A Horizon Scan to Support Chemical Pollution-Related Policymaking for Sustainable and Climate-Resilient Economies.

While chemicals are vital to modern society through materials, agriculture, textiles, new technology, medicines, and consumer goods, their use is not without risks. Unfortunately, our resources seem inadequate to address the breadth of chemical challenges to the environment and human health. Therefore, it is important we use our intelligence and knowledge wisely to prepare for what lies ahead. The present study used a Delphi-style approach to horizon-scan future chemical threats that need to be considered in the setting of chemicals and environmental policy, which involved a multidisciplinary, multisectoral, and multinational panel of 25 scientists and practitioners (mainly from the United Kingdom, Europe, and other industrialized nations) in a three-stage process. Fifteen issues were shortlisted (from a nominated list of 48), considered by the panel to hold global relevance. The issues span from the need for new chemical manufacturing (including transitioning to non-fossil-fuel feedstocks); challenges from novel materials, food imports, landfills, and tire wear; and opportunities from artificial intelligence, greater data transparency, and the weight-of-evidence approach. The 15 issues can be divided into three classes: new perspectives on historic but insufficiently appreciated chemicals/issues, new or relatively new products and their associated industries, and thinking through approaches we can use to meet these challenges. Chemicals are one threat among many that influence the environment and human health, and interlinkages with wider issues such as climate change and how we mitigate these were clear in this exercise. The horizon scan highlights the value of thinking broadly and consulting widely, considering systems approaches to ensure that interventions appreciate synergies and avoid harmful trade-offs in other areas. We recommend further collaboration between researchers, industry, regulators, and policymakers to perform horizon scanning to inform policymaking, to develop our ability to meet these challenges, and especially to extend the approach to consider also concerns from countries with developing economies. Environ Toxicol Chem 2023;42:1212-1228. © 2023 Crown copyright and The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC. This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.

Developing Innovative Virtual Reality Simulations to Increase Health Care Providers' Understanding of Social Determinants of Health.

INTRODUCTION: Health care providers (HCPs) who work primarily with Medicaid patients must be competent in identifying and addressing social determinants of health (SDH). A curricular gap exists between promoting an understanding of SDH and teaching HCPs how to recognize and increase empathy to manage them. The project aim was to develop two virtual reality simulations (VRSs) as innovative methods to teach HCPs to identify and manage SDH. A secondary aim was to decrease unconscious bias and increase empathy by experiencing SDH from their patients' perspective. METHODS: Scripts for two VRSs were created by two HCP educators and clinicians. Scripts were evaluated by experts using an index of content validity (CVI). An advisory panel critiqued the scripts for appropriateness for VRSs, adequacy of evidence-based practice, and use of VRS equipment and software. The panel participated in a focus group and completed a final evaluation. The VRSs then were pilot tested with five HCPs who assessed content and utility and participated in interviews. This led to iterative improvements. Qualitative data were analyzed using a content analysis approach. RESULTS: The VRS scripts demonstrated adequate content-related validity evidence with CVI scores of 0.81 and 0.75. The expert panel found the VRS easy to use, useful as an educational tool, while promoting empathy for patients. Overall, participants were satisfied with using the VRS as an educational experience. DISCUSSION: Through VRS technology, this project addresses a curricular gap in HCP training on SDH. VRS can be a useful tool to increase HCPs' understanding of SDH and, potentially, their empathy for patients.

Status assessment and probabilistic health risk modeling of metals accumulation in agriculture soils across China: A synthesis.

Heavy metal accumulation in agriculture soils is of particular concern in China, while the status and probabilistic health risks of metal contamination in Chinese agriculture soils have been rarely studied at the national scale. In this study, we compiled a database of heavy metal concentrations in Chinese agriculture soils and selected six heavy metals for pollution assessment and risk screening: arsenic (As), cadmium (Cd), chromium (Cr), nickel (Ni), lead (Pb) and Zinc (Zn). Monte Carlo simulation was employed to assess the probabilistic health risks, the associated uncertainties, as well as variations in toxicity parameters, ingestion rate and body weight. Results indicated that the concentrations of Cd were elevated above their reference standard and Cd had the highest mean geo-accumulation index (Igeo) of 1.79. Moreover, the mean hazard index (HI) through exposure to six heavy metals was 1.85E-01 and 2.87E-02 for children and adults, respectively, with 2.2% of non-cancer risks for children that exceeded the guideline value of 1. In contrast, 95.0% and 90.0% of the total cancer risks (TCR) through exposure to six heavy metals for children and adults, respectively, exceeded the guideline value of 1E-06. Six metals were ranked based on their percent of risk outputs exceeding the guideline values. Arsenic had the high exceedance of both cancer and non-cancer risks, while both Cr and Cd were metals with high concern that had high exceedance of cancer risk. Sensitivity analyses indicated that metal concentrations and ingestion rate of soil were the predominant contributors to total risk variance. Overall, the adverse health risks induced by exposure to heavy metals contaminated farmland were elevated. Results from this study may provide valuable implications for public health professionals and policy-makers to design effective strategy to manage nation-wide farmland and reduce heavy metal exposure.

Consequences of a changing US strategy in the global HIV investment landscape.

OBJECTIVE: The global fight against HIV/AIDS in Africa has long been a focus of US foreign policy, but this could change if the federal budget for 2018 proposed by the US Office of Management and Budget is adopted. We aim to inform public and Congressional debate around this issue by evaluating the historical and potential future impact of US investment in the African HIV response. DESIGN/METHODS: We use a previously published mathematical model of HIV transmission to characterize the possible impact of a series of financial scenarios for the historical and future AIDS response across Sub-Saharan Africa. RESULTS: We find that US funding has saved nearly five million adults in Sub-Saharan Africa from AIDS-related deaths. In the coming 15 years, if current numbers on antiretroviral treatment are maintained without further expansion of programs (the proposed US strategy), nearly 26 million new HIV infections and 4.4 million AIDS deaths may occur. A 10% increase in US funding, together with ambitious domestic spending and focused attention on optimizing resources, can avert up to 22 million HIV infections and save 2.3 million lives in Sub-Saharan Africa compared with the proposed strategy. CONCLUSION: Our synthesis of available evidence shows that the United States has played, and could continue to play, a vital role in the global HIV response. Reduced investment could allow more than two million avoidable AIDS deaths by 2032, whereas continued leadership by the United States and other countries could bring UNAIDS targets for ending the epidemic into reach.

Modelling the bioaccumulation of persistent organic pollutants in agricultural food chains for regulatory exposure assessment.

New models for estimating bioaccumulation of persistent organic pollutants in the agricultural food chain were developed using recent improvements to plant uptake and cattle transfer models. One model named AgriSim was based on K OW regressions of bioaccumulation in plants and cattle, while the other was a steady-state mechanistic model, AgriCom. The two developed models and European Union System for the Evaluation of Substances (EUSES), as a benchmark, were applied to four reported food chain (soil/air-grass-cow-milk) scenarios to evaluate the performance of each model simulation against the observed data. The four scenarios considered were as follows: (1) polluted soil and air, (2) polluted soil, (3) highly polluted soil surface and polluted subsurface and (4) polluted soil and air at different mountain elevations. AgriCom reproduced observed milk bioaccumulation well for all four scenarios, as did AgriSim for scenarios 1 and 2, but EUSES only did this for scenario 1. The main causes of the deviation for EUSES and AgriSim were the lack of the soil-air-plant pathway and the ambient air-plant pathway, respectively. Based on the results, it is recommended that soil-air-plant and ambient air-plant pathway should be calculated separately and the K OW regression of transfer factor to milk used in EUSES be avoided. AgriCom satisfied the recommendations that led to the low residual errors between the simulated and the observed bioaccumulation in agricultural food chain for the four scenarios considered. It is therefore recommended that this model should be incorporated into regulatory exposure assessment tools. The model uncertainty of the three models should be noted since the simulated concentration in milk from 5th to 95th percentile of the uncertainty analysis often varied over two orders of magnitude. Using a measured value of soil organic carbon content was effective to reduce this uncertainty by one order of magnitude.

Time for full inclusion of community actions in the response to AIDS.

INTRODUCTION: Community action, including activism, advocacy and service delivery, has been crucially important in the global response to AIDS from the beginning of the epidemic and remains one of its defining features. This indispensable contribution has been increasingly acknowledged in strategic planning documents from UNAIDS, the Global Fund to fight AIDS, Tuberculosis and Malaria, the World Bank, the World Health Organization and other organizations. A growing body of literature demonstrates that community-based services can have measurable impact, serve populations that are not accessing public health services and reach people at scale. DISCUSSION: Recognition of the powerful potential role of community has not translated into full incorporation of community responses in programme planning or financing, and communities are still not fully understood as true assets within overall systems for health. The diverse community contributions remain seriously underappreciated and under-resourced in national responses. CONCLUSIONS: It is time for a paradigm shift in how we think about, plan and finance community-based responses to HIV in order to achieve improved impact and move toward ending the epidemic. We must utilize the unique strengths of communities in creating resilient and sustainable systems for health. There are several priorities for immediate attention, including agreement on the need to nurture truly comprehensive systems for health that include public, private and community activities; re-examination of donor and national funding processes to ensure community is strategically included; improvement of data systems to capture the full spectrum of health services; and improved accountability frameworks for overall health systems. Health planning and financing approaches run by governments and donors should institutionalize consideration of how public, community and private health services can strategically contribute to meeting service needs and accomplishing public health targets.

Challenges of Recruitment and Retention in Rural Areas.

There have long been rural health care workforce shortages; however, the urgency to find real solutions has increased with the changing health care landscape. The evidence makes a compelling case to be intentional in the candidates we support and to align educational resources across multiple systems. Programs need to continually evolve, utilizing workforce data, best practices, and new technological advances. This leads the Office of Rural Health (ORH) to secure funding for therapists practicing in integrated settings and to expand loan repayment to general surgeons and providers creating access through telehealth. While access is ORH's core mission, North Carolina's rural health plan reframed the discussion around creating healthy rural communities. This will require further refinement of the critical workforce definition, and it brings to the forefront the fact that a variety of new partnerships will be key to achieving the objective of healthy rural communities.

Implementing systematic review techniques in chemical risk assessment: Challenges, opportunities and recommendations.

Systematic review (SR) is a rigorous, protocol-driven approach designed to minimise error and bias when summarising the body of research evidence relevant to a specific scientific question. Taking as a comparator the use of SR in synthesising research in healthcare, we argue that SR methods could also pave the way for a "step change" in the transparency, objectivity and communication of chemical risk assessments (CRA) in Europe and elsewhere. We suggest that current controversies around the safety of certain chemicals are partly due to limitations in current CRA procedures which have contributed to ambiguity about the health risks posed by these substances. We present an overview of how SR methods can be applied to the assessment of risks from chemicals, and indicate how challenges in adapting SR methods from healthcare research to the CRA context might be overcome. Regarding the latter, we report the outcomes from a workshop exploring how to increase uptake of SR methods, attended by experts representing a wide range of fields related to chemical toxicology, risk analysis and SR. Priorities which were identified include: the conduct of CRA-focused prototype SRs; the development of a recognised standard of reporting and conduct for SRs in toxicology and CRA; and establishing a network to facilitate research, communication and training in SR methods. We see this paper as a milestone in the creation of a research climate that fosters communication between experts in CRA and SR and facilitates wider uptake of SR methods into CRA.

Assessment and improvement of biotransfer models to cow's milk and beef used in exposure assessment tools for organic pollutants.

The aim of this study was to assess and improve the accuracy of biotransfer models for the organic pollutants (PCBs, PCDD/Fs, PBDEs, PFCAs, and pesticides) into cow's milk and beef used in human exposure assessment. Metabolic rate in cattle is known as a key parameter for this biotransfer, however few experimental data and no simulation methods are currently available. In this research, metabolic rate was estimated using existing QSAR biodegradation models of microorganisms (BioWIN) and fish (EPI-HL and IFS-HL). This simulated metabolic rate was then incorporated into the mechanistic cattle biotransfer models (RAIDAR, ACC-HUMAN, OMEGA, and CKow). The goodness of fit tests showed that RAIDAR, ACC-HUMAN, OMEGA model performances were significantly improved using either of the QSARs when comparing the new model outputs to observed data. The CKow model is the only one that separates the processes in the gut and liver. This model showed the lowest residual error of all the models tested when the BioWIN model was used to represent the ruminant metabolic process in the gut and the two fish QSARs were used to represent the metabolic process in the liver. Our testing included EUSES and CalTOX which are KOW-regression models that are widely used in regulatory assessment. New regressions based on the simulated rate of the two metabolic processes are also proposed as an alternative to KOW-regression models for a screening risk assessment. The modified CKow model is more physiologically realistic, but has equivalent usability to existing KOW-regression models for estimating cattle biotransfer of organic pollutants.

Generating hypotheses to explain declining HIV infection in four U.S. jurisdictions.

The aims of this study were (1) to generate hypotheses to explain declines in HIV incidence in Massachusetts, North Carolina, San Francisco, and Seattle, and (2) based on lessons learned from these jurisdictions, to offer recommendations for implementation elsewhere. Through in-depth interviews, we identified policies and practices that stakeholders across jurisdictions believe are important to achieving successful outcomes. The most unifying observation was that leadership within health departments is critical to achieving success. With this consideration, we developed a list of tools for public health officials to assert leadership to address challenges posed by HIV: extending access to health insurance, using an array of approaches to increase knowledge of serostatus, investing in services to retain people in care, collecting and using better data, translating data into policy change and public health practice, developing targeted programming for vulnerable populations, minimizing administrative policies that attenuate program success, and diversifying funding sources.

Rural health care: redefining access.

The population and demographics of rural America are shifting once again. As our nation's unprecedented health care reform unfolds, it is becoming clear that rural communities have unique strengths, and capitalizing on these strengths can position them well for this health care transformation. Equally important are the distinct challenges that--with careful planning, attention, and resources--can be transformed into opportunities to thrive in the new health care environment. The North Carolina Institute of Medicine's Task Force on Rural Health recently published a report that highlights the strengths and challenges of rural communities [1]. In order to fully leverage these opportunities, we must continue to acknowledge the fundamental importance of access to basic health care, while also broadening our discussion to collectively tackle the additional components necessary to create healthy, thriving rural communities. As we reexamine the needs of rural communities, we should broaden our discussions to include an expansion of the types of access that are necessary for strengthening rural health. Collaboration, successful recruitment and retention, availability of specialty services, quality care, and cost effectiveness are some of the issues that must come into discussions about access to services. With this in mind, this issue of the NCMJ explores opportunities to strengthen the health of North Carolina's rural communities.

The HIV Cure Research Agenda: The Role of Mathematical Modelling and Cost-Effectiveness Analysis.

The research agenda towards an HIV cure is building rapidly. In this article, we discuss the reasons for and methodological approach to using mathematical modeling and cost-effectiveness analysis in this agenda. We provide a brief description of the proof of concept for cure and the current directions of cure research. We then review the types of clinical economic evaluations, including cost analysis, cost-benefit analysis, and cost-effectiveness analysis. We describe the use of mathematical modeling and cost-effectiveness analysis early in the HIV epidemic as well as in the era of combination antiretroviral therapy. We then highlight the novel methodology of Value of Information analysis and its potential role in the planning of clinical trials. We close with recommendations for modeling and cost-effectiveness analysis in the HIV cure agenda.

Assessment of plant uptake models used in exposure assessment tools for soils contaminated with organic pollutants.

The aim of this study was to evaluate and improve the accuracy of plant uptake models for neutral hydrophobic organic pollutants (1 < logK(OW) < 9, -8 < logK(AW) < 0) used in regulatory exposure assessment tools, using uncertainty and sensitivity analyses. The models considered were RAIDAR, EUSES, CSOIL, CLEA, and CalTOX. In this research, CSOIL demonstrated the best performance of all five exposure assessment tools for root uptake from polluted soil in comparison with observed data, but no model predicted shoot uptake well. Recalibration of the transpiration and volatilisation parameters improved the performance of CSOIL and CLEA. The dominant pathway for shoot uptake simulated differed according to the properties of the chemical under consideration; those with a higher air-water partition coefficient were transported into shoots via the soil-air-plant pathway, while chemicals with a lower octanol-water partition coefficient and air-water partition coefficient were transported via the root. The soil organic carbon content was a particularly sensitive parameter in each model and using a site specific value improved model performance.

In vitro assessment of the bioaccessibility of brominated flame retardants in indoor dust using a colon extended model of the human gastrointestinal tract.

An in vitro colon extended physiologically based extraction test (CEPBET) which incorporates human gastrointestinal tract (GIT) parameters (including pH and chemistry, solid-to-fluid ratio, mixing and emptying rates) was applied for the first time to study the bioaccessibility of brominated flame retardants (BFRs) from the 3 main GIT compartments (stomach, small intestine and colon) following ingestion of indoor dust. Results revealed the bioaccessibility of γ-HBCD (72%) was less than that for α- and ß-isomers (92% and 80% respectively) which may be attributed to the lower aqueous solubility of the γ-isomer (2 µg L⁻¹) compared to the α- and ß-isomers (45 and 15 µg L⁻¹ respectively). No significant change in the enantiomeric fractions of HBCDs was observed in any of the studied samples. However, this does not completely exclude the possibility of in vivo enantioselective absorption of HBCDs, as the GIT cell lining and bacterial flora--which may act enantioselectively--are not included in the current CE-PBET model. While TBBP-A was almost completely (94%) bioaccessible, BDE-209 was the least (14%) bioaccessible of the studied BFRs. Bioaccessibility of tri-hepta BDEs ranged from 32-58%. No decrease in the bioaccessibility with increasing level of bromination was observed in the studied PBDEs.

A call to action for comprehensive HIV services for men who have sex with men.

Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments. Condom and lubricant access for MSM globally is highly cost effective. Antiretroviral-based prevention, and antiretroviral access for MSM globally, would also be cost effective, but would probably require substantial reductions in drug costs in high-income countries to be feasible. To address HIV in MSM will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

Moving beyond the alphabet soup of HIV prevention.

The 'ABCs' of prevention (abstinence, be faithful, use a condom) continue to be the subject of intense debate in the international dialogue on HIV/AIDS prevention policy. The authors argue that the ABC terminology infantilizes the prevention discussion by excluding essential interventions and oversimplifying the prevention challenge facing countries. The dialogue that is needed is less about the relative merits of one intervention over another, but rather how to promote comprehensive national prevention programmes that have a measurable impact on HIV incidence. Accountability is key to advancing HIV prevention on the national and international levels. Governments, donors and global agencies must be held accountable for prevention programming that is tailored to the specific characteristics of national epidemics, brings quality interventions to a scale, addresses environmental factors in vulnerability, and links prevention and treatment services. Whereas each national prevention response must remain unique, policy makers, donors and advocates can assess a country's prevention programming by the degree to which it is designed, scaled and implemented to make impact over time.

Accountability in the global response to HIV: measuring progress, driving change.

Accountability implies that institutions and individuals are answerable for their commitments and responsibilities. The concept of accountability is highly relevant in the global response to HIV/AIDS because governments, donors and other actors have often failed to keep their commitments to expand funding and service delivery levels. Many governments have not been held accountable for failing to address the HIV-related needs of their populations adequately. Accountability is about more than passing judgement. Effective accountability mechanisms can be powerful tools to improve service delivery by providing constructive assessments and motivating decision makers to avoid negative external critiques. An impressive variety of HIV-related accountability projects have emerged over the past few years, the most prominent being the ongoing monitoring of government compliance with the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment. Other accountability efforts are essential in order to capture perspectives and priorities outside of governments and aid agencies. Many civil society-based accountability projects are now tracking HIV policy, service delivery and funding levels. We make several suggestions to increase the impact of accountability efforts, including connecting accountability to sustained advocacy, holding multiple actors accountable, continually assessing what measures of success will be most powerful in driving improved outcomes, and supporting and building the capacity of civil society monitoring efforts. We also suggest exploring how the International AIDS Conferences could serve as an expanded platform for accountability.

Focus on quality in healthcare in Ireland.

PURPOSE: The purpose of this paper is to summarise the recent debates and issues on the healthcare system in Ireland, which have come to the fore through media exposure. The implications for these debates on quality are suggested and questions are raised to stimulate further debate. DESIGN/METHODOLOGY/APPROACH: Recent reports and media opinion articles are reviewed in the light of the health reform programme and the increased prosperity due to the Celtic Tiger era in Ireland. FINDINGS: The Health Service in Ireland is not what it should be. Progress has been made but resistance at all levels is significant due to the mistrust and miscommunication between the managerial and clinical personnel which have built up during the past number of years. The trust of the public is at an all-time low. However, once patients are within the system they are satisfied with their care. ORIGINALITY/VALUE: This is a discussion paper which raises more questions than answers and is timely with the focus on quality in healthcare, particularly now as Ireland prepares for a general election for a new government with healthcare a priority issue.

Medicine. The need for a global HIV vaccine enterprise.

A new collaborative model of research is needed to increase resources, to prioritize the R (ii) to increase the pace, reduce the overlap, and more systematically explore the elements of and delivery systems for vaccines; (iii) to use common standards for the prompt comparative testing of vaccine candidates; (iv) to expand resources for manufacturing vaccine candidates to speed their use in human trials; and (v) to increase the capacity for international clinical trials and to focus this effort toward quickly measuring the effectiveness of vaccine protection as prototype vaccine candidates are identified.