Public understanding and awareness of and response to monkeypox virus outbreak: A cross-sectional survey of the most affected communities in the United Kingdom during the 2022 public health emergency.

OBJECTIVES: Our objective was to examine the public response to public health and media messaging during the human monkeypox virus (MPXV) outbreak in the UK, focusing on at-risk communities. METHODS: A co-produced, cross-sectional survey was administered in June and July 2022 using community social media channels and the Grindr dating app. Basic descriptive statistics, logistic regression, and odds ratio p values are presented. RESULTS: Of 1932 survey respondents, 1750 identified as men, 88 as women, and 64 as gender non-conforming. Sexual identity was described as gay/lesbian/queer (80%), bisexual (12%), heterosexual (4%), and pansexual (2%); 39% were aged <40 years; 71% self-identified as White, 3% as Black, 8% as Asian, 2%as LatinX, and 11% as 'Mixed or Other' heritage groups. In total, 85% were employed and 79% had completed higher education. A total of 7% of respondents identified themselves as living with HIV. Overall, 34% reported limited understanding of public health information, 52% considered themselves at risk, 61% agreed that people with MPXV should isolate for 21 days, 49% reported they would first attend a sexual health clinic if symptomatic, 86% reported they would accept a vaccine, and 59% believed that MPXV originated from animals. The most trusted sources of information were healthcare professionals (37%), official health agencies (29%), and mainstream media (12%). CONCLUSIONS: Vaccine acceptability was very high, yet the understanding and acceptance of public health information varied. Social determinants of health inequalities already shaping the UK landscape risk were compounded in this new emergency. Engagement with structurally disadvantaged members of affected communities and better dissemination of public health messaging by trusted healthcare professionals are essential for the public health response.

Interrogating the World Bank's role in global health knowledge production, governance, and finance.

BACKGROUND: In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping 'global health' in the current era? MAIN BODY: As a group of historians, social scientists, and public health officials with experience studying the effects of the institution's investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank's position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank's influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda. CONCLUSIONS: As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank's financial and technical investments in the Global South.

Understanding PrEP Persistence: Provider and Patient Perspectives.

PrEP persistence, or PrEP use over time, has been shown to be short, with most PrEP users stopping within 6-12 months. Furthermore, those most vulnerable to HIV often use PrEP for shorter periods. This qualitative study explores patient, provider, and contextual factors that influence PrEP persistence. In interviews with 25 PrEP users and 18 PrEP providers in San Francisco's safety net clinics, we analyze the perceived benefits and difficulties of taking PrEP, including structural barriers. We identify different steps in receipt of PrEP care (clinic visits and lab tests, pharmacy interactions, and medication adherence), and describe barriers and facilitators for providers and patients at each step. Our findings suggest that drop-in visits, streamlined testing, standing orders for labs, and 90-day PrEP prescriptions are highly desirable for many PrEP users. Also important are the proactive provision of adherence support and counseling, and referrals for housing, substance use, and mental health services.

'Financial fallout' in the US biopharmaceutical industry: Maximizing shareholder value, regulatory capture, and the consequences for patients.

Patients are suffering the consequences of financialization - as shareholders demand high returns from pharmaceutical companies, pharmaceuticals squeeze profits out of top-selling products, and insurers charge higher premiums for limited coverage, the impact of financialization cascades across the value chain to compound the burden of cost for patients. This article offers a novel theoretical perspective and methods for understanding how "financial fallout" has impacted the pharmaceutical value chain, health systems, and patients. Financial fallout describes the cascade of consequences characteristic of and essential to industries reshaped by financialization. It characterizes how the effects of financialization have become so thoroughly engrained in industries and societies as to seem inevitable and how the consequences are also devastating, like the fallout that follows nuclear disasters. The research represented here examines how processes of financial fallout: 1) cascade across the pharmaceutical value chain from innovation to commercialization; 2) are enacted through 'regulatory capture' as regulations meant to safeguard the public from the exigencies of the market ultimately serve the interests of industry; and 3) have devastating consequences for patients who need access to life-saving therapies. The analysis is developed through the example of the market for monoclonal antibodies in the US, and the specific case of Keytruda - one of the top-selling monoclonal antibodies marketed for cancer therapy, which generated over 14 USD billion in revenue in 2020 and 17 billion in 2021. It traces how processes of financial fallout cascade down the value chain to impact health systems and compound the cost of care for patients. Financial fallout signals dire trends in providing health services and access to medicines. It diagnoses how our options for saving lives and improving health are overdetermined by and infused with the interests of financial capital.

COVID-19 and the political geography of racialisation: Ethnographic cases in San Francisco, Los Angeles and Detroit.

The COVID-19 pandemic has overwhelmed health systems around the globe, and intensified the lethality of social and political inequality. In the United States, where public health departments have been severely defunded, Black, Native, Latinx communities and those experiencing poverty in the country's largest cities are disproportionately infected and disproportionately dying. Based on our collective ethnographic work in three global cities in the U.S. (San Francisco, Los Angeles, and Detroit), we identify how the political geography of racialisation potentiated the COVID-19 crisis, exacerbating the social and economic toll of the pandemic for non-white communities, and undercut the public health response. Our analysis is specific to the current COVID19 crisis in the U.S, however the lessons from these cases are important for understanding and responding to the corrosive political processes that have entrenched inequality in pandemics around the world.

From advocacy to austerity: The new role of the U.S. public sector in HIV drug development and access.

Whereas advocacy was once the driving force for U.S. public support for HIV drug development and access, the nation's response to the global epidemic is now shaped by austerity. Extending past scholarship about the role of advocates and governments in support of drug development and access around the world, in this article I identify key shifts in U.S. public sector support over the past 40 years. During the early years of the AIDS epidemic, the U.S. government and civil society expedited drug development for antiretroviral therapy (ART). After the turn of the century, a new wave of advocacy expanded access for ART, including to low- and middle-income countries through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). On the heels of these accomplishments, advocates and governments set an ambitious agenda to 'End AIDS' by 2030. However, progress toward this goal has been limited by a new era of austerity, as demonstrated by U.S. government spending on HIV.

Missed opportunities to prevent HIV infections among pre-exposure prophylaxis users: a population-based mixed methods study, San Francisco, United States.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in-depth interviews with people who HIV seroconverted after using PrEP. METHODS: We identified individuals who initiated PrEP in an integrated safety-net public health system and performed in-depth chart review to determine person-time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention's Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in-depth interviews with those who seroconverted. RESULTS: Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person-years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5-fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on-demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP's benefit versus self-perceived risk; and entering a primary partnership. The individual who developed HIV using on-demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing. CONCLUSIONS: HIV incidence during gaps in PrEP use was nearly eight-fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non-daily PrEP may require additional education and support in the United States.