Harm reduction must be recognised an essential public health intervention during crises.

The COVID-19 had a substantial impact on the provision of harm reduction services for people who use drugs globally. These front-line public health interventions serve a population that due to stigma, discrimination and criminalisation, faces barriers to accessing health and social services and are particularly vulnerable to public health crises. Despite this, the pandemic has seen many harm reduction services close, reduce operations or have their funding reduced. Simultaneously, around the world, harm reduction services have been forced to adapt, and in doing so have demonstrated resilience, flexibility and innovation. Governments must recognise the unique abilities of harm reduction services, particularly those led by the community, and identify them as essential health services that must be protected and strengthened in times of crisis.

Decolonizing drug policy.

This paper reviews evidence of how drug control has been used to uphold colonial power structures in select countries. It demonstrates the racist and xenophobic impact of drug control policy and proposes a path to move beyond oppressive systems and structures. The 'colonization of drug control' refers to the use of drug control by states in Europe and America to advance and sustain the systematic exploitation of people, land and resources and the racialized hierarchies, which were established under colonial control and continue to dominate today. Globally, Black, Brown and Indigenous peoples are disproportionately targeted for drug law enforcement and face discrimination across the criminal system. These communities face higher arrest, prosecution and incarceration rates for drug offenses than other communities, such as majority populations, despite similar rates of drug use and selling among (and between) different races. Current drug policies have contributed to an increase in drug-related deaths, overdoses and sustained transnational criminal enterprises at the expense of the lives of people who use drugs, their families and greater society. This review provides further evidence of the need to reform the current system. It outlines a three-pillared approach to rebuilding drug policy in a way that supports health, dignity and human rights, consisting of: (1) the decriminalization of drugs and their use; (2) an end to the mass incarceration of people who use drugs; (3) the redirection of funding away from ineffective and punitive drug control and toward health and social programs.

Women and barriers to harm reduction services: a literature review and initial findings from a qualitative study in Barcelona, Spain.

BACKGROUND: There are an estimated 3.2 million women who inject drugs worldwide, constituting 20% of all people who inject drugs. The limited data that are available suggest that women who inject drugs are at greater risk of HIV and viral hepatitis acquisition than men who inject drugs. This increased vulnerability is a product of a range of environmental, social and individual factors affecting women, which also affect their ability to engage in health promoting services such as harm reduction. METHODS: The researchers undertook a narrative literature review examining access to harm reduction services for women who use drugs in Europe and conducted semi-structured focus groups with women who use drugs and harm reduction and prison health workers in Barcelona, Spain. RESULTS: Women who use drugs face multiple barriers to accessing harm reduction services. These include stigma, both in society in general and from health and harm reduction workers in prisons and in the community; gender-based violence and a lack of services that are equipped to address the interaction between drug use and experiences of violence; criminalisation in the form of legal barriers to access, arrest and harassment from law enforcement, and incarceration; and a lack of services focused on the specific needs of women, notably sexual and reproductive health services and childcare. In Barcelona, participants reported experiencing all these barriers, and that their engagement with the Metzineres harm reduction centre had to some extent mitigated them. However, women continued to experience structural barriers to harm reduction service access. CONCLUSIONS: Women and gender non-conforming people who use drugs face unique barriers to accessing harm reduction services. While services such as Metzineres can be life changing and life affirming for its members, it is incumbent on states to act to address the structural barriers to health faced by women who use drugs.

Severe Upper Limb Injuries in U.S. Military Personnel: Incidence, Risk Factor and Outcomes.

BACKGROUND: Severe upper limb injuries (SULI) may pose a significant public health challenge for the military; however, SULI has not been previously defined or studied in the US military. Objective: Determine SULI incidence, risk factors, and outcomes. MATERIALS AND METHODS: Active Component (AC) U.S. military personnel who served during January 1, 2003 to December 31, 2012 who met the case definition for SULI (N = 213,745) and a random sample from the same population without SULI were included. Data from the Defense Medical Surveillance System and Defense Medical Epidemiology Database was used to calculate incidence. Multiple logistic regression and Cox proportional hazards models were used to analyze SULI risk factors and attrition. RESULTS: SULI incidence was 15/1,000 person-years. Higher SULI risk was observed in men (OR 1.25; 95% CI 1.22-1.27), age 25-29 (OR 1.07; 95% CI 1.05-1.09) compared to age 20-24, E5-E9 (OR 1.14; 95% CI 1.12-1.17) compared to E1-E4, serving in Coast guard (OR 1.62; 95% CI 1.56-1.68) and Air Force (OR 1.17; 95% CI 1.14-1.19) relative to Army and with a deployment history (OR 2.16, 95% CI 2.12-2.19) while SULI risk was lower for blacks (OR 0.91; 95% CI 0.90-0.93) and those in the "other race" category (HR 0.81; 95% CI 0.80-0.84) compared to whites. SULI was associated with 23% increased risk of attrition (HR 1.23; 95% CI 1.22-1.24). CONCLUSION: The study findings provide preliminary evidence on the incidence, natural history and distribution of SULI in this population. The findings indicate SULI may impact readiness and result in premature military separation.

Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models.

BACKGROUND: The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements. METHODS: 11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy. FINDINGS: Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31-62%) and a 72% reduction in mortality (range 64-82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis. INTERPRETATION: Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level. FUNDING: Bill and Melinda Gates Foundation.

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models.

BACKGROUND: The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa. METHODS: We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice. FINDINGS: Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective. INTERPRETATION: Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary. FUNDING: Bill & Melinda Gates Foundation.

The need to accelerate access to new drugs for multidrug-resistant tuberculosis.

Approximately half a million people are thought to develop multidrug-resistant tuberculosis annually. Barely 20% of these people currently receive recommended treatment and only about 10% are successfully treated. Poor access to treatment is probably driving the current epidemic, via ongoing transmission. Treatment scale-up is hampered by current treatment regimens, which are lengthy, expensive, poorly tolerated and difficult to administer in the settings where most patients reside. Although new drugs provide an opportunity to improve treatment regimens, current and planned clinical trials hold little promise for developing regimens that will facilitate prompt treatment scale-up. In this article we argue that clinical trials, while necessary, should be complemented by timely, large-scale, operational research that will provide programmatic data on the use of new drugs and regimens while simultaneously improving access to life-saving treatment. Perceived risks - such as the rapid development of resistance to new drugs - need to be balanced against the high levels of mortality and transmission that will otherwise persist. Doubling access to treatment and increasing treatment success could save approximately a million lives over the next decade.

On estime à un demi-million le nombre de personnes qui contractent chaque année la tuberculose multirésistante. De nos jours, à peine 20% d'entre elles reçoivent le traitement recommandé, et seulement 10% environ sont traitées avec succès. L'accès limité au traitement est probablement responsable de l'épidémie actuelle qui se propage par une transmission continue. L'amélioration de l'accès au traitement est freinée par les schémas thérapeutiques actuels, lesquels sont très longs, chers, mal tolérés et difficiles à gérer dans les régions où résident la plupart des patients. Bien que de nouveaux médicaments permettent d'améliorer les schémas thérapeutiques, les essais cliniques actuels et prévus ne laissent que peu d'espoir quant au développement de schémas qui favoriseraient l'amélioration rapide de l'accès au traitement. Dans cet article, nous soutenons que les essais cliniques sont certes nécessaires, mais qu'ils doivent être accompagnés d'une recherche opérationnelle de grande ampleur effectuée en temps voulu. Cette recherche permettrait d'obtenir des données programmatiques sur l'utilisation des nouveaux médicaments et schémas tout en améliorant l'accès à un traitement pouvant sauver des vies. Les risques perçus ­ tels que le développement rapide d'une résistance aux nouveaux médicaments ­ doivent être mis en balance avec les taux élevés de mortalité et de transmission qui se maintiendraient sans cela. Doubler l'accès au traitement et accroître son efficacité permettrait de sauver environ un million de vies au cours de la décennie à venir.

Se estima que alrededor de 500.000 personas al año desarrollan tuberculosis multirresistente. Apenas el 20% de estas personas recibe un tratamiento recomendado y solo el 10% se somete a un tratamiento eficaz. Probablemente la epidemia actual, a través de la transmisión continua, se deba al escaso acceso al tratamiento. La ampliación del tratamiento se ve obstaculizada por los regímenes terapéuticos actuales, que son prolongados, caros, producen intolerancia y son complicados de administrar en los lugares donde residen los pacientes. A pesar de que los nuevos fármacos son una oportunidad de mejorar los regímenes terapéuticos, los ensayos clínicos actuales y planificados no ofrecen demasiadas esperanzas para desarrollar regímenes que faciliten una ampliación del tratamiento a corto plazo. En este artículo sostenemos que los ensayos clínicos, mientras sea necesario, deberían ir acompañados de una investigación operativa oportuna a gran escala que proporcione información programática sobre el uso de los nuevos fármacos y regímenes, mientras mejora el acceso a un tratamiento que salvará vidas. Los riesgos, como el rápido desarrollo de la resistencia a nuevos fármacos, deberían equilibrarse frente a los altos niveles de mortalidad y transmisión que, de otro modo, continuarán existiendo. Duplicar el acceso al tratamiento y aumentar su éxito podría salvar alrededor de un millón de vidas en la próxima década.

Access to new medications for the treatment of drug-resistant tuberculosis: patient, provider and community perspectives.

Multidrug-resistant tuberculosis (MDR-TB) is on the rise, and is difficult to treat. The approval of two new drugs, bedaquiline and delamanid, and growing evidence for the use of linezolid, offer renewed hope for addressing MDR-TB. However, access to these medicines remains a significant challenge. These drugs have not been registered for TB in most settings; barriers to preapproval access persist; and high pricing and intellectual property restrictions limit access. Many unanswered research questions about optimal use of these drugs also limit access, particularly for vulnerable populations. This review outlines challenges in accessing drugs encountered from the perspective of clinicians, patients and affected communities, and offers potential solutions.

Alignment of new tuberculosis drug regimens and drug susceptibility testing: a framework for action.

New tuberculosis drug regimens are creating new priorities for drug susceptibility testing (DST) and surveillance. To minimise turnaround time, rapid DST will need to be prioritised, but developers of these assays will need better data about the molecular mechanisms of resistance. Efforts are underway to link mutations with drug resistance and to develop strain collections to enable assessment of new diagnostic assays. In resource-limited settings, DST might not be appropriate for all patients with tuberculosis. Surveillance data and modelling will help country stakeholders to design appropriate DST algorithms and to decide whether to change drug regimens. Finally, development of practical DST assays is needed so that, in countries where surveillance and modelling show that DST is advisable, these assays can be used to guide clinical decisions for individual patients. If combined judiciously during both development and implementation, new tuberculosis regimens and new DST assays have enormous potential to improve patient outcomes and reduce the burden of disease.

Self-report measure of low back-related biomechanical exposures: clinical validation.

Low back pain and symptoms are major contributors to ambulatory visits, economic burden, and reduced readiness among military personnel and employers in the civilian workplace as well. While a link between low back pain and biomechanical exposures has been established, efficient surveillance methods of such exposures are still needed. Furthermore, the utility of self-report measures for biomechanical exposures has not been examined extensively. The present cross-sectional study analyzed questionnaire data from US Army soldiers (n = 279) working in previously identified occupational specialties that were associated with high risk for low back pain and/or low back pain disability. Demographic characteristics, physical workload, health behaviors, and psychosocial factors were assessed in addition to self-reported workplace biomechanical exposures using the Job Related Physical Demands (JRPDs). Outcomes included self-reported low back pain severity, low back symptoms, functional limitations, and general physical health. The results indicated that the self-report measure of biomechanical exposure had a high degree of internal consistency (Cronbach alpha, 0.95). The JRPD index correlated with low back symptoms, pain intensity, function, and perceived work load using the Borg scale. Regression analyses indicated statistically significant associations between the JRPD and back pain specific pain severity and physical function, but not for general physical health (SF-12) after controlling for age, gender, educational level, job type, and reported exercise and work stress. Specifically, higher JRPD scores (representing greater biomechanical exposure) were associated with higher levels of pain intensity and functional limitations. Higher JRPD scores were found to place an individual at a greater likelihood for being a case with low back pain within the past 12 months (OR = 1.01 per point increase in scale-95%; range 38-152; CI = 1.00-1.02, p < or = 0.05). While future longitudinal studies of the JRPD determining the predictive validity of the measure are needed, the present study provides evidence of the utility of the JRPD for assessing biomechanical exposures associated with low back pain within high-risk jobs. The findings suggest that the JRPD may assist with surveillance efforts and be useful as a process and/or outcome measure in research related to occupational rehabilitation.