Change in Alcohol Use Based on Self-Report and a Quantitative Biomarker, Phosphatidylethanol, in People With HIV.

The timeline followback (TLFB) takes more resources to collect than the Alcohol Use Disorder Identification Test (AUDIT-C). We assessed agreement of TLFB and AUDIT-C with the biomarker phosphatidylethanol (PEth) and compared changes in TLFB and PEth among persons with HIV (PWH) using secondary data from randomized trials. We calculated operating characteristics and agreement between TLFB (> 1 and > 2 average drinks/day), AUDIT-C ≥ 4 and PEth ≥ 20 among 275 men with HIV. Median age was 57 years, 80% were African-American; and 17% white. Sixty-eight percent had PEth ≥ 20, 46% reported > 2 average drinks/day on TLFB, 61% reported > 1 average drinks/day on TLFB, and 72% had an AUDIT-C ≥ 4. Relative to PEth, sensitivity for AUDIT-C ≥ 4 was 84% (kappa = 0.36), and for TLFB > 1 average drink/day was 76% (kappa = 0.44). Change in alcohol use appeared greater using TLFB measures than PEth. Strategies to robustly assess alcohol use in PWH may require both self-report and biomarkers.

Lockdowns and low- and middle-income countries: building a feasible, effective, and ethical COVID-19 response strategy.

Lockdowns can be an effective pandemic response strategy that can buy much needed time to slow disease transmission and adequately scale up preventative, diagnostic, and treatment capacities. However, the broad restrictive measures typically associated with lockdowns, though effective, also comes at a cost - imposing significant social and economic burdens on individuals and societies, especially for those in low- and middle-income countries (LMICs). Like most high-income countries (HICs), many LMICs initially adopted broad lockdown strategies for COVID-19 in the first wave of the pandemic. While many HICs experiencing subsequent waves have returned to employing lockdown strategies until they can receive the first shipments of COVID-19 vaccine, many LMICs will likely have to wait much longer to get comparable access for their own citizens. In leaving LMICs vulnerable to subsequent waves for a longer period of time without vaccines, there is a risk LMICs will be tempted to re-impose lockdown measures in the meantime. In response to the urgent need for more policy development around the contextual challenges involved in employing such measures, we propose some strategies LMICs could adopt for safe and responsible lockdown entrance/exit or to avoid re-imposing coercive restrictive lockdown measures altogether.

Validating Self-Reported Unhealthy Alcohol Use With Phosphatidylethanol (PEth) Among Patients With HIV.

BACKGROUND: We sought to compare self-reported alcohol consumption using Timeline Followback (TLFB) to biomarker-based evidence of significant alcohol use (phosphatidylethanol [PEth] > 20 ng/ml). Using data from patients with HIV (PWH) entering a clinical trial, we asked whether TLFB could predict PEth > 20 ng/ml and assessed the magnitude of association between TLFB and PEth level. METHODS: We defined unhealthy alcohol use as any alcohol use in the presence of liver disease, at-risk drinking, or alcohol use disorder. Self-reported alcohol use obtained from TLFB interview was assessed as mean number of drinks/day and number of heavy drinking days over the past 21 days. Dried blood spot samples for PEth were collected at the interview. We used logistic regression to predict PEth > 20 ng/ml and Spearman correlation to quantify the association with PEth, both as a function of TLFB. RESULTS: Among 282 individuals (99% men) in the analytic sample, approximately two-thirds (69%) of individuals had PEth > 20 ng/ml. The proportion with PEth > 20 ng/ml increased with increasing levels of self-reported alcohol use; of the 190 patients with either at-risk drinking or alcohol use disorder based on self-report, 82% had PEth > 20 ng/ml. Discrimination was better with number of drinks per day than heavy drinking days (AUC: 0.80 [95% CI: 0.74 to 0.85] vs. 0.74 [95% CI: 0.68 to 0.80]). The number of drinks per day and PEth were significantly and positively correlated across all levels of alcohol use (Spearman's R ranged from 0.29 to 0.56, all p values < 0.01). CONCLUSIONS: In this sample of PWH entering a clinical trial, mean numbers of drinks per day discriminated individuals with evidence of significant alcohol use by PEth. PEth complements self-report to improve identification of self-reported unhealthy alcohol use among PWH.

Correction to: Factors Associated with Mood Disorder Diagnosis Among a Population Based Cohort of Men and Women Living With and Without HIV in British Columbia Between 1998 and 2012.

Using data from the Comparison of Outcomes and Service Utilization Trends (COAST) study we examined factors associated with mood disorder diagnosis (MDD) among people living with HIV (PLHIV) and HIV-negative individuals in British Columbia, Canada. MDD cases were identified between 1998 and 2012 using International Classification of Disease 9 and 10 codes. A total of 491,796 individuals were included and 1552 (23.7%) and 60,097 (12.4%) cases of MDD were identified among the HIV-positive and HIV-negative populations, respectively. Results showed HIV status was associated with greater odds of MDD among men and lower odds among women. Among PLHIV, MDD was significantly associated with: identifying as gay, bisexual or other men who have sex with men compared to heterosexuals; higher viral load; history of injection drug use; and concurrent anxiety, dysthymia, and substance use disorders. Findings highlight the need for comprehensive and holistic HIV and mental health care.

Factors Associated with Mood Disorder Diagnosis Among a Population Based Cohort of Men and Women Living With and Without HIV in British Columbia Between 1998 and 2012.

Using data from the Comparison of Outcomes and Service Utilization Trends (COAST) study we examined factors associated with mood disorder diagnosis (MDD) among people living with HIV (PLHIV) and HIV-negative individuals in British Columbia, Canada. MDD cases were identified between 1998 and 2012 using International Classification of Disease 9 and 10 codes. A total of 491,796 individuals were included and 1552 (23.7%) and 60,097 (12.4%) cases of MDD were identified among the HIV-positive and HIV-negative populations, respectively. Results showed HIV status was associated with greater odds of MDD among men and lower odds among women. Among PLHIV, MDD was significantly associated with: identifying as gay, bisexual or other men who have sex with men compared to heterosexuals; higher viral load; history of injection drug use; and concurrent anxiety, dysthymia, and substance use disorders. Findings highlight the need for comprehensive and holistic HIV and mental health care.

Trends in discharges from the HIV/AIDS ward at a tertiary Canadian Hospital from 2005 to 2014.

Advances in HIV therapies have transformed HIV infection into a manageable chronic disease. Accordingly, hospital admission trends among people living with HIV may have evolved over time. This study describes discharge diagnoses from the dedicated HIV/AIDS ward at St. Paul's Hospital in Vancouver, Canada. A retrospective database review of admissions to the HIV/AIDS ward between 1 July 2005 and 30 June 2014 was conducted. Primary discharge diagnoses were manually categorized by condition and reviewed by two physicians. Data were analysed in 12-month intervals. Trends were fitted using generalized estimating equations. A total of 1595 individuals with 3919 admissions were included. The median age was 46 years, 77.1% identified as male, 63.6% had a history of injection drug use (IDU) and 61.8% had a history of hepatitis C virus exposure. The most common reasons for admission included non-opportunistic respiratory tract infections (18.2%), cellulitis (7.3%), gastroenteritis (6.0%), endocarditis/bacteremia (4.9%) and bone/joint infections (3.5%). The proportion of admissions attributable to opportunistic infections declined from 16.2% in 2005 to 5.5% in 2014. Over this period, the proportion of individuals on antiretroviral therapy and with virologic suppression increased (odds ratio 1.19 [95% confidence interval 1.16, 1.23] and 1.22 [95% confidence interval 1.17, 1.26], respectively). These results demonstrate a decline in admissions related to opportunistic infections but increased admissions due to other infections among people living with HIV. Preventive and outpatient care for respiratory infections and complications of IDU may further improve health care outcomes and decrease hospital admissions in this setting.

Mortality among people living with HIV/AIDS with non-small-cell lung cancer in the modern HAART Era.

People living with HIV (PLWHA) with adequate access to modern combination antiretroviral therapy (cART) are living longer and experiencing reduced AIDS-related morbidity and mortality. However, increases in non-AIDS related conditions, such as certain cancers, have accompanied these therapeutic advances over time. As such, our study objective was to determine the impact of HIV on all-cause and lung cancer-specific mortality amongst PLWHA with diagnoses of non-small-cell lung cancer (NSCLC) and HIV-negative individuals with NSCLC. This analysis was inclusive of PLWHA on and off cART over the age of 19 years and a 10% comparison sample from the BC population ≥19 years, over a 13-year period (2000-2013). Kaplan-Meier estimates, Cox PH models, and competing risk analysis for all-cause and cause-specific mortality (respectively) compared PLWHA to HIV-negative individuals, controlling for age, gender, cancer stage, co-morbidities; and nadir CD4 count, viral load, and injection drug use for a HIV-positive specific analysis. We identified 71 PLWHA and 2463 HIV-negative individuals diagnosed with NSCLC between 2000 and 2013. PLWHA with NSCLC were diagnosed at a significantly younger age than HIV-negative individuals (median age 57 vs 71 years, p < 0.01). We found no significant difference in lung cancer-specific mortality. However, in multivariate analysis, HIV was associated with greater all-cause mortality (adjusted hazard ratio [aHR]:1.44; 95% confidence interval [CI]: 1.08-1.90), with median survival of 4 months for PLWHA, and 10 months for HIV-negative. Higher nadir CD4 count was protective against mortality (aHR: 0.33, 95% CI: 0.17-0.64) amongst PLWHA in multivariate analysis. Our analysis suggests that PLWHA in the modern cART era experience similar lung cancer survival outcomes compared to the general BC population with NSCLC. However, we also observed significantly higher all-cause mortality among PLWHA with NSCLC, which may warrant further inquiry into the role of HIV in exacerbating mortality among PLWHA with comorbidities and cancer.

The impact of HCV co-infection status on healthcare-related utilization among people living with HIV in British Columbia, Canada: a retrospective cohort study.

BACKGROUND: The burden of HCV among those living with HIV remains a major public health challenge. We aimed to characterize trends in healthcare-related visits (HRV) of people living with HIV (PLW-HIV) and those living with HIV and HCV (PLW-HIV/HCV), in British Columbia (BC), and to identify risk factors associated with the highest HRV rates over time. METHODS: Eligible individuals, recruited from the BC Seek and Treat for Optimal Prevention of HIV/AIDS population-based retrospective cohort (N = 3955), were ≥ 18 years old, first started combination antiretroviral therapy (ART) between 01/01/2000-31/12/2013, and were followed for ≥6 months until 31/12/2014. The main outcome was HRV rate. The main exposure was HIV/HCV co-infection status. We built a confounder non-linear mixed effects model, adjusting for several demographic and time-dependent factors. RESULTS: HRV rates have decreased since 2000 in both groups. The overall age-sex standardized HRV rate (per person-year) among PLW-HIV and PLW-HIV/HCV was 21.11 (95% CI 20.96-21.25) and 41.69 (95% CI 41.51-41.88), respectively. The excess in HRV in the co-infected group was associated with late presentation for ART, history of injection drug use, sub-optimal ART adherence and a higher number of comorbidities. The adjusted HRV rate ratio for PLW-HIV/HCV in comparison to PLW-HIV was 1.18 (95% CI 1.13-1.24). CONCLUSIONS: Although HRV rates have decreased over time in both groups, PLW-HIV/HCV had 18% higher HRV than those only living with HIV. Our results highlight several modifiable risk factors that could be targeted as potential means to minimize the disease burden of this population and of the healthcare system.

Changes in mortality rates and causes of death in a population-based cohort of persons living with and without HIV from 1996 to 2012.

BACKGROUND: Non-HIV/AIDS-related diseases are gaining prominence as important causes of morbidity and mortality among people living with HIV. The purpose of this study was to characterize and compare changes over time in mortality rates and causes of death among a population-based cohort of persons living with and without HIV in British Columbia (BC), Canada. METHODS: We analysed data from the Comparative Outcomes And Service Utilization Trends (COAST) study; a retrospective population-based study created via linkage between the BC Centre for Excellence in HIV/AIDS and Population Data BC, and containing data for HIV-infected individuals and the general population of BC, respectively. Our analysis included all known HIV-infected adults (≥ 20 years) in BC and a random 10% sample of uninfected BC adults followed from 1996 to 2012. Deaths were identified through Population Data BC - which contains information on all registered deaths in BC (BC Vital Statistics Agency dataset) and classified into cause of death categories using International Classification of Diseases (ICD) 9/10 codes. Age-standardized mortality rates (ASMR) and mortality rate ratios were calculated. Trend test were performed. RESULTS: 3401 (25%), and 47,647 (9%) individuals died during the 5,620,150 person-years of follow-up among 13,729 HIV-infected and 510,313 uninfected individuals, respectively. All-cause and cause-specific mortality rates were consistently higher among HIV-infected compared to HIV-negative individuals, except for neurological disorders. All-cause ASMR decreased from 126.75 (95% CI: 84.92-168.57) per 1000 population in 1996 to 21.29 (95% CI: 17.79-24.79) in 2011-2012 (83% decline; p < 0.001 for trend), compared to a change from 7.97 (95% CI: 7.61-8.33) to 6.87 (95% CI: 6.70-7.04) among uninfected individuals (14% decline; p < 0.001). Mortality rates from HIV/AIDS-related causes decreased by 94% from 103.85 per 1000 population in 1996 to 6.72 by the 2011-2012 era (p < 0.001). Significant ASMR reductions were also observed for hepatic/liver disease and drug abuse/overdose deaths. ASMRs for neurological disorders increased significantly over time. Non-AIDS-defining cancers are currently the leading non-HIV/AIDS-related cause of death in both HIV-infected and uninfected individuals. CONCLUSIONS: Despite the significant mortality rate reductions observed among HIV-infected individuals from 1996 to 2012, they still have excess mortality risk compared to uninfected individuals. Additional efforts are needed to promote effective risk factor management and appropriate screening measures among people living with HIV.

The economic burden of prematurity in Canada.

BACKGROUND: Preterm birth is a major risk factor for morbidity and mortality among infants worldwide, and imposes considerable burden on health, education and social services, as well as on families and caregivers. Morbidity and mortality resulting from preterm birth is highest among early (< 28 weeks gestational age) and moderate (28-32 weeks) preterm infants, relative to late preterm infants (33-36 weeks). However, substantial societal burden is associated with late prematurity due to the larger number of late preterm infants relative to early and moderate preterm infants. METHODS: The aim in this study was to characterize the burden of premature birth in Canada for early, moderate, and late premature infants, including resource utilization, direct medical costs, parental out-of-pocket costs, education costs, and mortality, using a validated and published decision model from the UK, and adapting it to a Canadian setting based on analysis of administrative, population-based data from Québec. RESULTS: Two-year survival was estimated at 56.0% for early preterm infants, 92.8% for moderate preterm infants, and 98.4% for late preterm infants. Per infant resource utilization consistently decreased with age. For moderately preterm infants, hospital days ranged from 1.6 at age two to 0.09 at age ten. Cost per infant over the first ten years of life was estimated to be $67,467 for early preterm infants, $52,796 for moderate preterm infants, and $10,010 for late preterm infants. Based on population sizes this corresponds to total national costs of $123.3 million for early preterm infants, $255.6 million for moderate preterm infants, $208.2 million for late preterm infants, and $587.1 million for all infants. CONCLUSION: Premature birth results in significant infant morbidity, mortality, healthcare utilization and costs in Canada. A comprehensive decision-model based on analysis of a Canadian population-based administrative data source suggested that the greatest national-level burden is associated with moderate preterm infants due to both a large cost per infant and population size while the highest individual-level burden is in early preterm infants and the largest total population size is in late preterm infants. Although the highest medical costs are incurred during the neonatal period, greater resource utilization and costs extend into childhood.

Prevalence and predictors of infant and young child feeding practices in sub-Saharan Africa.

BACKGROUND: This study assessed the prevalence and predictors of minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) in sub-Saharan Africa (SSA). METHODS: A sample of 87 672 mother-child pairs from the 2010-2020 Demographic and Health Surveys of 32 countries in SSA was used. Multilevel binary logistic regression analysis was carried out to examine the predictors of MDD, MMF, and MAD. Percentages and adjusted odds ratios (aORs) with a 95% confidence interval (CI) were used to present the findings. RESULTS: The prevalence of MDD, MMF, and MAD in SSA were 25.3% (95% CI 21.7 to 28.9), 41.2% (95% CI 38.8 to 43.6), and 13.3% (95% CI 11.6 to 15.0), respectively. Children aged 18-23 months were more likely to have MDD and MAD but less likely to have MMF. Children of mothers with higher education levels were more likely to have MDD, MMF, and MAD. Children who were delivered in a health facility were more likely to have MDD and MAD but less likely to have MMF. CONCLUSIONS: Following the poor state of complementary feeding practices for infants and young children, the study recommends that regional and national policies on food and nutrition security and maternal and child nutrition and health should follow the internationally recommended guidelines in promoting, protecting, and supporting age-appropriate complementary foods and feeding practices for infants and young children.

Health trends in Canada 1990-2019: An analysis for the Global Burden of Disease Study.

OBJECTIVE: Monitoring trends in key population health indicators is important for informing health policies. The aim of this study was to examine population health trends in Canada over the past 30 years in relation to other countries. METHODS: We used data on disability-adjusted life years (DALYs), years of life lost (YLL), years lived with disability, life expectancy (LE), and child mortality for Canada and other countries between 1990 and 2019 provided by the Global Burden of Disease Study. RESULTS: Life expectancy, age-standardized YLL, and age-standardized DALYs all improved in Canada between 1990 and 2019, although the rate of improvement has leveled off since 2011. The top five causes of all-age DALYs in Canada in 2019 were neoplasms, cardiovascular diseases, musculoskeletal disorders, neurological disorders, and mental disorders. The greatest increases in all-age DALYs since 1990 were observed for substance use, diabetes and chronic kidney disease, and sense organ disorders. Age-standardized DALYs declined for most conditions, except for substance use, diabetes and chronic kidney disease, and musculoskeletal disorders, which increased by 94.6%, 14.6%, and 7.3% respectively since 1990. Canada's world ranking for age-standardized DALYs declined from 9th place in 1990 to 24th in 2019. CONCLUSION: Canadians are healthier today than in 1990, but progress has slowed in Canada in recent years in comparison with other high-income countries. The growing burden of substance abuse, diabetes/chronic kidney disease, and musculoskeletal diseases will require continued action to improve population health.

RéSUMé: OBJECTIF: La surveillance des tendances des indicateurs clés de la santé de la population est importante pour éclairer les politiques de santé. Dans cette étude, nous avons examiné les tendances de la santé de la population au Canada au cours des 30 dernières années par rapport à d'autres pays. MéTHODES: Nous avons utilisé des données sur les années de vie ajustées en fonction de l'incapacité (DALY), les années de vie perdues (YLL), les années vécues avec un handicap, l'espérance de vie (LE) et la mortalité infantile pour le Canada et d'autres pays entre 1990 et 2019, fournies par l'Étude mondiale sur le fardeau de la maladie. RéSULTATS: L'espérance de vie, les YLL ajustées selon l'âge et les DALY ajustées selon l'âge ont tous connu une amélioration au Canada entre 1990 et 2019, bien que le taux d'amélioration se soit stabilisé depuis 2011. Les cinq principales causes des DALY pour tous les âges au Canada en 2019 étaient les néoplasmes, les maladies cardiovasculaires, les affections musculosquelettiques, les affections neurologiques et les troubles mentaux. Les plus fortes augmentations des DALY pour tous les âges depuis 1990 ont été observées pour l'usage de substances, le diabète et les maladies rénales chroniques, ainsi que les troubles des organes sensoriels. Les DALY ajustées selon l'âge ont diminué pour la plupart des conditions, à l'exception de l'usage de substances, du diabète et des maladies rénales chroniques, ainsi que des troubles musculosquelettiques, qui ont augmenté de 94,6 %, 14,6 % et 7,3 % respectivement depuis 1990. Le classement mondial du Canada pour les DALY ajustées selon l'âge est diminué de la 9ième place en 1990 à la 24ième place en 2019. CONCLUSION: Les Canadiens sont en meilleure santé aujourd'hui qu'en 1990, mais les progrès se sont ralentis ces dernières années par rapport à d'autres pays à revenu élevé. La croissance du fardeau lié à l'abus de substances, au diabète/maladies rénales chroniques et aux affections musculosquelettiques exigera des actions continues pour améliorer la santé de la population.

Intensive statin therapy compared with moderate dosing for prevention of cardiovascular events: a meta-analysis of >40 000 patients.

AIMS: Statin therapy is associated with important benefits for patients at risk of, and with, established cardiovascular disease. There is widespread interest in whether intensive dosing of statins yields larger treatment effects. We aimed to determine if intensive dosing is clinically important using a meta-analysis of randomized clinical trials (RCTs). METHODS: We conducted comprehensive searches of electronic databases from inception to December 2010. We included any RCT evaluating a larger dose with a clinically common dose. Two reviewers independently extracted data, in duplicate. We performed random-effects meta-analysis and a trial sequential analysis. RESULTS: We identified 10 RCTs enrolling a total of 41 778 participants. Trials followed patients for a mean of 2.5 years. We did not find statistically significant effects on all-cause mortality [relative risk (RR) 0.92, 95% confidence interval (CI), 0.83-1.03, P = 0.14, I(2) = 38%] or cardiovascular disease (CVD) deaths (RR 0.89, 95% CI, 0.78-1.01, P = 0.07, I(2) = 34%). When we pooled the composite endpoint of coronary heart disease (CHD) death plus non-fatal myocardial infarction (MI), we found a significant protective effect of intensive statin dosing (RR 0.90, 95% CI, 0.84-0.96, P ≤ 0.0001, I(2) = 0%). We also found a significant effect on non-fatal MIs (RR 0.82, 95% CI, 0.76-0.89, P ≤ 0.0001, I(2) = 0%) and a significant reduction in the composite of fatal and non-fatal strokes (excluding transient ischaemic attacks) reported in 10 RCTs (RR 0.86, 95% CI, 0.77-0.96, P = 0.006, I(2) = 0%). A subgroup analysis of three trials examining acute coronary syndrome patients found significant effects on all-cause (RR 0.75, 95% CI, 0.61-0.91, P = 0.005, I(2) = 0%) and CVD mortality (RR 0.74, 95% CI, 0.59-0.94, P = 0.013, I(2) = 0%) with intensive dosing. Applying an analysis of optimal information size on the primary analysis, we found that the evidence for CHD death plus non-fatal MIs is conclusive. The evidence for CVD deaths alone is not yet conclusive. CONCLUSIONS: Available evidence suggests that intensive statin therapy reduces the risk of non-fatal events and may have a role in reducing mortality.

Dietary Diversity and Undernutrition in Children Aged 6-23 Months in Sub-Saharan Africa.

Dietary diversity plays a major role in the health status of children. However, evidence on its crucial role on children's health status remains inconclusive in sub-Saharan Africa (SSA). In this study, we examined the association between dietary diversity and undernutrition among children aged 6-23 months in SSA. We pooled data from the most recent Demographic and Health Surveys of 32 countries in SSA from 2010 to 2020. A sample of 48,968 mother-child pairs of children within the ages of 6-23 months and mothers aged 15-49 years were included in this study. Multilevel logistic regression analysis was carried out to examine the association between dietary diversity and stunting, wasting, and underweight. The results were presented as crude odds ratios (cOR) and adjusted odds ratios (aOR) with their 95% confidence intervals. Statistical significance was set at p < 0.05. The overall prevalence of minimum dietary diversity was 25.1%, with South Africa recording the highest prevalence (43.9%) and Burkina Faso recording the lowest prevalence (5.6%). The highest prevalence of stunting was recorded by Burundi (51.8%) while the lowest prevalence was found in Ghana (13.6%), with an overall regional prevalence of 28.6%. For wasting, prevalence from all countries was found to be 9.4%. South Africa recorded the lowest prevalence of wasting (2.1%) while Niger recorded the highest prevalence (27.3%). Lastly, the prevalence of underweight ranged from 5.3% in South Africa to 41.8% in Niger, with an all-country prevalence of 16.4%. Children who had adequate minimum dietary diversity had 12% less likelihood of being stunted (aOR = 0.88, 95% CI = 0.83, 0.94), compared to those who had inadequate minimum dietary diversity. Having an adequate minimum dietary diversity significantly lowered the risk of underweight among children by 17% (aOR = 0.83, 95% CI = 0.77, 0.91). Having an adequate minimum dietary diversity was associated with 13% reduced odds of wasting among children (aOR = 0.87, 95% CI = 0.78, 0.97), compared to those who had inadequate minimum dietary diversity. This study highlights the significant association between minimum dietary diversity and stunting, wasting, and underweight among 6-23 month-old children in SSA. There is an urgent need for additional nutrition-specific interventions and strengthening of existing interventions aimed at improving infant and young child feeding practices, including complementary feeding practices among children aged 6-23 months in the 32 countries in SSA. Such interventions should focus more on countries where the prevalence of adequate minimum dietary diversity was low and undernutrition was high.

Rethinking the Central Role of Equity in the Global Governance of Pandemic Response.

Our initial response to COVID-19 has been plagued by a series of failures-many of which have extended inequity within and across populations, especially in low- and middle-income countries. The global health governance of pandemic preparedness and response needs to move further away from the advocacy of a one-size-fits-all approach that tends to prioritize the interests of high-income countries towards a context-sensitive approach that gives equity a central role in guiding our pandemic preparedness and response strategies.

Providing antiretroviral care in conflict settings.

There has been an historic expectation that delivering combination antiretroviral therapy (cART) to populations affected by violent conflict is untenable due to population movement and separation of drug supplies. There is now emerging evidence that cART provision can be successful in these populations. Using examples from Médecins Sans Frontières experience in a variety of African settings and also local nongovernmental organizations' experiences in northern Uganda, we examine novel approaches that have ensured retention in programs and adequate adherence. Emerging guidelines from United Nations bodies now support the expansion of cART in settings of conflict.

Stroke and Systemic Thromboembolism Prevention in People Living With Human Immunodeficiency Virus With Atrial Fibrillation: A Review of Its Implications for Clinical Practice.

In the last few decades, types of diseases affecting people living with human immunodeficiency virus (PLHIV) have shifted as the population ages, with cardiovascular disease becoming a leading cause of death in this population. Atrial fibrillation (AF) is an increasingly common arrhythmia both in the general population and in PLHIV, with an estimated prevalence of 2% to 3% among PLHIV. Prevention of stroke and systemic thromboembolism (SSE) with antithrombotic therapy is a cornerstone of AF treatment and substantially decreases AF-related morbidity and mortality. Although updated guidelines extensively discuss this issue, they do not address the peculiarities of PLHIV. The role of human immunodeficiency virus (HIV) infection as an independent factor for SSE in individuals with AF and whether the presence of HIV should alter the threshold for SSE thromboprophylaxis are unknown. Nevertheless, a growing body of evidence describes the increasing burden of comorbidities such as hypertension and stroke in PLHIV, which predispose them to AF and SSE. In the absence of HIV-specific AF guidelines, PLHIV with AF should be comprehensively assessed for their risk of SSE and bleeding using commonly available scores despite them having been primarily validated in the non-HIV population. Both vitamin K antagonists and direct oral anticoagulants can be used in PLHIV. Addressing HIV-related comorbidities and potential drug-drug interactions with antiretrovirals is crucial to prevent SSE and reduce adverse reactions of oral anticoagulants. This review summarizes the current guidelines for SSE prevention in patients with AF and describes key considerations for their implementation among PLHIV receiving antiretroviral therapy.

Au cours des dernières décennies, les types de maladies qui touchent les personnes vivant avec le virus de l'immunodéficience humaine (PVVIH) ont évolué à mesure que la population vieillit. Les maladies cardiovasculaires deviennent ainsi les principales causes de décès dans cette population. La fibrillation auriculaire (FA) est une arythmie de plus en plus fréquente dans la population générale et chez les PVVIH. On estime que sa prévalence est de 2 % à 3 % chez les PVVIH. La prévention de l'accident vasculaire cérébral (AVC) et de la thrombo-embolie systémique (TES) par un traitement antithrombotique constitue la pierre angulaire du traitement de la FA et diminue considérablement la morbidité et la mortalité liées à la FA. Bien que les lignes directrices actualisées traitent en profondeur de cette question, elles ne portent pas sur les particularités des PVVIH. On ignore si l'infection par le virus de l'immunodéficience humaine (VIH) est un facteur indépendant de la TES chez les individus atteints de FA et si la présence du VIH devrait contribuer à modifier le seuil de thromboprophylaxie de la TES. Néanmoins, de plus en plus de données probantes décrivent le fardeau accru des comorbidités comme l'hypertension et l'AVC chez les PVVIH, qui les prédisposent à la FA et à la TES. En l'absence de lignes directrices en matière de FA lors de VIH, on devrait réaliser une évaluation exhaustive chez les PVVIH atteints de FA à l'aide des scores couramment disponibles même s'ils n'avaient pas d'abord été validés auprès de la population non atteinte du VIH. Les antagonistes de la vitamine K et les anticoagulants oraux directs peuvent être utilisés chez les PVVIH. Il est primordial de se pencher sur les comorbidités liées au VIH et sur les interactions médicamenteuses potentielles avec les antirétroviraux pour prévenir la TES et réduire les effets indésirables des anticoagulants oraux. La présente revue résume les lignes directrices actuelles en matière de prévention de la TES chez les patients atteints de FA et décrit les principales considérations quant à leur mise en œuvre auprès des PVVIH qui reçoivent un traitement antirétroviral.

Incidence of select chronic comorbidities among a population-based cohort of HIV-positive individuals receiving highly active antiretroviral therapy.

Objective: To characterize the incidence of select chronic comorbidities in the era of modern (pre-integrase-inhibitor) highly active antiretroviral therapy (HAART) in British Columbia, Canada. Methods: We used data from the Comparative Outcomes And Service Utilization Trends (COAST) study, a population-based cohort study of people living with HIV (PLWH), to determine incidence rates of six key chronic diseases among PLWH receiving HAART in BC from 2000 to 2012. The selected diseases included cardiovascular disease (CVD), diabetes mellitus (DM), hypertension (HTN), asthma/chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and chronic liver disease (CLD) defined using ICD-9 and -10 codes. Disease incidence was determined by number of new cases per year. We used Poisson regression to measure trends in incidence rates. Results: The study sample (n = 10,210) was predominantly male (83%), white (72%) and younger than 50 years of age at HAART initiation (88%). Incidence rates of HTN per 1000 person-years (PY) increased significantly between 2000 and 2012, after adjusting for age, sex, baseline-weighted Charlson Comorbidity Index, CD4 cell count and viral load (p < .001); incidence rates of CKD and CLD decreased significantly over time (p < .001). Unadjusted incidence rates of DM increased over time (p < .01), but remained stable in the adjusted model. Incidence rate patterns for CVD and COPD/asthma were stable over the study period. Conclusions: Population-level increases in incidence rates for HTN, and decreases for CLD and CKD, were observed among PLWH on modern (pre-integrase-inhibitor) HAART from 2000 to 2012. Overall, the increasing incidence of several of these chronic comorbidities in our study suggests that further efforts are needed to maximize the potential for healthy aging among PLWH receiving modern (pre-integrase-inhibitor) HAART.

Risk of myocardial infarction among people living with HIV: an updated systematic review and meta-analysis.

OBJECTIVE: Cardiovascular disease (CVD) is one of the leading non-AIDS-defining causes of death among HIV-positive (HIV+) individuals. However, the evidence surrounding specific components of CVD risk remains inconclusive. We conducted a systematic review and meta-analysis to synthesise the available evidence and establish the risk of myocardial infarction (MI) among HIV+ compared with uninfected individuals. We also examined MI risk within subgroups of HIV+ individuals according to exposure to combination antiretroviral therapy (ART), ART class/regimen, CD4 cell count and plasma viral load (pVL) levels. DESIGN: Systematic review and meta-analysis. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews until 18 July 2018. Furthermore, we scanned recent HIV conference abstracts (CROI, IAS/AIDS) and bibliographies of relevant articles. ELIGIBILITY CRITERIA: Original studies published after December 1999 and reporting comparative data relating to the rate of MI among HIV+ individuals were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers working in duplicate, independently extracted data. Data were pooled using random-effects meta-analysis and reported as relative risk (RR) with 95% CI. RESULTS: Thirty-two of the 8130 identified records were included in the review. The pooled RR suggests that HIV+ individuals have a greater risk of MI compared with uninfected individuals (RR: 1.73; 95% CI 1.44 to 2.08). Depending on risk stratification, there was moderate variation according to ART uptake (RR, ART-treated=1.80; 95% CI 1.17 to 2.77; ART-untreated HIV+ individuals: 1.25; 95% CI 0.93 to 1.67, both relative to uninfected individuals). We found low CD4 count, high pVL and certain ART characteristics including cumulative ART exposure, any/cumulative use of protease inhibitors as a class, and exposure to specific ART drugs (eg, abacavir) to be importantly associated with a greater MI risk. CONCLUSIONS: Our results indicate that HIV infection, low CD4, high pVL, cumulative ART use in general including certain exposure to specific ART class/regimen are associated with increased risk of MI. The association with cumulative ART may be an index of the duration of HIV infection with its attendant inflammation, and not entirely the effect of cumulative exposure to ART per se. PROSPERO REGISTRATION NUMBER: CRD42014012977.