factors which help explain the “failure” of global health governance, but it has largely neglected the global public policy processes which perpetuate that failure. In this paper we argue that there is such a thing as “global health policy” and set out a new framework for analyzing the processes through which it is made, highlighting the mixture of power and ideas, agency and structure, which impact upon the policy cycle. The framework rests upon four pillars: framing; paradigms; power; and the “deep core” of neoliberalism. Through integrating insights from a range of literatures, in particular from the global health governance and public policy analysis fields, we seek to enrich the conceptual basis of current work on global health governance.

A degree of surface contamination has been found to be beneficial for assembly quality of optoelectronics because it reduces the surface free energy of the ceramic substrates, therefore inhibits bleed of the epoxy adhesives used to assemble components to them. This study aimed to examine the implications for process control of current industrial practice where the control of ceramic surface free energy is not considered. This has been achieved by identifying and characterising the potential sources of the contamination found on ceramic sleds, which had passed through the optoelectronic supply chain, so that the variation in chemical composition and the degree of contamination could be determined. Two types of ceramic substrates, aluminium oxide and aluminium nitride were cleaned by plasma, then stored in commercial polymer waffle packs used for transportation and a variety of storage atmospheres for one month. XPS measurements to characterize the surface chemistry were subsequently carried out following the storage to identify the composition of contamination that had built up. Contact angle and bleed distance measurements were also made to quantify the effect of the contamination on the wetting properties of the contaminated surfaces. It was found that the composition of the contamination was not directly associated with the storage method or environment, but the quantity was. The highest degree of contamination occurred on samples stored using the industrial standard method of containment in polymer waffle packs with paper and polyethylene anti-static inserts, higher even than storage in open air. The major source of the contamination in this case was probably from the inserts, with a much smaller contribution from the waffle pack. The levels of contamination built up in such case produced apparent surface free energies only slightly lower than 30 mJ/m2, the threshold for acceptable levels of bleed to occur during the assembly process. This has indicated that if storage were to be used as a method of controlling epoxy bleed, it is likely that episodes of epoxy bleed would occur in a random manner on the production line, due to variation in the sample storage conditions and tendency to adsorb contaminants.

Chemical and physical variability in the as-received state of aluminium oxide and aluminium nitride ceramic substrate materials used in optoelectronic modules currently leads to a process yield less than 100% when adhesives are used for assembly and interconnection. The phenomenon of epoxy bleed is a contributing factor to this yield and steps are not yet taken in the industry to control or inhibit the undesirable wetting. Standard surface texture measurement techniques, XPS and contact angle measurements were implemented to characterise and compare commercial as-received samples. The quality controls currently in place are assessed and additional analysis methods in the QC stage are suggested for increasing yield. Commercially available conductive and thermally conductive adhesives, also used in optoelectronic module manufacture, were studied along with the surfaces. In this work the surface property measurements, wetting observations and shear failure modes are compared and discussed. It was found that varying as-received surface properties did not affect adhesion strength between the adhesives and ceramics enough to induce an undesirable failure mode, although epoxy bleed distance varies dramatically with varying surface conditions.

We analysed the performance of Ethiopia in achieving the health-related millennium development goals (MDGs) with the aim of acquiring lessons for the sustainable development goals (SDGs). Ethiopia achieved most of the health MDGs: a 67% reduction in under-five mortality, a 71% decline in maternal mortality ratio, a 90% decline in new HIV infections, a decrease in malaria-related deaths by 73% and a more than 50% decline in mortality due to tuberculosis. We argue that these achievements are due to implementation of a mix of comprehensive strategies within the health system and across other sectors of the government. Scaling up of interventions by disease control programmes (including the health extension programme) and strengthening of the health system have played important roles towards the achievements. These health gains could not have been realised without progress in the other MDGs: poverty reduction, education, access to safe drinking-water and peace and stability of the country. However, the gains were not equitable, with differences between urban and rural areas, among regions and socioeconomic strata. Ethiopia's remarkable success in meeting most of the targets of the health-related MDGs could be explained by its comprehensive and multisectoral approach for health development. The inequity gap remains a challenge that achieving the health-related SDGs requires the country to implement strategies, which specifically target more marginal populations and geographic areas. This also needs peace and stability, without which it is almost impossible to improve health.

Neurosyphilis emerged as a clinical entity at the beginning of the nineteenth century with the condition, 'General Paralysis of the Insane' (GPI). Noted for its sudden appearance in mostly men in mid-life, patients invariably died in hospital within one to five years from the first onset of symptoms. Our study sought to examine the impact of GPI and other manifestations of neurosyphilis on asylum admissions in Queensland in the pre-antibiotic era, analysing the patient records of the Goodna Hospital for the Insane in the period 1880 to 1920. Those diagnosed with GPI on admission were more likely to be married and employed in professional, administrative, technical/trade occupations. The average age of death was just over forty-three years. Conversely, those admitted for other psychiatric presentations where syphilis was presumed to be causal, tended to be predominantly unmarried, and more likely to be in labouring occupations. Average age of death was fifty-two years.

The focus of this chapter is the World Trade Organization’s (WTO’s) Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) as a central component in trade-related governance affecting the pharmaceutical industry. TRIPS is therefore illustrative of how health issues and outcomes are not necessarily determined by actors and institutions primarily associated with health. The chapter begins by discussing how intellectual patent rights and access to medicines came to be understood as a global health issue with the coming into force of TRIPS in 1995. Second, the chapter traces the manner in which TRIPS and its adverse health impacts were subsequently challenged by counter-framings based on human rights. Finally, we link TRIPS to the emergence of institutions and actors involved in addressing the access to medicines issue.

Background: The heads of the Global Fund and the GAVI Alliance have recently promoted the idea of an international tiered pricing framework for medicines, despite objections from civil society groups who fear that this would reduce the leeway for compulsory licenses and generic competition. This paper explores the extent to which an international tiered pricing framework and the present leeway for compulsory licensing can be reconciled, using the perspective of the right to health as defined in international human rights law. Discussion: We explore the practical feasibility of an international tiered pricing and compulsory licensing framework governed by the World Health Organization. We use two simple benchmarks to compare the relative affordability of medicines for governments ? average income and burden of disease ? to illustrate how voluntary tiered pricing practice fails to make medicines affordable enough for low and middle income countries (if compared with the financial burden of the same medicines for high income countries), and when and where international compulsory licenses should be issued in order to allow governments to comply with their obligations to realize the right to health. Summary: An international tiered pricing and compulsory licensing framework based on average income and burden of disease could ease the tension between governments? human rights obligation to provide medicines and governments? trade obligation to comply with the Agreement on Trade-Related Aspects of Intellectual Property Rights.

The authors examine how health governance is being transformed amid globalization, characterized by the emergence of new actors and institutions, and the interplay of competing ideas about global health. They explore how this has affected the governance of specific health issues and how it relates to global governance more broadly.

This chapter discusses the relationship, in an age of globalisation, between global health governance and the governance of individual health issues such as HIV/AIDS, pandemic influenza, tobacco control and access to medicines. It does this within the context of changes to global governance more generally. It proposes a new way of envisaging this relationship, which captures the evolving political dynamics. In particular the chapter identifies a narrative of transformative change in global health governance based on three elements: the globalisation of health; the emergence of competing visions of global health governance; and the changing institutional landscape.

This chapter identifies how transformations in global health governance are reflected in the governances of specific health issues such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), pandemic influenza, tobacco control and access to medicines. It illustrates the importance of ideas such as security, rights, economics, development and bio-medicine in the formation and legitimisation of interests in global health. The chapter explains the link between global health governance and other areas of global governance. It also underscores the multisectoral nature of global health governance and how this is reflected in institutions and actors. Finally it suggests that the way forward in improving global health governance is to link health and other concerns both in the framing of issues and in institutional architecture.

The Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement, which inaugurated a global regime of minimum intellectual property rights (IPR) standards, marked the high point in the neoliberal tide as it surged across the pharmaceutical sector. The introduction and enforcement of pharmaceutical product patents, hitherto uncommon in the Global South (and also not recognized in many developed countries), was often accompanied by the privatization or closure of state-owned drug firms and an opening-up of the drug sector to foreign investment. IPR standards have been further extended and deepened post-1995 through bilateral and regional trade agreements. While the TRIPS agreement has advantaged the interests of the multinational pharmaceutical companies (MNCs), the variable degree of implementation of this agreement in different countries reported in this volume is one factor limiting that advantage. For the contemporary movement for access to affordable medicines, however, the question is whether the weaknesses in the global IPR regime itself and the resistance described in this volume are likely to be sufficient to secure such access worldwide.

Some two decades will shortly have passed since the World Trade Organization’s Agreement on Trade Related Aspects of Intellectual Property Rights (henceforth WTO and TRIPS) came into force in 1995 (World Trade Organization, 1994). TRIPS has proven to be one of the most politically charged and divisive multilateral agreements yet negotiated. The agreement has polarized opinion with regard to its effects on knowledge production and consumption in areas as diverse as agriculture and food security, literacy and education, software and the internet economy, and its general implications for capitalist accumulation.

There have been recent indications that the primacy of AIDS among global health issues may be under threat. In this article we examine one response to have emerged from the AIDS policy community as a result of this perceived threat: the 'AIDS plus Millennium Development Goals (MDGs)' approach, which argues that the AIDS response (the focus of MDG6) is essential to achieving the other MDG targets by 2015, stressing the two-way relationship between AIDS and other development issues. By framing AIDS in this way, the AIDS plus MDGs approach draws on an established narrative of a 'virtuous circle' between health and development, but at the same time makes some important concessions to critics of the AIDS response. This article - the first critical academic analysis of the AIDS plus MDGs approach - uses this case to illuminate aspects of the utilisation of framing in global health, shedding light both on the extent to which new framings draw upon established 'common sense' narratives as well as the ways in which framers must adapt to the changing material and ideational context in which they operate.

This study explores how an 'Intellectual Property Rights (IPR)/trade regime' has generated a particular set of problems regarding access to medicines despite patents on drugs being presented as economically necessary for reward and future drug innovation. These problems have also inspired and informed activities by so-called new actors in global health. This study argues that a parallel 'pro-access regime' has developed in order to correct some of the most high-profile issues associated with a dysfunctional global pharmaceutical market, especially problems regarding price and innovation that have been exacerbated by stringent global patent rights on new drugs. Therefore, the IPR/trade regime's basic role in global-health governance diverges from how it has been framed and understood, not least of all by its constituent agents and donors. The pro-access regime encompasses new actors in health such as Global Health Partnerships (e.g., GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria), major philanthropic foundations (e.g., the Gates and Clinton Foundations) and new access initiatives (e.g., UNITAID). The study problematises these actors' governance roles with respect to the overarching authority of the IPR/trade regime and makes a case that the two regimes should be understood as being closely connected with respect to the governance of access to medicines and the global political economy of pharmaceuticals.

The landscape of global health governance has undergone a radical transformation. Perhaps the most striking change has been the rise of private actors and their incorporation into what was previously a publicly dominated governance system. Their rise to prominence in global health has brought many benefits, not least in the vast resources that they have harnessed for addressing key global health problems. Yet they have attracted criticism as well as praise. The fact that there have often been heated debates surrounding the roles of global health partnerships (GHPs) and philanthropic foundations is testament to the simple fact that something fundamental has taken place in the field of global health. In a relatively short period of time, beginning in the mid-1990s, these actors have revolutionised the health governance architecture to an extent that the wider international system has not witnessed since the creation of the modern multilateral system, in the aftermath of the Second World War. In contrast to those earlier seismic shifts in international governance, the entrance of private actors in global health governance has not been the result of a carefully planned process. There has been no equivalent of the San Francisco or Bretton Woods Conferences. Rather, the change in global health governance has been a gradual and often ad hoc process. There are no clear lines of authority, either politically or legally. Mandates often overlap and compete. Traditional governance actors, from states to the World Health Organization (WHO), have been forced to adapt to this new reality.

An increase in demand for miniature electronic devices with higher transmission rates and reduced power consumption has led to advances in science and technology. Optoelectronics can be defined as a coalition of optics and electronics. The communication, health care, and the defence sector all vastly benefit from the use of optoelectronics components in various devices such as lasers, optical fibres and imaging sensors. Components in the optoelectronics industry can be surface mounted on to the substrate materials. In this study aluminium oxide (Al 2 O 3 ) and aluminium nitride (AlN) have been laser micro machined in order to study the effects of laser machining on accuracy and repeatability. It was desirable to achieve features of sufficient quality as to be used as passive alignment features in the assembly process. A previous study carried out by Williams et al. (1) concentrated on limiting the epoxy adhesive flow, and demonstrated ways in which epoxy bleed could be successfully controlled. It highlighted excimer laser machining as a repeatable and capable process for producing precise geometries. However, it was concluded that further development was required before the features could be used in an optoelectronic assembly. In this study Al 2 O 3 and AlN ceramic substrates were surface micro-machined with KrF excimer laser. The objective of this work was to investigate the feasibility of producing accurate and repeatable micron scale feature designs (

With the emergence of global health comes governance challenges which are equally global in nature. This article identifies some of the initial limitations in analyses of global health governance (GHG) before discussing the focus of this special supplement: the framing of global health issues and the manner in which this impacts upon GHG. Whilst not denying the importance of material factors (such as resources and institutional competencies), the article identifies how issues can be framed in different ways, thereby creating particular pathways of response which in turn affect the potential for and nature of GHG. It also identifies and discusses the key frames operating in global health: evidence-based medicine, human rights, security, economics and development.

Polycrystalline aluminium oxide and aluminium nitride sleds were machined using a CO 2 laser to explore the capability of the method to produce passive alignment and assembly features for use in optoelectronic assemblies. The geometry of machined features and surface texture of machined surfaces were characterised and found to be limited by the ablation method. Consequently, a KrF excimer laser was utilised in the trials for bulk machining of the ceramics but was observed also to be restricted by its slow ablation rate. However, the combined CO 2 with KrF excimer laser were then employed to exploit the benefits offered by both, fast processing time of the CO 2 laser and enhanced geometry and texture control with the KrF excimer laser. In this study, the geometry and surface texture generated by the individual and the combined methods are characterised and compared to identify the processing limitations. The ability for the machining methods to produce patterns of sufficient accuracy to act as passive alignment features is therefore discussed. The suitability to produce the various artifacts to enable adhesive flow control was also examined, which can be applied for micro-scale precise assembly of high density packaging. By considering the production of such features with desirable geometry and textures, the effects of the processing parameters on the bulk material and the substrate surfaces where the energy of laser beam directly interacted was particularly investigated. This will ultimately assist to establish optimum settings of processing parameters in association with the type, properties and thickness of the substrates.

Maintaining cleanliness of substrates for assembly in optoelectronic modules is important where surfaces will be subjected to further processes in which the surface properties can affect performance. Cleanliness is counter productive when considering epoxy bleed, since the carbon based contamination of surfaces has been seen to reduce surface free energy and inhibit the spread of epoxy material. The origin of this contamination can be from a number of sources including atmosphere, handling, surface treatments and outgassing from storage media. Whilst allowing contamination to remain on the surface can be an effective means of controlling the epoxy bleed, it is not a reliable solution through lack of controllability. Identifying and quantifying this contamination will be a useful step towards the understanding and control of epoxy bleed, whilst its removal will homogenise all surfaces allowing controllable solutions to be implemented. The substrate materials of interest were aluminium oxide and aluminium nitride, which are commonly used in the optoelectronics industry. Storage methods used in industry were recreated for the purpose of this study with storage of samples in tin foil used for comparison. Samples were stored in commercial polymer waffle packs in a variety of atmospheres which they might experience in industry, on an industrial site, for one month. XPS measurements were made following storage to identify the composition of the contamination and its source. Both the degree of carbon contamination and the functional groups of any adsorbed species are known to affect surface energy and epoxy bleed. Therefore narrow band XPS spectra for carbon were analysed for all samples. Of the many methods which could be employed to remove the surface contamination, solvent, plasma cleaning and firing were chosen for their suitability and due to their availability to industry. XPS was performed on samples following cleaning. It was found that the composition of the contamination on the surfaces was not linked to their storage method but the quantity of contamination was. Storing ceramics in polymer waffle packs does not protect them from build up of carbon contamination regardless of storage atmosphere. The use of tin foil for storage can reduce the degree of contamination presence significantly, but not prevent build up entirely. A high degree of bleed was seen in both samples cleaned but not stored as well as in samples cleaned after storage, showing the effects of storage contamination are easily reversed. While storing ceramics for an extended period of time will allow build up of sufficient contamination to stop bleed occurring, samples fresh from suppliers will not have built up sufficient contamination to reduce the surface free energy to a degree such that bleed will not occur.

In this chapter we seek to provide an overarching theoretical and conceptual framework for the analysis of global health and contemporary global health governance by means of an international political economy (IPE) approach. The chapter, and indeed this volume, is the first major attempt to generate an IPE of global health governance, wherein explanations of contemporary crises in global health and the contested space of global health policies are explicitly rooted in IPE. We seek to offer a corrective to what is a striking poverty of IPE approaches to this fundamental area of globality and human life, an absence which has persisted despite the almost routine linkage of new disease patterns and resource scarcity in healthcare with key features of globalisation (Fidler, 2001 and 2004; Lee et al., 2002). Works on global health governance regularly footnote the centrality of economic globalisation, including how such factors as increased volumes of international trade, investment and finance are having direct and indirect effects on human health, not least in the more rapid transmission of infectious diseases resulting from trade flows and spatial compression. Similarly, and in political terms, scholars and health policy communities are increasingly sensitive to the fact that global health governance is also changing (and has arguably changed from a system of ‘international’ health governance) because of the increasing influence of a range of International Organisations (IOs) and economic actors with little or no previous health remit (Brown et al., 2006).

Acknowledgements Notes on Contributors Introduction: The International Political Economy of Global Health Governance A.Kay & O.Williams PART I: THE POLITICS OF GLOBAL HEALTH GOVERNANCE Understandings of Global Health Governance: The Contested Landscape K.Lee National Security and Global Health Governance C.McInnes Global Governance Capacities in Health: WHO and Infectious Diseases S.Rushton The International Political Economy of Global Responses to HIV/AIDS A.Ingram Chronic Diseases and Global Health Governance: The Contrasting Cases of Food and Tobacco S.Barraclough PART II: THE ECONOMY OF GLOBAL HEALTH GOVERNANCE Unpacking Economism and Remapping the Terrain of Global Health M.Sparke The Power of Money: Global Financial Markets, National Politics, and Social Determinants of Health T.Schrecker Trade and Health R.Labonte, C.Blouin & L.Forman IMF Policies and Health in Sub-Saharan Africa R.P.Buckley & J.Baker The World Bank and Health S.Harman The Competition State and the Private Control of Health Care H.Lofgren Index

Optoelectronics manufacturers are under continuous pressure for miniaturisation of optoelectronic modules. One route to further miniaturisation is to reduce the spacing between the optical and optoelectronic components in the optical path adhesively mounted to ceramic carriers. Flow control of the adhesives over the ceramic surface is then imperative. Uncontrolled wetting can lead to an excessive adhesive footprint which interferes in the application of other adhesives for subsequent components. However, insufficient wetting can lead to low strength bonds vulnerable to thermal fatigue and shear failure. This investigation focuses on determining the factors controlling the wetting of adhesives to ceramic surfaces, with the goal of minimising the potential for uncontrolled wetting while maintaining resistance to thermal fatigue and shear forces. In addition positional stability of adhered parts on cure and in-service must not be detrimentally affected. The first step in the investigation was to characterise the surface properties of alumina and aluminium nitride ceramic plates variously processed by commercial suppliers. The surface conditions included lapped, polished, etched and as-fired. The lubricants and abrasives used by the supplier companies for the mechanical surface treatments were not specified. Initial characterisation was performed by XPS, contact angle, SEM and surface texture analysis, amongst others. Commercially available conductive and thermally conductive adhesives were applied to the ceramics and their wetting behaviour linked to the surface properties observed. Finally, single lap joints were prepared with the ceramics and adhesives and were shear tested, and the shear failure modes identified. In this work the surface property measurements, wetting observations and shear failure modes are compared and discussed.

Ink jet printing of self-assembled monolayers (SAMs) on copper provides a potential route to the digital manufacture of patterned tracks and micro-fabricated devices. However, forming a SAM layer using conventional solution methods is challenging due to the native oxide layer on copper, and this issue is magnified for ink-jet printing, where the oxide layer must be removed, without rendering the substrate unsuitable for high resolution printing. In this study, ink-jet patterning of SAMs on copper is reported. The correlation between oxide removal method and print resolution and SAM distribution within a deposited drop is investigated. In addition, the quality of the deposited layer is assessed using a variety of approaches including surface energy measurement.