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Introduction: Radiologist shortages threaten the sustainability of breast cancer screening programmes. Artificial intelligence (AI) products that can interpret mammograms could mitigate this risk. While previous studies have suggested this technology has accuracy comparable to radiologists most have been limited by using 'enriched' datasets and/or not considering the interaction between the algorithm and human readers. This study will address these limitations by comparing the accuracy of a workflow using AI alongside radiologists on a large consecutive cohort of examinations from a breast cancer screening programme. The study will combine the strengths of a large retrospective design with the benefit of prospective data collection. It will test this technology without risk to screening programme participants nor the need to wait for follow-up data. With a sample of 2 years of consecutive screening examinations, it is likely the largest test of this technology to date. The study will help determine whether this technology can safely be introduced into the BreastScreen New South Wales (NSW) population-based screening programme to address radiology workforce risks without compromising cancer detection rates or increasing false-positive recalls., Methods and Analysis: A retrospective, consecutive cohort of digital mammography screens from 658 207 examinations from BreastScreen NSW will be reinterpreted by the Lunit Insight MMG AI product. The cohort includes 4383 screen-detected and 1171 interval cancers. The results will be compared with radiologist single reading and the AI results will also be used to replace the second reader in a double-reading model. New adjudication reading will be performed where the AI disagrees with the first reader. Recall rates and cancer detection rates of combined AI-radiologist reading will be compared with the rates obtained at the time of screening., Ethics and Dissemination: This study has ethical approval from the NSW Health Population Health Services Research Ethics Committee (2022/ETH02397). Findings will be published in peer-reviewed journals and presented at conferences. The findings of this evaluation will be provided to programme managers, governance bodies and other stakeholders in Australian breast cancer screening programmes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Breast cancer screening (BCS) participation rates are often suboptimal and vary geographically. Environmental features may influence BCS participation, but few studies have assessed this relationship. This study assessed the associations between BCS participation, residential area sociodemographic characteristics, distance to BCS venue, and venue location attributes. Data for 384,433 women residing in Greater Sydney, Australia, invited to BCS during 2011-2014 were spatially joined to their state suburb (SSC) (n = 800). SSC sociodemographic measures included women's median age, proportion women speaking English at home, full-time employed, and university educated; and proportion dwellings with motor-vehicles. Road network distance was calculated to each BCS venue. BCS venues were coded as co-located with bus-stop, train-station, hospital, general practitioner (GP), and shop. Hot spots were calculated to quantify spatial clustering of BCS participation. Multilevel logistic models were used to estimate the associations between environmental predictors and BCS participation, accounting for SSC-level clustering. BCS participation was 53.9% and spatially clustered. BCS was positively associated with SSC-level median age for women, proportions women speaking English and university educated, and dwellings with motor-vehicles. Distance to venue was inversely associated with BCS. Venue co-location with GP was positively associated and co-location with bus-stop, train-station, and shop, hospital were negatively associated with BCS. Residential sociodemographic features, geographic access, and venue location attributes are associated with BCS participation. These findings implicate the relevance of social and built environmental factors to programmatic aims to raise BCS participation. Additional research on venue location features is required to understand where best to site BCS venues., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Understanding environmental predictors of women's use of closest breast screening venue versus other site(s) may assist optimal venue placement. This study assessed relationships between residential-area sociodemographic measures, venue location features, and women's use of closest versus other venues. Data of 320,672 Greater Sydney screening attendees were spatially joined to residential state suburbs (SSCs) ( n = 799). SSC-level sociodemographic measures included proportions of: women speaking English at home; university-educated; full-time employed; and dwellings with motor-vehicles. A geographic information system identified each woman's closest venue to home, and venue co-location with bus-stop, train-station, hospital, general practitioner, and shop(s). Multilevel logistic models estimated associations between environmental measures and closest venue attendance. Attendance at closest venue was 59.4%. Closest venue attendance was positively associated with SSC-level women speaking English but inversely associated with SSC-level women university-educated, full-time employed, and dwellings with motor-vehicles. Mobile venue co-location with general practitioner and shop was positively, but co-location with bus-stop and hospital was inversely associated with attendance. Attendance was positively associated with fixed venue co-location with train-station and hospital but inversely associated with venue co-location with bus-stop, general practitioner, and shop. Program planners should consider these features when optimising service locations to enhance utilisation. Some counterintuitive results necessitate additional investigation.

Objectives: Participation in breast cancer screening (BCS) varies at the small-area level, which may reflect environmental influences. This study assessed small-area variation in BCS invitation response rates (IRRs) and associations between small-area BCS IRR, sociodemographic factors, BCS venue distance and venue location features in Greater Sydney, Australia., Methods: BCS IRR data for 2011-2012 were compiled for 9528 Australian Bureau of Statistics Statistical Area Level 1 (SA1) units (n=227 474 women). A geographial information system was used to extract SA1-level sociodemographic features (proportions of women speaking English at home, full-time employed and university educated, and proportion of dwellings with motor vehicles), SA1-level distance to closest venue(s) (expressed as quartiles), and closest venue(s) colocated with bus stops, train station, hospital, general practitioner and shops. Associations between area-level features, BCS venue distance, venue location features and IRR were estimated using ordinary least square-type spatial lag models including area education as a covariate., Results: BCS IRR varied across SA1s (mean=59.8%, range: 0%-100%), with notable spatial autocorrelation (Moran's I=0.803). BCS IRR was positively associated with greater SA1-level proportion of women speaking English at home (β=2.283, 95% CI 2.024 to 2.543), women's education (in the model including speaking English at home β=0.454, 95% CI 0.211 to 0.697), dwellings with motor vehicles (β=1.836, 95% CI 1.594 to 2.078), greater distance to venue (eg, most distant quartile compared with closest: β=6.249, 95% CI 5.489 to 7.008), and BCS venue colocated with shops (β=0.762, 95% CI 0.273 to 1.251). Greater SA1-level women employment (β=-0.613, 95% CI -0.898 to -0.328) and venue colocated with train station (β=-1.889, 95% CI -2.376 to -1.402) or hospital (β=-0.677, 95% CI -1.164 to -0.189) were inversely related to BCS IRR., Conclusions: Small-area variation in BCS IRR exists for Greater Sydney and is strongly related to sociodemographic factors that, together with BCS venue location features, could inform targeted attempts to improve IRR., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective The aims of this study were to assess the effects of screening through BreastScreen NSW on the stage of cancer at diagnosis, and differences in cancer stage at diagnosis according to sociodemographic factors. Methods Using linked BreastScreen NSW screening attendance records and NSW Cancer Registry data, the effects of screening participation and sociodemographic characteristics on stage at diagnosis were investigated using Kruskal-Wallis analysis of variance or the Mann-Whitney U-test for the 2002-13 diagnostic period. Multivariate logistic regression was used to investigate predictors of stage at diagnosis. Results The association between BreastScreen NSW participation and earlier stage at diagnosis was strongest when the last screening episode occurred within 24 months of the cancer diagnosis, with an odds ratio of localised versus non-localised cancer of 1.61 (95% confidence interval 1.51-1.72). Women aged ≥70 years, Aboriginal women, residents of major cities and women living in areas of socioeconomic disadvantage were more likely to have distant than non-distant stage at diagnosis. A trend towards more distant stage in more recent diagnostic years was evident after adjusting for screening participation. Conclusions The strongest and most consistent predictor of earlier stage at diagnosis was BreastScreen NSW participation. Continued efforts to increase screening participation are important to achieve earlier stage at diagnosis, particularly for sociodemographic groups with more advanced disease. What is known about the topic? Earlier cancer stage at diagnosis is a prerequisite for mortality reduction from screening. Past research indicated that screening participation in New South Wales (NSW) was strongly associated with early stage at diagnosis and mortality reduction. More contemporary data are needed to monitor screening performance in NSW and assess differences in cancer stage across sociodemographic subgroups. What does this paper add? Using data linkage, this paper indicates associations between screening, sociodemographic factors and stage at diagnosis for the NSW population in 2002-13. Contrary to expectations, major city residents tended to have a lower proportion of early stage breast cancer at diagnosis, which may be indicative of lower screening coverage and barriers to screening. Compared with past research, similar effects of screening and other sociodemographic factors on the stage of breast cancer at diagnosis were observed. This paper compares screening histories across sociodemographic groups, indicating statistically significant differences. What are the implications for practitioners? Increasing screening participation is particularly important for sociodemographic groups who are diagnosed at more advanced stages, including women from lower socioeconomic areas, Aboriginal and Torres Strait Islander women and residents of major cities. In particular, the results reinforce the need to further develop targeted strategies to increase screening participation among NSW women from lower socioeconomic areas and Aboriginal and Torres Strait Islander women. Further investigation into screening coverage and barriers to screening for residents in major cities is needed.

Background: The principal target age for Australian BreastScreen services was 50-69 years in 1991-2013 and 50-74 years from 2014. History of BreastScreen NSW screening participation of NSW women diagnosed with breast cancer in 2005-2014 was examined using linked BreastScreen and Cancer Registry data., Methods: Differences in BreastScreen participation were investigated by sociodemographic and tumour characteristics, and diagnostic period, using the Pearson Chi-square test, or Fisher's Exact test when numbers were small, and by multivariate logistic regression., Results: At breast cancer diagnosis, a history of BreastScreen participation varied by age from 23 % for 40-49 years to 68 % for 50-59 years, 72 % for 70-74 years and 78 % for 60-69 years. Among women experiencing breast cancer at age 50-69 years, 60 % had participated in BreastScreen <24 months of diagnosis. Higher odds of BreastScreen participation applied to residents of inner regional and remote compared with major city areas and for women with localized compared with more distant cancer spread. BreastScreen participation was lower in Indigenous than non-Indigenous women. Differences in participation existed by country of birth and residential location, but they were not pronounced., Conclusion: The history of BreastScreen NSW participation of 60 % <24 months for women aged 50-69 years at breast-cancer diagnosis is less than the 70 % target for biennial screening coverage at a population level, but this target has never been reached by an Australian jurisdiction. Qualitative research of screening barriers and opportunities may provide a useful guide for reducing barriers across the population., Competing Interests: Declaration of Competing Interest All authors declare no competing interests., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: At the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS), Member States agreed to regularly review progress made in national responses to HIV. This article provides (1) a brief overview of how the resultant global UNGASS reporting system was developed; (2) the origins, background, limitations and potential of that system; (3) an overview of the articles in this supplement; and (4) crosscutting institutional and methodological issues., Methods: United Nations Member States biennially provide The Joint United Nations Programme on HIV/AIDS (UNAIDS) with data on 25 core indicators of national responses to HIV, collected in Country Progress Reports. This article critically reviews and interprets these data in light of international political considerations and overall data needs., Results: There has been a considerable improvement in response rates, accompanied by an increase in data quality and completeness. Both nationally and internationally, the UNGASS process is viewed as being more substantial and important than a reporting exercise to the United Nations General Assembly. The process has catalyzed the development of national monitoring systems and has created opportunities for civil society to monitor and challenge government commitments and deeds., Conclusions: Although the UNGASS global reporting system now comprises an unequaled wealth of data on HIV responses, collected from a broad range of countries, it cannot yet answer several critical questions about the progress and effectiveness of those responses. Evaluation studies that go beyond indicator monitoring are needed, but they will take time to design, fund, implement and interpret. In the meantime, this global monitoring system provides a good indication of the overall progress in the global response to HIV and whether Millennium Development Goal (MDG) 6 (to halt and reverse the HIV epidemic) is likely to be reached by 2015.

Objectives: This article describes the development of the international reporting system to monitor the implementation of the Declaration of Commitment on HIV/AIDS that resulted from the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS)., Design: The UNGASS reporting system is based on the biennial submission of Country Progress Reports. These include data on a set of core indicators and are prepared and submitted by Member States using a transparent collaborative process., Methods: This article reviews the evolution of the system and analyzes the quality and completeness of data from the most recent 2008 reporting round., Results: Over the course of 3 rounds of reporting response rates increased from 54% to 77%. This increase occurred alongside an increase in the completeness of the reported data. Increases in reporting are consistent across countries regardless of the severity of the HIV epidemic., Conclusions: UNGASS reporting has resulted in an unparalleled body of evidence on the response to HIV. Data from 147 countries are now available on the patterns of HIV epidemics, the behaviors related to them, and the programmatic responses that have been mounted by countries. The ultimate goal is for national governments and their civil society partners to achieve ownership of the reporting process. The reporting system has provided a catalyst for the development of national systems for monitoring and evaluating HIV programs and for guiding more effective, efficient, and sustainable responses to the HIV epidemic.

Objectives: In the Declaration of Commitment of the 2001 United Nations General Assembly Special Session on AIDS, all Member States agreed to a series of actions to address HIV. This article examines the availability of data to measure progress toward reducing HIV incidence and AIDS mortality and discusses the extent to which changes can be attributed to programs., Methods: Lacking a method to directly measure HIV incidence, trends in HIV prevalence among 15-year to 24-year olds and groups with high-risk behaviors are used as a proxy measure for incidence trends among adults in generalized and concentrated/low-level epidemics, respectively. Although there is limited empirical data on trends in new infections among children, progress in the treatment area is tracked through indicators for the percentage of people who remain on antiretroviral treatment 12 months after initiation and the coverage of antiretroviral treatment. Successive iterations of epidemiological models using surveillance data from pregnant women and groups with high-risk behavior and data from national household surveys, demographic data and epidemiological assumptions have produced increasingly robust estimates of HIV prevalence, incidence and mortality., Results: Globally, incidence has decreased among adults (accompanied by evidence of changes in behavior in several countries) and children over the past decade. The decline in AIDS mortality is more recent. On the basis of the underlying logical framework and mathematical models, it is concluded that programs have contributed to a reduction in HIV incidence and AIDS mortality., Conclusions: More data are needed to reliably inform trends in HIV incidence and AIDS mortality in many countries to allow an assessment of progress against national and global targets. In addition, impact evaluation studies are needed to assess the relationship between changes in incidence and mortality and the HIV response and to determine the extent to which these changes can be attributed to specific programmatic interventions.

Aims: To estimate the range and severity of heroin overdose related morbidity., Design: Cross-sectional survey., Setting: Sydney, Australia., Participants: 198 heroin users., Findings: Sixty-nine per cent had experienced a heroin overdose, 28% in the preceding 12 months. Of those who had overdosed, 79% had experienced at least one overdose-related morbidity symptom. An ambulance had attended overdoses for 59% of subjects, 33% had required hospital treatment for overdose, and 14% had experienced overdose-related complications of sufficient severity to be admitted to a hospital ward. Indirect overdose-related morbidity included: physical injury sustained when falling at overdose (40%), burns (24%) and assault while unconscious (14%). Direct overdose-related morbidity included: peripheral neuropathy (49%), vomiting (33%), temporary paralysis of limbs (26%), chest infections (13%) and seizure (2%)., Conclusions: There appears to be extensive morbidity associated with non-fatal overdose. This is clearly an area that requires more research to document the prevalence and nature of these harms, and factors associated with them.

A number of unique challenges are faced when attempting to estimate mortality attributable to illicit drugs. The hidden nature of illicit drug use creates difficulties in quantifying the prevalence of such use; identifying adverse health effects associated with exposure, and calculating the risk of these effects. The use of cohort studies of drug users allows the identification of causes of mortality associated with drug use and the determination of the risk of these causes. This risk estimate can then be used in conjunction with estimates of the prevalence of drug use to extrapolate the burden of mortality. We identify a number of such studies and present some solutions to the major challenges faced when attempting to estimate the global burden of mortality attributable to illicit drug use.

Over the past decade fatal opioid overdose has emerged as a major public health issue internationally. This paper examines the risk factors for overdose from a biomedical perspective. While significant risk factors for opioid overdose fatality are well recognized, the mechanism of fatal overdose remains unclear. Losses of tolerance and concomitant use of alcohol and other CNS depressants clearly play a major role in fatality; however, such risk factors do not account for the strong age and gender patterns observed consistently among victims of overdose. There is evidence that systemic disease may be more prevalent in users at greatest risk of overdose. We hypothesize that pulmonary and hepatic dysfunction resulting from such disease may increase susceptibility to both fatal and non-fatal overdose. Sequelae of non-fatal overdose are recognized in the clinical literature but few epidemiological data exist describing the burden of morbidity arising from such sequelae. The potential for overdose to cause persisting morbidity is reviewed.

Objectives: To determine the acceptability of intervention strategies that increase the responsible service of alcohol by non-metropolitan rugby league clubs., Method: Rugby league clubs were provided an information kit and advice by local public health workers, police and a lead agency regarding their responsible service of alcohol practices. Rugby League clubs and public health workers completed an acceptability survey at the conclusion of the study., Results: Data were collected from 160 contactable clubs (100% consent) and 12 of 14 participating public health workers. Almost all clubs reported of contact with the lead agency, public health workers and police to be acceptable. Fifty-nine percent of clubs reported contact with public health workers to be useful. One-third of the public health workers considered that they were not the most suitable professional group to be involved in delivering the intervention., Conclusions: In spite of a suggested culture of harmful alcohol consumption among rugby league participants and spectators, non-metropolitan rugby league clubs appear receptive to public health strategies that increase their responsible service of alcohol., Implications: The ability of the public health sector to meet this opportunity appears limited, and may require additional strategies to increase the capacity of public health workers to develop/deliver inter-sectorial interventions in this setting.

Objective: To assess householders' satisfaction with the process of residential lead abatement in an urban Australian population., Method: The study area consisted of suburbs immediately surrounding a lead-related industry on Australia's east coast. Nineteen of 20 remediated households in the study area agreed to participate in the survey. One trained interviewer conducted semi-structured qualitative interviews with one 'key' person from each remediated household. Participants were asked for their personal views as well as general household views about the rationale for, process and results of lead remediation., Results: The 19 households varied from three to seven people and contained 1-5 children (16 years or under). The opinions of residents of remediated households were polarised, with the majority being either greatly satisfied or greatly dissatisfied with the process. Level of satisfaction was clearly linked to perceived quality of the remediation works., Conclusions: Satisfaction with household lead remediation could be improved by ensuring effective communication between all parties; providing clear, simple, but detailed information about the remediation works to be undertaken on each household; providing timely support for householders when problems arise; and ensuring that all contractors are skilled, reputable and have acceptable communication skills.