Preliminary indications of the burden of COVID-19 among people who inject drugs in England and Northern Ireland and the impact on access to health and harm reduction services.

OBJECTIVE: The aim of the study was to describe the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on people who inject drugs (PWID) in England, Wales and Northern Ireland. STUDY DESIGN: This is a cross-sectional Unlinked Anonymous Monitoring (UAM) Survey of PWID. METHODS: People who had ever injected psychoactive drugs were recruited to the UAM Survey by specialist drug/alcohol services in England, Wales and Northern Ireland. From June 2020, in addition to providing a dried blood spot sample and completing the UAM behavioural questionnaire, participants were asked to complete an enhanced coronavirus disease 2019 (COVID-19) questionnaire. Preliminary data are presented to the end of October and were compared with data from the 2019 UAM Survey, where possible. RESULTS: Between June and October, 288 PWID were recruited from England and Northern Ireland. One in nine (11%; 29/260) PWID reported testing positive for SARS-CoV-2 or experiencing COVID-19 symptoms. Fifteen percent (26/169) reported injecting more frequently in 2020 than in 2019; cocaine injection in the preceding four weeks increased from 17% (242/1456) to 25% (33/130). One in five PWID (19%; 35/188) reported difficulties in accessing HIV and hepatitis testing, and one in four (26%; 47/179) reported difficulties in accessing equipment for safer injecting. CONCLUSIONS: Our preliminary findings suggest that PWID have experienced negative impacts on health, behaviours and access to essential harm reduction, testing and treatment services owing to the COVID-19 pandemic. Continued monitoring through surveillance and research is needed to understand the subsequent impact of COVID-19 on blood-borne virus transmission in this population and on health inequalities.

Area level impacts on emergency hospital admissions of the integrated care and support pioneer programme in England: difference-in-differences analysis.

OBJECTIVE: To examine whether any differential change in emergency admissions could be attributed to integrated care by comparing pioneer and non-pioneer populations from a pre-pioneer baseline period (April 2010 to March 2013) over two follow-up periods: to 2014/2015 and to 2015/2016. DESIGN: Difference-in-differences analysis of emergency hospital admissions from English Hospital Episode Statistics. SETTING: Local authorities in England classified as either pioneer or non-pioneer. PARTICIPANTS: Emergency admissions to all NHS hospitals in England with local authority determined by area of residence of the patient. INTERVENTION: Wave 1 of the integrated care and support pioneer programme announced in November 2013. PRIMARY OUTCOME MEASURE: Change in hospital emergency admissions. RESULTS: The increase in the pioneer emergency admission rate from baseline to 2014/2015 was smaller at 1.93% and significantly different from that of the non-pioneers at 4.84% (p=0.0379). The increase in the pioneer emergency admission rate from baseline to 2015/2016 was again smaller than for the non-pioneers but the difference was not statistically significant (p=0.1879). CONCLUSIONS: It is ambitious to expect unequivocal changes in a high level and indirect indicator of health and social care integration such as emergency hospital admissions to arise as a result of the changes in local health and social care provision across organisations brought about by the pioneers in their early years. We should treat any sign that the pioneers have had such an impact with caution. Nevertheless, there does seem to be an indication from the current analysis that there were some changes in hospital use associated with the first year of pioneer status that are worthy of further exploration.

The European Virus Archive goes global: A growing resource for research.

The European Virus Archive (EVA) was created in 2008 with funding from the FP7-EU Infrastructure Programme, in response to the need for a coordinated and readily accessible collection of viruses that could be made available to academia, public health organisations and industry. Within three years, it developed from a consortium of nine European laboratories to encompass associated partners in Africa, Russia, China, Turkey, Germany and Italy. In 2014, the H2020 Research and Innovation Framework Programme (INFRAS projects) provided support for the transformation of the EVA from a European to a global organization (EVAg). The EVAg now operates as a non-profit consortium, with 26 partners and 20 associated partners from 21 EU and non-EU countries. In this paper, we outline the structure, management and goals of the EVAg, to bring to the attention of researchers the wealth of products it can provide and to illustrate how end-users can gain access to these resources. Organisations or individuals who would like to be considered as contributors are invited to contact the EVAg coordinator, Jean-Louis Romette, at jean-louis.romette@univmed.fr.

New horizons in comprehensive geriatric assessment.

In this article, we discuss the emergence of new models for delivery of comprehensive geriatric assessment (CGA) in the acute hospital setting. CGA is the core technology of Geriatric Medicine and for hospital inpatients it improves key outcomes such as survival, time spent at home and institutionalisation. Traditionally It is delivered by specialised multidisciplinary teams, often in dedicated wards, but in recent years has begun to be taken up and developed quite early in the admission process (at the 'front door'), across traditional ward boundaries and in specialty settings such as surgical and pre-operative care, and oncology. We have scanned recent literature, including observational studies of service evaluations, and service descriptions presented as abstracts of conference presentations to provide an overview of an emerging landscape of innovation and development in CGA services for hospital inpatients.

Gonadal function is associated with cardiometabolic health in pre-pubertal boys with Klinefelter syndrome.

The most common sex chromosome aneuploidy, Klinefelter syndrome (KS), is associated with primary gonadal failure and increased morbidity and mortality from cardiometabolic disorders in adulthood. Children with KS also have a high prevalence of metabolic syndrome (MetS) features. To assess the relationship of gonadal and cardiometabolic function in children with KS, we evaluated serum hormones [gonadotropins, inhibin B (INHB), anti-mullerian hormone (AMH), total testosterone (TT)], and features of MetS (waist circumference, fasting lipid panel, fasting blood glucose (FBG), and blood pressure) in 93 pre-pubertal boys with KS age 4-12 years (mean 7.7 ± 2.5 years). The cohort was grouped by age and tanner stage, and biomarkers were compared to normal ranges. A total of 80% of this pre-pubertal cohort had ≥1 feature of metabolic syndrome (MetS) and 11% had ≥3 features of MetS. Risk of MetS was independent of age and body mass index. Sertoli cell dysfunction was common with 18% having an INHB below the normal range. A low INHB was associated with higher FBG, triglycerides, LDL, and lower HDL (p < 0.05). An INHB <50 ng/dL yielded a sensitivity of 83% and a specificity of 79% for having ≥3 features of MetS. INHB and AMH positively correlated with each other (p < 0.001), and high AMH was protective of MetS. TT was below the lower limit of normal in 49% of subjects, with mean values significantly lower than expected (3.3 ng/dL vs. 4.9 ng/dL, p < 0.0001), however, no convincing relationship between TT and MetS was seen. In conclusion, gonadal and cardiometabolic dysfunction are prevalent in pre-pubertal boys with KS. Although the relationship of testosterone deficiency and MetS is well-known, this study is the first to report an association between impaired Sertoli cell function and cardiometabolic risk.

Comparing primary and secondary health-care use between diagnostic routes before a colorectal cancer diagnosis: cohort study using linked data.

BACKGROUND: Survival in cancer patients diagnosed following emergency presentations is poorer than those diagnosed through other routes. To identify points for intervention to improve survival, a better understanding of patients' primary and secondary health-care use before diagnosis is needed. Our aim was to compare colorectal cancer patients' health-care use by diagnostic route. METHODS: Cohort study of colorectal cancers using linked primary and secondary care and cancer registry data (2009-2011) from four London boroughs. The prevalence of all and relevant GP consultations and rates of primary and secondary care use up to 21 months before diagnosis were compared across diagnostic routes (emergency, GP-referred and consultant/other). RESULTS: The data set comprised 943 colorectal cancers with 24% diagnosed through emergency routes. Most (84%) emergency patients saw their GP 6 months before diagnosis but their symptom profile was distinct; fewer had symptoms meeting urgent referral criteria than GP-referred patients. Compared with GP-referred, emergency patients used primary care less (IRR: 0.85 (95% CI 0.78-0.93)) and urgent care more frequently (IRR: 1.56 (95% CI 1.12; 2.17)). CONCLUSIONS: Distinct patterns of health-care use in patients diagnosed through emergency routes were identified in this cohort. Such analyses using linked data can inform strategies for improving early diagnosis of colorectal cancer.

Safety and efficacy of oxandrolone in growth hormone-treated girls with Turner syndrome: evidence from recent studies and recommendations for use.

There has been no consensus regarding the efficacy and safety of oxandrolone (Ox) in addition to growth hormone (GH) in girls with Turner syndrome (TS), the optimal age of starting this treatment, or the optimal dose. This collaborative venture between Dutch, UK and US centers is intended to give a summary of the data from three recently published randomized, placebo-controlled, double-blind studies on the effects of Ox. The published papers from these studies were reviewed within the group of authors to reach consensus about the recommendations. The addition of Ox to GH treatment leads to an increase in adult height, on average 2.3­4.6 cm. If Ox dosages<0.06 mg/kg/day are used, side effects are modest. The most relevant safety concerns are virilization(including clitoromegaly and voice deepening) and a transient delay of breast development. We advise monitoring signs of virilization breast development and possibly blood lipids during Ox treatment, in addition to regular follow-up assessments for TS. In girls with TS who are severely short for age, in whom very short adult stature is anticipated,or in whom the growth rate is modest despite good compliance with GH, adjunctive treatment with Ox at a dosage of 0.03­0.05 mg/kg/day starting from the age of 8­10 years onward scan be considered.

Hospital activity and cost incurred because of unregistered patients in England: considerations for current and new commissioners.

BACKGROUND: Commissioners are responsible for providing health care for defined geographical areas. A lack of comprehensive national and local information on health needs of unregistered populations makes health service planning difficult. METHODS: A cross-sectional study using Hospital Episode Statistics to quantify the level of inpatient and outpatient activity, and associated cost by patients not registered in primary care in English NHS hospitals. Unregistered patients were defined as those without a valid GP registration, prisoners, military personnel, asylum seekers/immigrants and the homeless. RESULTS: Unregistered patients accounted for 99 615 inpatient admissions and 370 504 outpatient attendances in 2009/10, at a total cost of £242 m. Mental health accounted for 30% of all inpatient costs. The majority of unregistered patients were male and aged 20-39 years. There were high levels of activity and cost in urban local authorities (LAs) (Birmingham and London) and LAs with links to military services (Salisbury, Richmondshire, Southampton). A high total inpatient cost was attributed to trauma, general medicine and mental health specialties. A high total outpatient cost was attributed to genitourinary medicine and trauma specialties. CONCLUSIONS: Health care use by unregistered populations is an important consideration for resource allocation and planning health care services at national and local levels.

Effect of a home-based end-of-life nursing service on hospital use at the end of life and place of death: a study using administrative data and matched controls.

OBJECTIVE: To assess the effect of routinely delivered home-based end-of-life care on hospital use at the end of life and place of death. DESIGN: Retrospective analysis using matched controls and administrative data. SETTING: Community-based care in England. PARTICIPANTS: 29,538 people aged over 18 who received Marie Curie nursing support compared with 29,538 controls individually matched on variables including: age, socioeconomic deprivation, prior hospital use, number of chronic conditions and prior diagnostic history. INTERVENTION: Home-based end-of-life nursing care delivered by the Marie Curie Nursing Service (MCNS), compared with end-of-life care available to those who did not receive MCNS care. MAIN OUTCOME MEASURES: Proportion of people who died at home; numbers of emergency and elective inpatient admissions, outpatient attendances and attendances at emergency departments in the period until death; and notional costs of hospital care. RESULTS: Intervention patients were significantly more likely to die at home and less likely to die in hospital than matched controls (unadjusted OR 6.16, 95% CI 5.94 to 6.38, p<0.001). Hospital activity was significantly lower among intervention than matched control patients (emergency admissions: 0.14 vs 0.44 admissions per person, p<0.001) and average costs across all hospital services were lower (unadjusted average costs per person, £610 (intervention patients) vs £1750 (matched controls), p<0.001). Greater activity and cost differences were seen in those patients who had been receiving home nursing for longer. CONCLUSIONS: Home-based end-of-life care offers the potential to reduce demand for acute hospital care and increase the number of people able to die at home.

Generalized neuromuscular hypoplasia, reduced smooth muscle myosin and altered gut motility in the klotho model of premature aging.

BACKGROUND: Gastrointestinal symptoms, particularly constipation, increase with aging, but their underlying mechanisms are poorly understood due to lack of experimental models. Previously we established the progeric klotho mouse as a model of aging-associated anorexia and gastric dysmotility. We also detected reduced fecal output in these animals; therefore, the aim of this study was to investigate in vivo function and cellular make-up of the small intestinal and colonic neuromuscular apparatus. METHODS: Klotho expression was studied by RT-PCR and immunohistochemistry. Motility was assessed by dye transit and bead expulsion. Smooth muscle and neuron-specific gene expression was studied by Western immunoblotting. Interstitial cells of Cajal (ICC) and precursors were analyzed by flow cytometry, confocal microscopy, and three-dimensional reconstruction. HuC/D(+) myenteric neurons were enumerated by fluorescent microscopy. KEY RESULTS: Klotho protein was detected in neurons, smooth muscle cells, and some ICC classes. Small intestinal transit was slower but whole-gut transit of klotho mice was accelerated due to faster colonic transit and shorter intestinal lengths, apparent only after weaning. Fecal water content remained normal despite reduced output. Smooth muscle myosin expression was reduced. ICC, ICC precursors, as well as nitrergic and cholinergic neurons maintained their normal proportions in the shorter intestines. CONCLUSIONS & INFERENCES: Progeric klotho mice express less contractile proteins and develop generalized intestinal neuromuscular hypoplasia mainly arising from stunted postweaning growth. As reduced fecal output in these mice occurs in the presence of accelerated colonic and whole-gut transit, it likely reflects reduced food intake rather than intestinal dysmotility.

Using routine intelligence to target inspection of healthcare providers in England.

BACKGROUND: The Healthcare Commission, the national regulator for the National Health Service in England, has to assess providers (NHS trusts) on compliance with core standards in a way that targets appropriate local inspection resources. OBJECTIVES: To develop and evaluate a system for targeting inspections in 2006 of 44 standards in 567 healthcare organisations. METHODS: A wide range of available information was structured as a series of indicators (called items) that mapped to the standards. Each item was scored on a common scale (a modified Z-score), and these scores were aggregated to indicate risks of undeclared non-compliance for all trusts and standards. In addition, local qualitative intelligence was coded and scored. RESULTS: The information sets used comprised 463 875 observations structured in 1689 specific items, drawn from 83 different data streams. Follow-up inspections were undertaken on the 10% of trusts with the highest-risk scores (where the trust had declared compliance with a standard) and an additional 10% of trusts randomly selected from the remainder. The success of the targeting was measured by the number of trust declarations that were "qualified" following inspection. In the risk-based sample, the proportion of inspected standards that were qualified (26%) was significantly higher than in the random sample (13%). The success rate for targeting varied between standards and care sectors. CONCLUSION: This innovative approach to using information to target inspection activity achieved its overall aims. The method worked better for some standards and in some settings than for others, and is being improved in the light of experience gained. Such applications are increasingly important as modern regulators strive to be targeted and proportionate in their activities.

Healthcare-associated infection in acute hospitals: which interventions are effective?

This study investigated the potential factors linked to healthcare-associated infection (HCAI) rates in acute National Health Service hospitals, analysing mandatory surveillance data with existing data available to the Healthcare Commission, and supplemented by a bespoke questionnaire. A questionnaire was developed to cover important elements related to the management and control of HCAI. Additional data were collated from other sources. Infection outcomes comprised the mandatory surveillance data, for both meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia and Clostridium difficile-associated diarrhoea (CDAD). The response rate was 90%. A lower MRSA rate was linked to hand hygiene and isolation and a lower rate of CDAD to cleanliness, good antimicrobial prescribing practices and surveillance of infections. Lower rates of both organisms were related to strategic planned interventions, such as the inclusion of infection control in the staff development programme. However, certain interventions, for example increased levels of training, were related to a higher infection rate. These findings for MRSA and CDAD are supported by evidence from the infection control literature. We have found relationships between interventions and higher infection rates that are counterintuitive and that may represent examples of what we call 'reactive practice' to higher rates of infection. Whilst it is interesting to hypothesise that these interventions may be swift and simple to introduce and may not be sustained compared to more strategic and planned interventions linked to lower infection rates, they most probably simply represent the beginning of a culture change and embedding of infection control practice.

Fluoroquinolone resistance in invasive Streptococcus pyogenes isolates due to spontaneous mutation and horizontal gene transfer.

Fluoroquinolone resistance in Streptococcus pyogenes has been described only anecdotally. In this study we describe two invasive ciprofloxacin-resistant S. pyogenes isolates (ciprofloxacin MICs, 8 mg/liter), one of which shows evidence of interspecies recombination. The quinolone resistance-determining regions of gyrA and parC were sequenced. In both isolates, there was no evidence for an efflux pump and no mutation in gyrA. Both isolates had an S79F mutation in parC that is known to confer fluoroquinolone resistance. In addition, a D91N mutation in parC, which is not related to fluoroquinolone resistance but is a feature of the parC sequence of Streptococcus dysgalactiae, was found in one isolate. The parC nucleotide sequence of that isolate showed greater diversity than that of S. pyogenes. A GenBank search and phylogenetic analysis suggest that this isolate acquired resistance by horizontal gene transfer from S. dysgalactiae. Statistical testing for recombination confirmed interspecies recombination of a 90-bp sequence containing the S79F mutation from S. dysgalactiae. For the other isolate, we could confirm that it acquired resistance by spontaneous mutation by identifying the susceptible ancestor in an outbreak setting.

Exploring the effects of population mobility on cervical screening coverage.

London has the lowest cervical screening coverage in England and in 1998/1999 accounted for 11 of the 13 health authorities that fell below the national 80% coverage target. There are several factors which may contribute to the difference in coverage between the capital and the rest of the country. London's population is much more diverse, there is greater deprivation and there are well-established structural differences in primary care. London has high levels of population mobility which will also affect the ability of GPs to achieve high population coverage. This paper explores the possible size of the effect that population mobility is likely to have on coverage of the cervical screening programme in London. The analysis estimates the size of 'missing populations' that may not receive an invitation for a smear test, or artificially inflate the list size of registered patients. A simple model suggests that in some London Health Authorities up to 14% of residents, and 11% of patients on GP lists, may miss out on invitations for screening as a result of population mobility. Moreover the large differences between list and resident populations in some areas mean that the current government target of 80% coverage of the registered population will be largely unattainable for many London Health Authorities and Primary Care Trusts. Moving towards a resident-based system, whereby the numbers screened are related to the number of residents, avoids some of the problems associated with list inflation and gives a fairer picture of coverage of the eligible population.

Estimating the numbers of refugees in London.

BACKGROUND: Local populations of refugees and asylum seekers are growing in many urban areas in Western Europe and it is increasingly important to develop health and welfare services that are appropriate for these groups. However, in the United Kingdom there are no routine data sources at local level that give even the most basic information such as the numbers of refugees within a given area. METHODS: The total number of asylum seekers entering the United Kingdom was calculated using cumulative data on asylum seekers at national level. This population was then apportioned first to Greater London and then to the boroughs within London. The apportionment to London boroughs was based on analysis of four datasets. In the absence of any better evidence, an average of these four approaches was used to produce the final borough level estimates. RESULTS: The total numbers of refugees and asylum seekers in London who have entered the United Kingdom over the past 15 years was estimated to be between 240,000 and 280,000. At borough level the estimates of refugee populations ranged from under 1,000 to values up to 20,000. There were statistically significant associations between the four data sources when the proportions of the London total in each borough were compared. However, for some boroughs there could be large differences between estimates based on different data sources. CONCLUSION: The estimates provided give an indication of the size of the refugee population in London. None of the data sources used to apportion the London total were ideal and all were proxy values with their own strengths and weaknesses. This work points to the importance of developing information systems that in future will allow better estimates of the size of the refugee populations. This is particularly important in view of the UK national policy of dispersal proposed in the latest Immigration and Asylum Act.

Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates.

OBJECTIVES: To calculate socioeconomic and health status measures for the primary care groups in London and to examine the association between these measures and hospital admission rates. DESIGN: Cross sectional study. SETTING: 66 primary care groups in London, total list size 8.0 million people. MAIN OUTCOME MEASURES: Elective and emergency standardised hospital admission ratios; standardised admission rates for diabetes and asthma. RESULTS: Standardised hospital admission ratios varied from 74 to 116 for total admissions and from 50 to 124 for emergency admissions. Directly standardised admission rates for asthma varied from 152 to 801 per 100 000 (mean 364) and for diabetes from 235 to 1034 per 100 000 (mean 538). There were large differences in the mortality, socioeconomic, and general practice characteristics of the primary care groups. Hospital admission rates were significantly correlated with many of the measures of chronic illness and deprivation. The strongest correlations were with disability living allowance (R=0.64 for total admissions and R=0.62 for emergency admissions, P<0.0001). Practice characteristics were less strongly associated with hospital admission rates. CONCLUSIONS: It is feasible to produce a range of socioeconomic, health status, and practice measures for primary care groups for use in needs assessment and in planning and monitoring health services. These measures show that primary care groups have highly variable patient and practice characteristics and that hospital admission rates are associated with chronic illness and deprivation. These variations will need to be taken into account when assessing performance.

Estimating the balance of general practice versus family planning clinic coverage of contraception services in London.

OBJECTIVE: To compare levels of provision of contraception from general practice and family planning clinics for the populations of the 32 London Boroughs. METHOD: Retrospective analysis of routine activity data, including the estimated numbers of first attendance, for 295 family planning clinics (managed by 28 NHS Trusts) and more than 1800 GP partnerships in Greater London, supplemented by data from a survey of family planning clinics. The results were expressed as the estimated percentage of women aged 16-49 obtaining advice on contraception from GPs and family planning clinics. These results were compared to those expected based on results in the General Household Survey. RESULTS: Across London in 1995/96, 12% of women aged 16-49 obtained contraception services from family planning clinics, and 24% obtained contraception services from a GP. At a borough level there was variation from 11% to 25% in coverage by family planning clinics, and from 11% to 41% in coverage by GPs. Estimates of the proportion of women in this age group not using NHS-provided medical or surgical contraception ranged from 0 to 30%. Across all boroughs, there was no consistent relationship between levels of GP activity and family planning clinic activity. CONCLUSION: The results indicate substantial variations between boroughs in the proportion of women using NHS-provided medical or surgical methods of contraception. The absence of any clear inverse relationship between activity in family planning clinics and activity in general practice suggests that changes to one will not be compensated by changes in the other. More specifically, health authorities that opt to purchase lower levels of family planning clinic activity cannot assume that women may opt to use GPs as an alternative. Such a strategy may increase the likelihood that women who would have used family planning clinic services will either not use contraception at all, or will use less effective 'over the counter' methods.

Assessing the outcomes of total knee replacement.

The past few years have seen a growth of interest in outcome measurement in a variety of settings including audit, health care management and commissioning - besides the traditional applications in research work. This paper reports on a study of the outcomes of total knee replacement in an acute hospital where the outcomes were studied as part of an audit process. The outcome measures used included clinical and symptomatic measures as well as generic health status scales. The initial study in one hospital was expanded to include a number of others in the same region and a comparative database of outcomes developed. Examples of the results are shown. The technical measures using knee scores and general health status measure show significant improvement from pre-operatively to 3 months later. This improvement was maintained up to the 1-year follow-up on both measures. Although the information systems for collecting and measuring outcomes has been successful, the ability of such measures to lead to behavioural change has been limited. The problems in using outcome measures are discussed in particular in the context of an audit within hospitals, and for purchasing agencies.

Impact of HIV on adult (15-54) mortality in London: 1979-96.

OBJECTIVE: To describe the impact of HIV on mortality in men and women aged 15-54 in London. DESIGN: Combination of routine mortality statistics with reports of AIDS deaths adjusted for underreporting and change in address from time of report to time of death. Calculation of standardised mortality ratios (SMRs) for males including and excluding HIV comparing inner London and outer London with the rest of England and Wales. METHODS: Comparison of trends in all cause mortality and SMRs in males over time. Comparison of trends in HIV related deaths with other main causes of deaths in males and females in London. RESULTS: Age standardised rates for the rest of England and Wales showed a continual decline from 1979 to 1996 but rates in inner London males (ages 15-54) stopped declining around 1984-5 leading to a considerable increase in the SMR for inner London from 127 for 1985-7 to 171 for 1994-6. SMRs excluding HIV related deaths for inner London, however, showed no significant change over this time. There was a fall in HIV related mortality in 1996, though HIV was still the leading cause of death in males and second leading cause of death in females in inner London, and the fourth commonest cause of death in males in outer London. CONCLUSION: These data are the first to indicate the impact of HIV on mortality within a significant population in England and Wales. They show that public health priorities in London are different from the rest of the country. Analyses of trends of all cause mortality in people under 65 may mislead unless they take account of HIV.