Pre-exposure prophylaxis and telemedicine during coronavirus (COVID-19): a qualitative study of the experiences of health care professionals in Mexico.

Background Telemedicine, which involves utilising technologies for remote health care delivery, proved useful to continue offering certain health services during the coronavirus disease 2019 (COVID-19) lockdown. However, the extent of its effectiveness in delivering pre-exposure prophylaxis services for HIV prevention remains underexplored from the viewpoint of health care providers. Therefore, this study aimed to assess the experiences of health care professionals in Mexico who utilised telemedicine for delivering pre-exposure prophylaxis services during the COVID-19 contingency. Methods A qualitative study was performed: 15 virtual interviews with health care professionals were conducted, transcribed and coded in ATLAS.ti. Results The results indicate that telemedicine effectively mitigated COVID-19 exposure, facilitated users' access to pre-exposure prophylaxis counselling, minimised waiting times and enhanced health care professionals' perceived control during sessions. While implementing remote services, certain organisational challenges, which were somewhat latent before the pandemic, became more apparent: colleagues recognised the necessity for more formal communication channels to disseminate information effectively. Additionally, there was a recognised need for electronic patient files to streamline data-sharing processes. An optimal approach would involve a blend of face-to-face and virtual services, contingent upon the availability of essential infrastructure, well-defined implementation protocols and comprehensive training programs. Conclusions Telemedicine streamlined certain processes, garnered positive acceptance from healthcare professionals and holds promise as a valuable post-pandemic tool for improving retention among pre-exposure prophylaxis users.

Awareness of U = U among Sexual and Gender Minorities in Brazil, Mexico, and Peru: Differences According to Self-reported HIV Status.

The slogan Undetectable equals Untransmittable (U = U) communicates that people living with HIV (PLHIV) who are on antiretroviral therapy (ART) will not transmit HIV to their sexual partners. We describe awareness of U = U among sexual and gender minorities (SGM) living in Brazil, Mexico, and Peru by self-reported HIV status (PLHIV, negative, unknown) during 2021 using an online survey. We estimated two models using Poisson regression for each population group: Model A including socio-demographic factors (country, gender, age, race, education, and income), and then Model B including taking ART (for PLHIV) or risk behavior, ever-taking PrEP, and HIV risk perception (for HIV-negative or of unknown HIV status). A total of 21,590 respondents were included (Brazil: 61%, Mexico: 30%, Peru: 9%). Among HIV-negative (74%) and unknown status (12%), 13% ever used PrEP. Among PLHIV (13%), 93% reported current use of ART. Awareness of U = U was 89% in both Brazil and Mexico, which was higher than in Peru 64%. Awareness of U = U was higher among PLHIV (96%) than HIV-negative (88%) and HIV-unknown (70%). In multivariate models, PLHIV with lower education were less aware of U = U, while those taking ART were more aware. Among HIV-negative, non-cisgender, lower income, and those with lower education had lower awareness of U = U, while individuals ever using PrEP had higher awareness. In conclusion, awareness of U = U varied by HIV status, socio-demographic characteristics, and HIV risk behavior. The concept of U = U should be disseminated through educational strategies and include a focus on SGM to combat HIV stigma.

RESUMEN: Indetectable = Intransmisible (I = I) comunica que las personas que viven con VIH (PVVIH) y reciben tratamiento antirretroviral (TAR) no transmitirán el VIH a sus parejas sexuales. En este estudio, describimos la concienciación sobre I = I entre las minorías sexuales y de género (MSG) de Brasil, México y Perú según el estado de VIH autoreportado (PVVIH, negativo, desconocido) durante 2021 utilizando una encuesta en línea. Se estimaron dos modelos mediante regresión de Poisson para cada grupo: Modelo A, que incluyó factores sociodemográficos (país, sexo, edad, raza, educación e ingresos) y Modelo B, que incluyó recibir TAR (para PVVIH) o comportamiento de riesgo, uso de PrEP y percepción de riesgo (para VIH negativo o desconocido). Se incluyó 21,590 encuestados (Brasil: 61%, México: 30%, Perú: 9%). Entre aquellos negativos para VIH (74%) y con estado desconocido (12%), el 13% utilizó alguna vez PrEP. Entre las PVVIH (13%), el 93% reportó recibir actualmente TAR. La concienciación de I = I fue del 89% tanto en Brasil como en México, superior al 64% de Perú. La concienciación de I = I fue mayor entre PVVIH (96%) que entre los VIH-negativos (88%) y los VIH-desconocidos (70%). En los modelos multivariados, las PVVIH con menor educación eran menos conscientes de I = I, mientras que los que tomaban TAR eran más conscientes. Entre los VIH-negativos, las personas no cisgéneros, con menores ingresos y con menor educación eran menos consciente de I = I, mientras que los que tenían experiencia usando PrEP eran más conscientes. En conclusión, la concienciación sobre I = I varió según el estado serológico de VIH, las características sociodemográficas y el comportamiento de riesgo. El concepto de I = I debe difundirse a través de estrategias educativas, incluyendo un enfoque en MSG para combatir el estigma del VIH.

A systematic review of the literature on the impact of the Seguro Popular.

BACKGROUND: The Seguro Popular (SP) was launched in 2004 to increase access to healthcare and reduce catastrophic expenditures among the Mexican population. To document the evidence on its effectiveness, we conducted a systematic review of impact evaluations of the SP. METHODS: We included papers using rigorous quasi-experimental designs to assess the effectiveness of the SP. We evaluated the quality of each study and presented the statistical significance of the effects by outcome category. RESULTS: We identified 26 papers that met the inclusion criteria. Sixteen studies that evaluated the impact of SP on financial protection found consistent and statistically significant positive effects in 55% of the 65 outcomes analyzed. Nine studies evaluating utilization of health services for the general and infant populations found effectiveness on 40% of 30 outcomes analyzed. Concerning screening services for hypertension, diabetes, and cervical and prostate cancer, we found three studies evaluating 14 outcomes and finding significant effects on 50% of them. Studies looking at the impact of SP on diabetes, hypertension, and general health care and treatment evaluated 19 outcomes and found effects on 21% of them. One study assessed five diabetes monitoring services and found positive effects on four of them. The only study on morbidity and mortality found positive results on three of the four outcomes of interest. CONCLUSION: We found mixed evidence on the impact of SP on financial protection, healthcare utilization, morbidity and mortality. In the 26 studies included in this review, researchers found positive effects in roughly half of the outcomes and null results on the rest.

Regional disparity of HIV incidence and prevalence among men who have sex with men.

BACKGROUND: HIV incidence can be estimated with cross-sectional studies using clinical, serological, and molecular data. Worldwide, HIV incidence data in only men who have sex with men (MSM) are scarce and principally focus on those with healthcare or under treatment. However, better estimates can be obtained through studies with national representativeness. The objective was to estimate the prevalence, incidence, and factors associated with acquiring HIV in a national sample of MSM who attend meeting places, considering geographical regions. METHODS: A nationally representative survey of MSM attending meeting places was performed in Mexico. Participants answered a questionnaire, and a dried blood spot (DBS) was collected. Samples were classified as recent infections using an algorithm with HIV status, antiretroviral therapy, and the result of BED-EIA assay. Parameters were analysed considering regions and demographic and sexual behaviour characteristics. RESULTS: The national HIV prevalence was 17.4% with regional differences; the highest prevalence (20.7%) was found in Mexico City, and the lowest prevalence was found in the West region (11.5%). The incidence was 9.4 per 100 p/y, with regional values from 6.2 to 13.2 for the Northeast and the Centre regions, respectively. Age, age at sexual debut, low wealth index, and rewarded sex were associated with HIV prevalence. Centre region, use of private clinics as health services, and having sex exclusively with men were associated with recent HIV infections. CONCLUSIONS: The incidence and prevalence showed regional differences, suggesting a difference in the dynamics of HIV transmission; some regions have a greater case accumulation, and others have a greater rate of new infections. Understanding this dynamic will allow developing health programs focused on HIV prevention or treating people already living with HIV.

Cost of tuberculosis treatment in low- and middle-income countries: systematic review and meta-regression.

BACKGROUND: Despite a scarcity of tuberculosis (TB) cost data, a substantial body of evidence has been accumulating for drug-susceptible TB (DS-TB) treatment. In this study, we review unit costs for DS-TB treatment from a provider´s perspective. We also examine factors driving cost variations and extrapolate unit costs across low- and middle-income countries (LMICs).METHODS: We searched published and grey literature for any empirically collected TB cost estimates. We selected a subgroup of estimates looking at DS-TB treatment. We extracted information on activities and inputs included. We standardised costs into an average per person-month, fitted a multi-level regression model and cross-validated country-level predictions. We then extrapolated estimates for facility-based, directly observed DS-TB treatment across countries.RESULTS: We included 95 cost estimates from 28 studies across 17 countries. Costs predictions were sensitive to characteristics such as delivery mode, whether hospitalisation was included, and inputs accounted for, as well as gross domestic product per capita. Extrapolation results are presented with uncertainty intervals (UIs) for LMICs. Predicted median costs per 6 months of treatment were US$315.30 (95% CI US$222.60-US$417.20) for low-income, US$527.10 (95% CI US$395.70-US$743.70) for lower middle-income and US$896.40 (95% CI US$654.00-US$1214.40) for upper middle-income countries.CONCLUSIONS: Our study provides country-level DS-TB treatment cost estimates suitable for priority setting. These estimates, while not standing as a substitute for local high-quality primary data, can inform global, regional and national exercises.

Did "Conduce Sin Alcohol" a Program that Monitors Breath Alcohol Concentration Limits for Driving in Mexico City Have an Effect on Traffic-Related Deaths?

In September 2003, Mexico City introduced "Conduce sin Alcohol" (CSA)-drive without alcohol-a program that monitors breath alcohol concentration limits among drivers to reduce road traffic crashes. To our knowledge, no study has evaluated the impact of this program on mortality. We estimated the effect of CSA on the monthly rate of traffic-related deaths (deaths per one million people) in Mexico City. We applied interrupted time series analyses (ITSA) using monthly data from 1998 to 2016, adjusting for number of people covered by a public health insurance, monthly number of public health care facilities in the city, monthly average rain precipitation in milliliters, and number of vehicles registered. Our results show a statistically significant average reduction in the monthly trend of traffic-related deaths of 0.08 per 1 million people/per month after the program was implemented relative to the pre-intervention trend. The relative difference comparing pre- and post-intervention predicted values from the ITSA model shows that there was a 23.2% reduction in the fatality rate. Findings from this study can be used to scale up programs to monitor alcohol concentration limits among drivers in cities with high alcohol-related crashes and deaths where the program has not been implemented.

Costs and economies of scale in the accelerated program for prevention of mother-to-child transmission of HIV in Zimbabwe.

BACKGROUND: Despite a growing body of literature on HIV service costs in sub-Saharan Africa, only a few studies have estimated the facility-level cost of prevention of Mother-to-Child Transmission (PMTCT) services, and even fewer provide insights into the variation of PMTCT costs across facilities. In this study, we present the first empirical costs estimation of the accelerated program for the prevention of mother-to-child transmission of HIV in Zimbabwe and investigate the determinants of heterogeneity of the facility-level average cost per service. To understand such variation, we explored the association between average costs per service and supply-and demand-side characteristics, and quality of services. One aspect of the supply-side we explore carefully is the scale of production-which we define as the annual number of women tested or the yearly number of HIV-positive women on prophylaxis. METHODS: We collected rich data on the costs and PMTCT services provided by 157 health facilities out of 699 catchment areas in five provinces in Zimbabwe for 2013. In each health facility, we measured total costs and the number of women covered with PMTCT services and estimated the average cost per woman tested and the average cost per woman on either ARV prophylaxis or ART. We refer to these facility-level average costs per service as unitary costs. We also collected information on potential determinants of the variation of unitary costs. On the supply-side, we gathered data on the scale of production, staff composition and on the types of antenatal and family planning services provided. On the demand side, we measured the total population at the catchment area and surveyed eligible pairs of mothers and infants about previous use of HIV testing and prenatal care, and on the HIV status of both mothers and infants. We explored the determinants of unitary cost variation using a two-stage linear regression strategy. RESULTS: The average annual total cost of the PMTCT program per facility was US$16,821 (median US$8,920). The average cost per pregnant woman tested was US$80 (median US$47), and the average cost per HIV-positive pregnant woman initiated on ARV prophylaxis or treatment was US$786 annually (median US$420). We found substantial heterogeneity of unitary costs across facilities regardless of facility type. The scale of production was a strong predictor of unitary costs variation across facilities, with a negative and statistically significant correlation between the two variables (p<0.01). CONCLUSIONS: These findings are the first empirical estimations of PMTCT costs in Zimbabwe. Unitary costs were found to be heterogeneous across health facilities, with evidence consistent with economies of scale.

The role of management on costs and efficiency in HIV prevention interventions for female sex workers in Nigeria: a cluster-randomized control trial.

BACKGROUND: While the world has made much global progress toward the reduction of new HIV infections, HIV continues to be an important public health problem. In the face of constantly constrained resources, donors and grantees alike must seek to optimize resources and deliver HIV services as efficiently as possible. While there is evidence that management practices can affect efficiency, this has yet to be rigorously tested in the context of HIV service delivery. METHODS: The present protocol describes the design of a cluster-randomized control trial to estimate the effect of management practices on efficiency. Specifically, we will evaluate the impact of an intervention focused on improving management practices among community-based organizations (CBOs), on the costs of HIV prevention services for female sex workers (FSW) in Nigeria. To design the intervention, we used a qualitative, design thinking-informed methodology that allowed us to understand management in its organizational context better and to develop a user-centered solution. After designing the suite of management tools, we randomly assigned 16 CBOs to the intervention group, and 15 CBOs to the control group. The intervention consisted of a comprehensive management training and a management "toolkit" to support better planning and organization of their work and better communication between CBOs and community volunteers. Both treatment and control groups received training to record data on efficiency-inputs used, and outputs produced. Both groups will be prospectively followed through to the end of the study, at which point we will compare the average unit cost per FSW served between the two groups using a quasi-experimental "difference-in-differences" (DiD) strategy. This approach identifies the effect of the intervention by examining differences between treatment and control groups, before and after the intervention thus accounting for time-constant differences between groups. Despite the rigorous randomization procedure, the small sample size and diversity in the country may still cause unobservable characteristics linked to efficiency to unbalanced between treatment and control groups at baseline. In anticipation of this possibility, using the quasi-experimental DiD approach allows any baseline differences to be "differenced out" when measuring the effect. DISCUSSION: This study design will uniquely add to the literature around management practices by building rigorous evidence on the relationship between management skills and practices and service delivery efficiency. We expect that management will positively affect efficiency. This study will produce valuable evidence that we will disseminate to key stakeholders, including those integral to the Nigerian HIV response.Trial registration This trial has been registered in Clinical Trials (NCT03371914). Registered 13 December 2018.

Occupational and leisure time physical inactivity and the risk of type II diabetes and hypertension among Mexican adults: A prospective cohort study.

There is a lack of longitudinal data linking physical inactivity and chronic diseases among Mexicans. OBJECTIVE: To examine the relationship between total, leisure and occupational moderate-to-vigorous physical activity (MVPA) and incidence of type II diabetes (T2D) and hypertension in the Mexico City Diabetes Study. Study design and population. A prospective cohort study was conducted from 1989 to 2009 among 2282 men and non-pregnant women residing in six low-income neighborhoods in Mexico City. MAIN OUTCOME: Incidence of T2D and hypertension. RESULTS: After controlling for confounders, <1 MET/min/week of MVPA during leisure time was associated with higher risk of hypertension (HR 1.29, CI 95% 1.01, 1.66) and T2D (HR 1.31 CI 95% 1.00, 1.74). In addition, accumulating <1 MET/min/week of occupational MVPA was associated with higher risk of hypertension (HR 1.47, CI 95% 1.13, 1.90). CONCLUSION: The absence of leisure and occupational MVPA was associated with an increased risk of hypertension. However, no associations were found between occupational MVPA and T2D.

Targeted screening and treatment for latent tuberculosis infection using QuantiFERON-TB Gold is cost-effective in Mexico.

OBJECTIVE: To assess the cost-effectiveness of screening for latent tuberculosis infection (LTBI) using a commercially available detection test and treating individuals at high risk for human immunodeficiency virus (HIV) infection in a middle-income country. DESIGN: We developed a Markov model to evaluate the cost per LTBI case detected, TB case averted and quality-adjusted life year (QALY) gained for a cohort of 1000 individuals at high risk for HIV infection over 20 years. Baseline model inputs for LTBI prevalence were obtained from published literature and cross-sectional data from tuberculosis (TB) screening using QuantiFERON-TB Gold In-Tube (QFT-GIT) testing among sex workers and illicit drug users at high risk for HIV recruited through street outreach in Tijuana, Mexico. Costs are reported in 2007 US dollars. Future costs and QALYs were discounted at 3% per year. Sensitivity analyses were performed to evaluate model robustness. RESULTS: Over 20 years, we estimate the program would prevent 78 cases of active TB and 55 TB-related deaths. The incremental cost per case of LTBI detected was US$730, cost per active TB averted was US$529 and cost per QALY gained was US$108. CONCLUSIONS: In settings of endemic TB and escalating HIV incidence, targeting LTBI screening and treatment among high-risk groups may be highly cost-effective.