[The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in healthA iniciativa "Todas as mulheres, todas as crianças" oferece apoio aos países da América Latina e Caribe para reduzir as desigualdades sociais de saúde]. / La iniciativa Todas las Mujeres Todos los Niños brinda apoyo a los países de América Latina y el Caribe para reducir las desigualdades sociales en la salud.

Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women's, Children's and Adolescents' Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC's three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

A iniciativa "Todas as mulheres, todas as crianças da América Latina e Caribe" (EWEC-LAC, na sigla em inglês) foi criada em 2017 como um mecanismo interinstitucional regional. Coordena a implementação regional da Estratégia Mundial para a Saúde da Mulher, da Criança e do Adolescente 2016-2030 na América Latina e Caribe (ALC), incluindo sua adaptação a necessidades específicas da região, para acabar com as mortes evitáveis, garantir a saúde e o bem-estar e expandir ambientes propícios para a saúde e o bem-estar de mulheres, crianças e adolescentes. Para promover o alcance equitativo desses objetivos, os três grupos de trabalho da EWEC-LAC apoiam coletivamente os países da ALC com a medição e o monitoramento das desigualdades sociais de saúde, a promoção de sua redução, e o delineamento e a implementação de estratégias, políticas e intervenções voltadas para a equidade. Esse apoio para fechar as lacunas atuais assegura que ninguém seja deixado para trás. Os membros da iniciativa EWEC-LAC incluem UNFPA, OPAS, ONU Mulheres, UNAIDS, UNICEF, Banco Mundial, Banco Interamericano de Desenvolvimento, USAID, Aliança Neonatal Regional para ALC e Grupo de Trabalho Regional para a Redução da Mortalidade Materna. Até o momento, a EWEC-LAC desenvolveu e compilou ferramentas e recursos inovadores e começou a colaborar com os países para utilizá-los a fim de reduzir as lacunas de equidade. Isso inclui uma estrutura de medição das desigualdades sociais de saúde, ferramentas de promoção de dados (como um painel de dados para visualizar tendências nas desigualdades sociais de saúde), uma metodologia para estabelecer metas para reduzir as desigualdades e um compêndio de ferramentas e métodos para identificar e abordar as desigualdades sociais de saúde. A EWEC-LAC trabalhou na região para enfatizar a importância de reconhecer essas desigualdades nos níveis social e político, e defendeu sua redução. A atenção para o fechamento das lacunas de equidade na saúde é cada vez mais crítica frente à pandemia de COVID-19, que exacerbou as vulnerabilidades existentes. Sistemas de saúde mais equitativos estarão mais bem preparados para lidar com futuras crises de saúde.

La iniciativa Todas las Mujeres Todos los Niños brinda apoyo a los países de América Latina y el Caribe para reducir las desigualdades sociales en la salud

[RESUMEN]. La iniciativa Todas las Mujeres Todos los Niños América Latina y el Caribe (EWEC-LAC, por su sigla en inglés) se estableció en el 2017 como un mecanismo interinstitucional regional. Coordina la implementación regional de la Estrategia Mundial para la Salud de la Mujer, el Niño y el Adolescente 2016-2030 en América Latina y el Caribe (ALC), lo que incluye su adaptación a necesidades específicas de la Región, para poner fin a las muertes evitables, garantizar la salud y el bienestar, y ampliar los entornos propicios para la salud y el bienestar de mujeres, niños y adolescentes. Para promover el logro equitativo de estos objetivos, los tres grupos de trabajo de EWEC-LAC apoyan colectivamente a los países de ALC en la medición y el monitoreo de las desigualdades sociales en la salud, la promoción de la disminución de estas y el diseño e implementación de estrategias, políticas e intervenciones orientadas a la equidad. Este apoyo para cerrar las brechas actuales asegura que nadie se quede atrás. Los miembros de la iniciativa EWEC-LAC incluyen al UNFPA, la OPS, ONU-Mujeres, ONUSIDA, UNICEF, el Banco Mundial, el Banco Interamericano de Desarrollo, USAID, la Alianza Regional Neonatal para ALC y el Grupo de Trabajo Regional para la Reducción de la Mortalidad Materna. A la fecha, EWEC-LAC ha desarrollado y recopilado herramientas y recursos innovadores, y ha comenzado a colaborar con los países para utilizarlos a fin de reducir las brechas en la equidad. Estos incluyen un marco de medición de las desigualdades sociales en la salud, herramientas de promoción de datos, como un tablero de datos para visualizar tendencias en las desigualdades sociales en la salud, una metodología para establecer metas en la disminución de las desigualdades, y un compendio de herramientas y métodos para identificar y abordar las desigualdades sociales en la salud. EWEC-LAC ha trabajado en la Región para enfatizar la importancia de reconocer estas desigualdades a los niveles sociales y políticos, y ha abogado por su disminución. La atención para cerrar las brechas de equidad en la salud es cada vez más crítica frente a la pandemia de COVID-19, que ha agudizado las vulnerabilidades existentes. Los sistemas de salud más equitativos estarán mejor preparados para hacer frente a futuras crisis de salud.

[ABSTRACT]. Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) was established in 2017 as a regio- nal inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women’s, Children’s and Adolescents’ Health in Latin America and the Caribbean (LAC), including adapta- tion to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC’s three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recogni- zing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

[RESUMO]. A iniciativa “Todas as mulheres, todas as crianças da América Latina e Caribe” (EWEC-LAC, na sigla em inglês) foi criada em 2017 como um mecanismo interinstitucional regional. Coordena a implementação regio- nal da Estratégia Mundial para a Saúde da Mulher, da Criança e do Adolescente 2016-2030 na América Latina e Caribe (ALC), incluindo sua adaptação a necessidades específicas da região, para acabar com as mortes evitáveis, garantir a saúde e o bem-estar e expandir ambientes propícios para a saúde e o bem-estar de mulheres, crianças e adolescentes. Para promover o alcance equitativo desses objetivos, os três grupos de trabalho da EWEC-LAC apoiam coletivamente os países da ALC com a medição e o monitoramento das desigualdades sociais de saúde, a promoção de sua redução, e o delineamento e a implementação de estra- tégias, políticas e intervenções voltadas para a equidade. Esse apoio para fechar as lacunas atuais assegura que ninguém seja deixado para trás. Os membros da iniciativa EWEC-LAC incluem UNFPA, OPAS, ONU Mulheres, UNAIDS, UNICEF, Banco Mundial, Banco Interamericano de Desenvolvimento, USAID, Aliança Neonatal Regional para ALC e Grupo de Trabalho Regional para a Redução da Mortalidade Materna. Até o momento, a EWEC-LAC desenvolveu e compilou ferramentas e recursos inovadores e começou a colaborar com os países para utilizá-los a fim de reduzir as lacunas de equidade. Isso inclui uma estrutura de medição das desigualdades sociais de saúde, ferramentas de promoção de dados (como um painel de dados para visualizar tendências nas desigualdades sociais de saúde), uma metodologia para estabelecer metas para reduzir as desigualdades e um compêndio de ferramentas e métodos para identificar e abordar as des- igualdades sociais de saúde. A EWEC-LAC trabalhou na região para enfatizar a importância de reconhecer essas desigualdades nos níveis social e político, e defendeu sua redução. A atenção para o fechamento das lacunas de equidade na saúde é cada vez mais crítica frente à pandemia de COVID-19, que exacerbou as vulnerabilidades existentes. Sistemas de saúde mais equitativos estarão mais bem preparados para lidar com futuras crises de saúde.

The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in health.

The Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) initiative was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women's, Children's and Adolescents' Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC's three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

RESUMEN: La iniciativa Todas las mujeres, Todos los niños América Latina y el Caribe (EWEC-LAC, por su sigla en inglés) se estableció en 2017 como un mecanismo interinstitucional regional. Coordina la implementación regional de la Estrategia Mundial para la Salud de la Mujer, el Niño y el Adolescente en América Latina y el Caribe (ALC), incluyendo la adaptación a necesidades específicas de la región, para poner fin a muertes evitables, garantizar la salud y el bienestar y ampliar entornos propicios para la salud y el bienestar de mujeres, niños, niñas y adolescentes. Para promover el logro equitativo de estos objetivos, los tres grupos de trabajo de EWEC-LAC colectivamente apoyan a los países de ALC en la medición y monitoreo de las desigualdades sociales en salud, la abogacía por la disminución de estas y el diseño e implementación de estrategias, políticas e intervenciones orientadas a la equidad. Este apoyo para cerrar brechas actuales asegura que nadie se quede atrás. Miembros de EWEC-LAC incluyen FPNU, OPS, ONU Mujeres, ONUSIDA, UNICEF, el Banco Mundial, el Banco Interamericano de Desarrollo, USAID, la Alianza Regional Neonatal para ALC, y el Grupo de Trabajo Regional para la Reducción de la Mortalidad Materna. A la fecha, EWEC-LAC ha desarrollado y recopilado herramientas y recursos innovadores y ha comenzado a colaborar con los países para utilizarlos a fin de reducir brechas de equidad. Estos incluyen un marco de medición de desigualdades sociales en salud, herramientas de promoción de datos incluyendo un tablero de datos para visualizar tendencias en desigualdades sociales en salud, una metodología para establecer metas en la disminución de las desigualdades y un compendio de herramientas y métodos para identificar y abordar las desigualdades sociales en salud. EWEC-LAC ha trabajado en la región para enfatizar la importancia de reconocer estas desigualdades a niveles sociales y políticos, y ha abogado por la disminución de éstas. La atención para cerrar las brechas de equidad en salud es cada vez más crítica frente a la pandemia de COVID-19, que ha agudizado las vulnerabilidades existentes. Sistemas de salud más equitativos estarán mejor preparados para hacer frente a futuras crisis de salud.

La iniciativa Todas las Mujeres Todos los Niños brinda apoyo a los países de América Latina y el Caribe para reducir las desigualdades sociales en la salud / The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in health / A iniciativa "Todas as mulheres, todas as crianças" oferece apoio aos países da América Latina e Caribe para reduzir as desigualdades sociais de saúde

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ABSTRACT Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women's, Children's and Adolescents' Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC's three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

RESUMO A iniciativa "Todas as mulheres, todas as crianças da América Latina e Caribe" (EWEC-LAC, na sigla em inglês) foi criada em 2017 como um mecanismo interinstitucional regional. Coordena a implementação regional da Estratégia Mundial para a Saúde da Mulher, da Criança e do Adolescente 2016-2030 na América Latina e Caribe (ALC), incluindo sua adaptação a necessidades específicas da região, para acabar com as mortes evitáveis, garantir a saúde e o bem-estar e expandir ambientes propícios para a saúde e o bem-estar de mulheres, crianças e adolescentes. Para promover o alcance equitativo desses objetivos, os três grupos de trabalho da EWEC-LAC apoiam coletivamente os países da ALC com a medição e o monitoramento das desigualdades sociais de saúde, a promoção de sua redução, e o delineamento e a implementação de estratégias, políticas e intervenções voltadas para a equidade. Esse apoio para fechar as lacunas atuais assegura que ninguém seja deixado para trás. Os membros da iniciativa EWEC-LAC incluem UNFPA, OPAS, ONU Mulheres, UNAIDS, UNICEF, Banco Mundial, Banco Interamericano de Desenvolvimento, USAID, Aliança Neonatal Regional para ALC e Grupo de Trabalho Regional para a Redução da Mortalidade Materna. Até o momento, a EWEC-LAC desenvolveu e compilou ferramentas e recursos inovadores e começou a colaborar com os países para utilizá-los a fim de reduzir as lacunas de equidade. Isso inclui uma estrutura de medição das desigualdades sociais de saúde, ferramentas de promoção de dados (como um painel de dados para visualizar tendências nas desigualdades sociais de saúde), uma metodologia para estabelecer metas para reduzir as desigualdades e um compêndio de ferramentas e métodos para identificar e abordar as desigualdades sociais de saúde. A EWEC-LAC trabalhou na região para enfatizar a importância de reconhecer essas desigualdades nos níveis social e político, e defendeu sua redução. A atenção para o fechamento das lacunas de equidade na saúde é cada vez mais crítica frente à pandemia de COVID-19, que exacerbou as vulnerabilidades existentes. Sistemas de saúde mais equitativos estarão mais bem preparados para lidar com futuras crises de saúde.

Psychosocial approaches to violence and aggression: contextually anchored and trauma-informed interventions.

Psychosocial interventions are part of the complex understanding and treatment of violent behavior in our state mental health hospitals. A comprehensive assessment of violence and aggression includes attention to all 3 domains of prevention and assessment (primary-institutional, secondary-structural, and tertiary-direct). Trauma experiences and their consequences may include behavioral violence and aggression. The authors' premise is that trauma is a universal component in the individual assessment of violent behavior. Therapeutic interventions must include a trauma-informed formulation to be effective. Organizational commitment to trauma-informed, person-centered, recovery-oriented (TPR) care is crucial to the efficacy of any of the interventions discussed. Thus, the dynamic nature of the individual, interpersonal, environmental, and cultural factors associated with the daily operations of the inpatient unit need to be assessed through the lens of primary and secondary violence prevention, building on the recognition that the majority of persons served and staff have significant trauma histories. Once a compassionate, respectful, empathic, and empowering approach is embraced by leadership and staff, the work with individuals can proceed more effectively. Interventions used include a variety of cognitive-behavioral, interpersonal, and somatosensory therapies. These interventions, when effectively applied, result in more self-esteem, self-mastery, self-control for the person served, and diminished behavioral violence.

A combination strategy for enhancing linkage to and retention in HIV care among adults newly diagnosed with HIV in Mozambique: study protocol for a site-randomized implementation science study.

BACKGROUND: Despite the extraordinary scale up of HIV prevention, care and treatment services in sub-Saharan Africa (SSA) over the past decade, the overall effectiveness of HIV programs has been significantly hindered by high levels of attrition across the HIV care continuum. Data from "real-life" settings are needed on the effectiveness of an easy to deliver package of services that can improve overall performance of the HIV care continuum. METHODS/DESIGN: We are conducting an implementation science study using a two-arm cluster site-randomized design to determine the effectiveness of a combination intervention strategy (CIS) using feasible, evidence-based, and practical interventions-including (1) point-of-care (POC) CD4 count testing, (2) accelerated antiretroviral therapy initiation for eligible individuals, and (3) SMS reminders for linkage to and retention in care-as compared to the standard of care (SOC) in Mozambique in improving linkage and retention among adults following HIV diagnosis. A pre-post intervention two-sample design is nested within the CIS arm to assess the incremental effectiveness of the CIS plus financial incentives (CIS + FI) compared to the CIS without FI on study outcomes. Randomization is done at the level of the study site, defined as a primary health facility. Five sites are included from the City of Maputo and five from Inhambane Province. Target enrollment is a total of 2,250 adults: 750 in the SOC arm, 750 in the CIS cohort of the intervention arm and 750 in the CIS + FI cohort of the intervention arm (average of 150 participants per site). Participants are followed for 12 months from time of HIV testing to ascertain a combined endpoint of linkage to care within 1 month after testing and retention in care 12 months from HIV test. Cost-effectiveness analyses of CIS compared to SOC and CIS + FI compared to CIS will also be conducted. DISCUSSION: Study findings will provide evidence on the effectiveness of a CIS and the incremental effectiveness of a CIS + FI in a "real-life" service delivery system in a SSA country severely impacted by HIV. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01930084.

High levels of adherence and viral suppression in a nationally representative sample of HIV-infected adults on antiretroviral therapy for 6, 12 and 18 months in Rwanda.

BACKGROUND: Generalizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa. METHODS: We conducted a cross-sectional survey with chart abstraction, patient interviews and site assessments in a nationally representative sample of adults on ART for 6, 12 and 18 months at 20 sites in Rwanda. Adherence was assessed using 3- and 30-day patient recall. A systematically selected sub-sample had viral load (VL) measurements. Multivariable logistic regression examined predictors of non-perfect (<100%) 30-day adherence and detectable VL (>40 copies/ml). RESULTS: Overall, 1,417 adults were interviewed and 837 had VL measures. Ninety-four percent and 78% reported perfect adherence for the last 3 and 30 days, respectively. Eighty-three percent had undetectable VL. In adjusted models, characteristics independently associated with higher odds of non-perfect 30-day adherence were: being on ART for 18 months (vs. 6 months); younger age; reporting severe (vs. no or few) side effects in the prior 30 days; having no documentation of CD4 cell count at ART initiation (vs. having a CD4 cell count of <200 cells/µL); alcohol use; and attending sites which initiated ART services in 2003-2004 and 2005 (vs. 2006-2007); sites with ≥600 (vs. <600 patients) on ART; or sites with peer educators. Participation in an association for people living with HIV/AIDS; and receiving care at sites which regularly conduct home-visits were independently associated with lower odds of non-adherence. Higher odds of having a detectable VL were observed among patients at sites with peer educators. Being female; participating in an association for PLWHA; and using a reminder tool were independently associated with lower odds of having detectable VL. CONCLUSIONS: High levels of adherence and viral suppression were observed in the Rwandan national ART program, and associated with potentially modifiable factors.

Patients enrolled in HIV care in Mozambique: baseline characteristics and follow-up outcomes.

OBJECTIVE: To utilize routinely collected service delivery data from HIV care and treatment clinics in Mozambique to describe the patient population and programmatic outcomes from 2003 to 2009. METHODS: Data from patient charts were entered into an electronic database at 28 clinics in 5 Mozambican provinces. Patients' characteristics at enrollment in HIV care and at antiretroviral therapy (ART) initiation were examined. We calculated a corrected 12-month mortality estimate using a recently developed nomogram for sub-Saharan African ART patients. RESULTS: A total of 154,188 HIV-infected individuals (10,164 children <15 years old) were enrolled in HIV care services between 2003 and 2009. Of the 51,269 (36%) adults who started ART, 35% initiated ART with CD4 count <100 cells per microliter and 14.4% with World Health Organization stage IV. Just more than 10% (10.5%) of women were documented to be pregnant at enrollment. One-third of the 3,745 (37%) children who initiated ART were <2 years old, and 53% of those <5 years initiated ART severely immunosuppressed (CD4% <15%). Thirty-five percent of all children and 30% of those initiating ART met the definition of severe malnourishment (weight-for-age Z score <-3). Among those who initiated ART, the median estimated 12-month mortality rate across sites was 13.1% (interquartile range: 11.5%-16.0%) and 13.5% (interquartile range: 11.4%-17.4%) for adults and children, respectively. CONCLUSIONS: A substantial number of HIV-infected patients have been enrolled in HIV care and initiated on ART, with many patients having advanced HIV disease. With the release of new guidelines for ART use for adults, pregnant women, and children, extensive efforts are needed to ensure more timely initiation of ART.

Pregnancy desires, and contraceptive knowledge and use among prevention of mother-to-child transmission clients in Rwanda.

OBJECTIVE: To understand pregnancy intentions and contraception knowledge and use among HIV-positive and negative women in the national prevention of mother-to-child transmission (PMTCT) program in Rwanda. DESIGN: A cross-sectional survey of 236 HIV-positive and 162 HIV-negative postpartum women interviewed within 12 months of their expected delivery date in 12 randomly selected public-sector health facilities providing PMTCT services. METHODS: : Bivariate analyses explored fertility intentions, and family planning knowledge and use by HIV status. Multivariate analysis identified socio-demographic and service delivery-related predictors of reporting a desire for additional children and modern family planning use. RESULTS: HIV-positive women were less likely to report wanting additional children than HIV-negative women (8 vs. 49%, P < 0.001), and although a majority of women reported discussing family planning with a health worker during their last pregnancy (HIV-positive 79% vs. HIV-negative 69%, P = 0.057), modern family planning use remained low in both groups (HIV-positive 43% vs. HIV-negative 12%, P < 0.001). Condoms were the most commonly used method among HIV-positive women (31%), whereas withdrawal was most frequently reported among HIV-negative women (19%). In multivariate analysis, HIV-negative women were 16 times more likely to report wanting additional children and nearly 85% less likely to use modern family planning. Women who reported making two or less antenatal care visits were 77% less likely to use modern family planning. CONCLUSION: Our results highlight success in provision of family planning counseling in PMTCT services in Rwanda. As family planning use was low among HIV-positive and negative women, further efforts are needed to improve uptake of modern methods, including dual protection, in Rwandan PMTCT settings.

Differences among U.S. states in estimating the number of people living with HIV/AIDS: impact on allocation of federal Ryan White funding.

OBJECTIVE: We assessed the impact of differing laboratory reporting scenarios on the completeness of estimates of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA) in the U.S., which are used to guide allocation of federal Ryan White funds. METHODS: We conducted a four-year simulation study using clinical and laboratory data on 1,337 HIV-positive women, including 477 (36%) who did not have AIDS at baseline. We estimated the completeness of HIV (non-AIDS) case ascertainment for three laboratory reporting scenarios: CD4 < 200 cells/microL and detectable viral load (Scenario A); CD4 < 500 cells/microL and no viral load reporting (Scenario B); and CD4 < 500 cells/microL and detectable viral load (Scenario C). RESULTS: Each scenario resulted in an increasing proportion of HIV (non-AIDS) cases being ascertained over time, with Scenario C yielding the highest by Year 4 (Year 1: 69.0%, Year 4: 88.1%), followed by Scenario A (Year 1: 63.3%, Year 4: 84.5%), and Scenario B (Year 1: 43.0%, Year 4: 67.7%). Overall completeness of PLWHA ascertainment after four years was highest for Scenario C (95.8%), followed by Scenario A (94.5%), and Scenario B (88.5%). CONCLUSIONS: Differences in laboratory reporting regulations lead to substantial variations in the completeness of PLWHA estimates, and may penalize jurisdictions that are most successful at treating HIV/AIDS patients or those with weak or incomplete HIV/AIDS surveillance systems.

Barriers and missed opportunities in breast and cervical cancer screening among women aged 50 and over, New York City, 2002.

OBJECTIVES: Breast and cervical cancer screening both are routinely recommended for women. However, data are sparse on factors associated with joint screening behaviors. Our objective to describe the factors associated with receiving both, one, or neither screening test among women aged > or = 50. METHODS: Using data from the New York City Community Health Survey (NYC CHS), we compared the characteristics of women > age 50 (n = 2059) who missed (1) a Pap smear only, (2) mammography only, or (3) both screening procedures with the characteristics of women who received both tests. Analyses were performed using multiple logistic regression. RESULTS: Seventy-three percent of women had both screening tests, 6.7% needed a Pap smear only, 10% missed mammography only, and 10% missed both tests. After multiple logistic regression, missing a Pap smear only was more likely among women > 70 years compared with younger women and among women from Queens than from Manhattan. Missing mammography only was more common among women not reporting a personal doctor than among those with a doctor and among uninsured women relative to the privately insured. Missing both tests was more common among women > 74 years, current smokers compared with never smokers, women without a personal doctor, and the uninsured. This was less common among women from the Bronx than women from Manhattan and among racial/ethnic minorities compared with non-Hispanic white women. CONCLUSIONS: The predictors of each screening outcome appear to be qualitatively different. Changes in provider practices and targeted education may improve Pap smear screening rates, whereas policy initiatives and increased access for the uninsured may raise mammography rates. To achieve optimal preventive care, coscreening should be considered.

Thrombolytic treatment of acute cerebral infarction.

Stroke is a common cause of death and disability throughout the world. Acute neurologic deficits due to ischemic injury deserve rapid recognition and diagnosis in order to provide effective therapy. Intravenous tissue plasminogen activator (t-PA) provided to carefully selected patients that can be treated within 3 hours of stroke onset results in improved outcome in these patients. Intra-arterial administration of t-PA within a 6-hour window is performed at several academic centers in patients with middle cerebral and other intracranial artery occlusions based on results of one randomized clinical trial and numerous case reports. Although acute therapy of ischemic stroke has received much attention since the approval of intravenous t-PA, only a small percentage of individuals suffering a stroke actually receive t-PA. This article will review the optimal management of the acute stroke patient and discuss thrombolytic clinical trials that have been completed as well as those that are in progress.

Sickle cell disease -- when opioids and physicians fail.

An interview with a 32-year-old male with sickle cell anemia and multiple sequential admissions for vaso-occlusive crises, receiving high dose narcotic analgesics, is presented. The subsequent clinical discussion outlines psychiatric, psychosocial and treatment issues. Management of acute vaso-occlusive crisis is summarized along with a discussion of the value of comprehensive care for sickle cell disease patients. This article will be useful to physicians and consultation-liaison psychiatrists treating patients with sickle cell disease as well as policy makers developing service delivery models for this population.