Costs of a Brief Alcohol Consumption Reduction Intervention for Persons Living with HIV in Southwestern Uganda: Comparisons of Live Versus Automated Cell Phone-Based Booster Components.

Low-cost interventions are needed to reduce alcohol use among persons with HIV (PWH) in low-income settings. Brief alcohol interventions hold promise, and technology may efficiently deliver brief intervention components with high frequency. We conducted a costing study of the components of a randomized trial that compared a counselling-based intervention with two in-person one-on-one sessions supplemented by booster sessions to reinforce the intervention among PWH with unhealthy alcohol use in southwest Uganda. Booster sessions were delivered twice weekly by two-way short message service (SMS) or Interactive Voice Response (IVR), i.e. via technology, or approximately monthly via live calls from counsellors. We found no significant intervention effects compared to the control, however the cost of the types of booster sessions differed. Start up and recurring costs for the technology-delivered booster sessions were 2.5 to 3 times the cost per participant of the live-call delivered booster intervention for 1000 participants. These results suggest technology-based interventions for PWH are unlikely to be lower cost than person-delivered interventions unless they are at very large scale.

Sub-district costs and efficiency of a combination HIV/AIDS prevention-intervention in the Northwest Province of South Africa.

Background: We reviewed a combination prevention program to strengthen HIV prevention programming, community support mechanisms, community-based HIV testing, referral systems, and HIV prevention integration at the primary care level. The intervention included situational analysis to inform programming, community engagement and mobilization, and community-based biomedical and behavioral prevention. In support of PEPFAR's country-ownership paradigm, we costed the combination HIV prevention program to determine data needed for local ownership. This research used costing and health system perspectives. Results: Cost per person reached with individual or small group prevention interventions ranged from $63.93 to $4,344.88. (cost per health facility strengthened). Personnel costs drove the intervention. This was true regardless of year or activity (i.e. wellness days or events, primary health care strengthening, community engagement, and wellness clubs). Conclusions: Labor-intensive rather than capital-intensive interventions for low-income settings, like this one, are important for treating and preventing HIV/AIDS and other health conditions sustainably. Over time, costs shifted from international cost centers to in-country headquarters offices, as required for sustainable PEPFAR initiatives. Such costing center evolution reflected changes in the intervention's composition, including (1) the redesign and re-deployment of service delivery sites according to local needs, uptake, and implementation success and (2) the flexible and adaptable restructuring of intervention components in response to community needs.

Improving Pandemic Response With Military Tools: Using Enhanced Intelligence, Surveillance, and Reconnaissance.

The coronavirus disease 2019 (COVID-19) pandemic rocked the world, spurring the collapse of national commerce, international trade, education, air travel, and tourism. The global economy has been brought to its knees by the rapid spread of infection, resulting in widespread illness and many deaths. The rise in nationalism and isolationism, ethnic strife, disingenuous governmental reporting, lockdowns, travel restrictions, and vaccination misinformation have caused further problems. This has brought into stark relief the need for improved disease surveillance and health protection measures. National and international agencies that should have provided earlier warning in fact failed to do so. A robust global health network that includes enhanced cooperation with Military Intelligence, Surveillance, and Reconnaissance (ISR) assets in conjunction with the existing international, governmental, and nongovernment medical intelligence networks and allies and partners would provide exceptional forward-looking and early-warning and is a proactive step toward making our future safe. This will be achieved both by surveilling populations for new biothreats, fusing and disseminating data, and then reaching out to target assistance to reduce disease spread in unprotected populations.

A case-based approach to teaching epidemic and pandemic-related global health diplomacy and security in African countries.

A challenging concept to teach, few combined courses on epidemic-related global health diplomacy and security exist, and no known courses are currently available that have been exclusively designed for African nationals. In response, the University of California, San Francisco's Center for Global Health Delivery, Diplomacy and Economics (CGHDDE) developed and delivered a workshop for LMIC learners to better understand how politics, policy, finance, governance and security coalesce to influence global health goals and outcomes.

COVID-19 Pandemic as an Excellent Opportunity for Global Health Diplomacy.

Undoubtedly, the COVID-19 pandemic is not the first and most frightening global pandemic, and it may not be the last. At the very least, this phenomenon has though seriously challenged the health systems of the world; it has created a new perspective on the value of national, regional, and international cooperation during crises. The post-coronavirus world could be a world of intensified nationalist rivalries on the economic revival and political influence. However, strengthening cooperation among nations at different levels will lead to the growth of health, economy, and security. The current situation is a touchstone for international actors in coordinating the efforts in similar future crises. At present, this pandemic crisis cannot be resolved except through joint international cooperation, global cohesion, and multilateralism. This perspective concludes that the pandemic could be an excellent opportunity for the scope of global health diplomacy (GHD) and how it can be applied and practiced for strengthening five global arenas, namely (1) International Cooperation and Global Solidarity, (2) Global Economy, Trade and Development, (3) Global Health Security, (4) Strengthening health systems, and (5) Addressing inequities to achieve the global health targets. GHD proves to be very useful for negotiating better policies, stronger partnerships, and achieving international cooperation in this phase with many geopolitical shifts and nationalist mindset among many nations at this stage of COVID-19 vaccine roll-out.

Comparing substance use and mental health among sexual and gender minority and heterosexual cisgender youth experiencing homelessness.

Youth homelessness has been demonstrated to disproportionately affect sexual and gender minority (SGM) youth compared to heterosexual cisgender peers. In this context, we aimed to compare health risks between service-seeking SGM and heterosexual cisgender youth experiencing homelessness, including harmful risks stemming from substance use and severity of symptoms of mental health disorders. We recruited 100 racially diverse, unstably housed participants aged 18-24 who access services at an urban non-profit organization in San Francisco, CA. Data analysis included 56 SGM participants who identified as gay, lesbian, bisexual, pansexual, unsure, transgender, and nongender, and 44 heterosexual cisgender participants. In contrast to previous studies reporting significantly higher frequency of substance use and more severe symptoms of depression, generalized anxiety, and post-traumatic stress disorder among SGM youth compared to heterosexual cisgender peers, many of these health disparities were not observed in our diverse study population of service-seeking youth. Furthermore, with the exception of methamphetamine, SGM participants did not exhibit greater harmful risks resulting from substance use, such as health, social, financial, and legal complications. We discuss the reduced burden of health disparities between SGM and heterosexual cisgender youth in our service-seeking study population within the context of gender- and sexuality-affirming programming offered at the partnering community organization. We conclude that longitudinal data on these tailored community-level interventions are needed to further explore the reduced burden of health disparities observed among service-seeking SGM youth experiencing homelessness in San Francisco in order to continue supporting pathways out of homelessness for youth of all sexual and gender identities nationwide.

One step forward, two steps back: Tensions between malaria elimination and improved malaria surveillance in the Solomon Islands.

The Solomon Islands experienced, between 2010, an apparent meteoric fall in the level of malaria incidence and prevalence [1]. Thanks ostensibly to the efforts of bilateral and multilateral partners and donors, annual parasite incidence (API) fell from 70 to 40 per 1,000 population. With such dramatic progress, international efforts were hailed as dramatic successes and showcased as progress towards malaria elimination and eradication, Yet, paradoxically, the true caseload of malaria in the Solomon Islands has revealed a situation that calls for more, rather than less, support.

Capacity building, local ownership and implementation of a multi-level HIV/AIDS positive health, dignity, and prevention initiative in Mozambique: approach, challenges and lessons learned.

Mozambique has for many years suffered from a high burden of HIV with an estimated prevalence of 11.1% among adults age 15-49 years. In response, Positive Health, Dignity, and Prevention (or Positive Prevention as it is known in Mozambique), was developed as a method of integrating HIV care and prevention via capacity building. Through comprehensive holistic care, HIV transmission is prevented while simultaneously promoting the health of people living with HIV/AIDS. Our initiative used a three-tiered approach, and included activities at national, provincial, and community levels. In order to change patient behavior and successfully train health-care workers in Positive Prevention, it was therefore considered necessary to work at multiple levels of influence. This ensured that the individual-level behavior change of PLHIV and health-care providers was maximized through supportive environments and policies. Related national-level achievements included the establishment of a Positive Prevention technical working group; the development of a Positive Prevention policy document; training national policy-makers on Positive Prevention; the development and distribution of a nationally approved Positive Prevention training package; the integration of Positive Prevention into existing Ministry of Health curricula; the development and approval of national data collection forms; and the drafting of a related national strategy. The framework and key activities of the Mozambique Positive Prevention Program may help to inform and assist others involved in similar work, as well as advancing country or local ownership of HIV/AIDS treatment, care and prevention efforts. By using a three-tiered approach, a supportive system was created. This was critical to both optimizing Positive Prevention provision and building long-term capacity. In order for related efforts to be successful in other settings, we encourage implementing partners to also work at multiple levels, with local ownership principles in mind, in order that Positive Prevention programs may have the greatest possible effect.

Effects of a peer educator program for HIV status disclosure and health system strengthening: Findings from a clinic-based disclosure support program in Mozambique.

BACKGROUND: In Mozambique, HIV counseling and testing (HCT) rates are low and the cascade (or continuum) of care is poor. Perhaps more importantly, low disclosure rates and low uptake of joint testing are also related to both (1) limitations on access to services and (2) the availability of trained staff. We describe the implementation and impact of a disclosure support implemented by peer educators (PE). METHODS: Ten PEs, previously trained in basic HIV and post-test counseling, completed additional training on providing disclosure support for newly-diagnosed persons living with HIV (PLH). RESULTS: Of the 6,092 persons who received HCT, 677 (11.1%) tested positive. Any newly-diagnosed PLH who was tested when PEs were present (606 / 677) was approached about participating in the disclosure program; of these, 94.2% of PLH (n = 574) agreed to participate. Of these, at follow-up (between 1 day and 3 months later, depending on client inclination and availability) 91.9% (n = 528) said that they had disclosed their HIV infection, of whom 66.9% (n = 384) were female and 24.1% (n = 144) male. In turn, 92.7% of partners (n = 508) who had received HIV-related exposure information were tested; of these, 78.7% (n = 400) were found to be HIV-positive. Of the latter, 96.3% (n = 385) were then seen by health care providers and referred for further diagnosis and treatment. CONCLUSIONS: Supporting newly-diagnosed PLH is important both for their own health and that of others. For the newly-diagnosed, there are extensive challenges related to understanding the implications of their illness; social support from clinical care teams can be vital in planning and coping. Our study has shown that such support of PLH is also crucial to disclosure, in part via improving awareness of positive health implications for (and from) family, friends and other support networks.

The need for health diplomacy in health security operations.

The concept of health security involves the intersection of several fields and disciplines and is an inherently political and sensitive area. It is also a relatively a new field of study and practice which lacks a precise definition - though numerous disciplines and areas like foreign policy, national interests, trade interests, health security, disaster relief, and human rights contribute to the concept. The purpose of this paper is to highlight the need for, health diplomacy in improving health security. For example, it is not unusual for developing country societies to build their health security measures by restricting travel and movement of those emanating from affected areas. When extreme health security measures threaten cordial and cooperative relations between nations, the issue of protection of one country's population may lead to the risk of international conflict. As the World Health Organization (WHO) stated in 2007 that'functioning health systems are the bedrock of health security,' it is crucial that partners with sound financial and technical capacities benefit developing countries through their assistance and sharing information. This paper explores how health diplomacy holds great promise to address the needs of global health security through binding or nonbinding instruments, enforced by global governance mechanisms.

Global health diplomacy, health and human security: The ascendancy of enlightened self-interest.

The political, social, economic, and security implications of health-related issues such as emerging infectious diseases or the epidemic of Non Communicable Diseases offer a rare opportunity for professionals in foreign policy and international relations to engage with the health arena and at the same time for global health experts to enter into and intersect with the domain of diplomacy. The aim of this review is to understand and explore the concepts of global health diplomacy (GHD), health security, and human security. For this narrative review, a literature search was done in PubMed, Scopus, and EBSCO for the "global health diplomacy," "health security," and "human security," and full-texts were reviewed. The recent outbreaks of Ebola in West Africa and Zika in South America are pertinent examples of the nature of the human security crisis and the imminent and severe threat posed to human life across the globe as a result of these epidemics. The Commission on Human Security defines human security as the protection of the vital core of all human lives from critical and pervasive threats. We highlight the ways in which health has now become an issue of national security/global concern and also how GHD can aid in the development of new bilateral or multilateral agreements to safeguard the health and security of people in our globalized world. The paper provides a prospective about, and overview of, health and human security that essentially emphasizes the growing interlinkages between global health, diplomacy, and foreign policy.

A vision for global heath diplomacy in the foreign policy process: using smart power to prevent and resolve international conflict.

In the twenty-first Century, the developed world attempts to provide global health assistance, to poorer countries - at least in part in the pursuit and maintenance of world order and stability. Rarely, however - and in most cases, then on an ad hoc basis - are related foreign policy tools deployed in combination with each other. Nonetheless, there is currently greater openness than ever before to such interdigitation. Not least this reflects the unprecedented challenges of modern political and security conditions - struggling to operate amidst a broader culture of global adverserialism, and conflict which conventional systems of intervention have struggled to successfully resolve. The problems presented in this regard by the Iraq and Afghanistan conflicts have evolved into, and been magnified by, the limited range and availability of effective responses to contemporary threats such as the Islamic State, international terrorism, jihadism, and the Syrian civil war. The risk of further contagion to even more severe world stability concerns that these situations present calls for an urgent restructuring of the way in which foreign policy processes and initiatives work, including systems of coordination and consultation between national and international agencies of defense, diplomacy, and development.

Diplomacy and Health: The End of the Utilitarian Era.

Cost-effectiveness analysis (CEA), as a system of allocative efficiency for global health programs, is an influential criterion for resource allocation in the context of diplomacy and inherent foreign policy decisions therein. This is because such programs have diplomatic benefits and costs that can be uploaded from the recipient and affect the broader foreign policy interests of the donor and the diplomacy landscape between both parties. These diplomatic implications are vital to the long-term success of both the immediate program and any subsequent programs; hence it is important to articulate them alongside program performance, in terms of how well their interrelated interventions were perceived by the communities served. Consequently, the exclusive focus of cost-effectiveness on medical outcomes ignores (1) the potential non-health benefits of less cost-effective interventions and (2) the potential of these collateral gains to form compelling cases across the interdisciplinary spectrum to increase the overall resource envelope for global health. The assessment utilizes the Kevany Riposte's "K-Scores" methodology, which has been previously applied as a replicable evaluation tool1 and assesses the trade-offs of highly cost-effective but potentially "undiplomatic" global health interventions. Ultimately, we apply this approach to selected HIV/AIDS interventions to determine their wider benefits and demonstrate the value alternative evaluation and decision-making methodologies. Interventions with high "K-Scores" should be seriously considered for resource allocation independent of their cost-effectiveness. "Oregon Plan" thresholds2 are neither appropriate nor enforceable in this regard while "K-Score" results provide contextual information to policy-makers who may have, to date, considered only cost-effectiveness data. While CEA is a valuable tool for resource allocation, its use as a utilitarian focus should be approached with caution. Policy-makers and global health program managers should take into account a wide range of outcomes before agreeing upon selection and implementation.

Global Health Diplomacy, Monitoring & Evaluation, and the Importance of Quality Assurance & Control: Findings from NIMH Project Accept (HPTN 043): A Phase III Randomized Controlled Trial of Community Mobilization, Mobile Testing, Same-Day Results, and Post-Test Support for HIV in Sub-Saharan Africa and Thailand.

BACKGROUND: Provision and scale-up of high quality, evidence-based services is essential for successful international HIV prevention interventions in order to generate and maintain intervention uptake, study integrity and participant trust, from both health service delivery and diplomatic perspectives. METHODS: We developed quality assurance (QAC) procedures to evaluate staff fidelity to a cluster-randomized trial of the NIMH Project Accept (HPTN 043) assessing the effectiveness of a community-based voluntary counseling and testing strategy. The intervention was comprised of three components-Mobile Voluntary Counseling and Testing (MVCT), Community Mobilization (CM) and Post-Test Support Services (PTSS). QAC procedures were based on standardized criteria, and were designed to assess both provider skills and adherence to the intervention protocol. Supervisors observed a random sample of 5% to 10% of sessions each month and evaluated staff against multiple criteria on scales of 1-5. A score of 5 indicated 100% adherence, 4 indicated 95% adherence, and 3 indicated 90% adherence. Scores below 3 were considered unsatisfactory, and protocol deviations were discussed with the respective staff. RESULTS: During the first year of the intervention, the mean scores of MVCT and CM staff across the 5 study sites were 4 (95% adherence) or greater and continued to improve over time. Mean QAC scores for the PTSS component were lower and displayed greater fluctuations. Challenges to PTSS staff were identified as coping with the wide range of activities in the PTSS component and the novelty of the PTSS process. QAC fluctuations for PTSS were also associated with new staff hires or changes in staff responsibilities. Through constant staff monitoring and support, by Year 2, QAC scores for PTSS activities had reached those of MVCT and CM. CONCLUSIONS: The implementation of a large-sale, evidence based HIV intervention requires extensive QAC to ensure implementation effectiveness. Ongoing appraisal of study staff across sites ensures consistent and high quality delivery of all intervention components, in keeping with the goals of the study protocol, while also providing a forum for corrective feedback, additional supervision and retraining of staff. QAC ensures staff fidelity to study procedures and is critical to the successful delivery of multi-site HIV prevention interventions, as well as the delivery of services scaled up in programmatic situations.

Maternal Health Service Disparities Across Incomes and Implications on Prevention of Mother-to-Child Transmission Service Coverage: Current Context in Sub-Saharan Africa.

About 69% of people living with HIV globally and over 90% of the children who acquired HIV infection are in Sub-Saharan Africa. Despite this, promising results have been observed, especially over the last decade - for example, a 25% decline in new HIV infections as compared to 2001 and a 38% decline in the number of children newly infected by HIV in 2012 as compared to 2009. However, the Global Plan and the Global Fast-Track Commitments of eliminating new HIV infections among children require addressing impediments to service expansion. In this regard, this paper attempts to draw attention to the extent to which disparities across income in using antenatal care (ANC) services may constrain the prevention of mother-to-child transmission (PMTCT) service expansion in Sub-Saharan Africa. The analysis is based on ANC service coverage data from Demographic and Health Surveys conducted between 2008 and 2015 in 31 Sub-Saharan African countries; and PMTCT coverage data from UNAIDS datasets released in 2016. Our analysis found that women in the highest wealth quintile are about three times more likely to frequently use ANC services (at least four visits) as compared to those in the lowest wealth quintile (95%CI: 1.7-5.7, P<0.0001). A regression analysis shows that one-quarter of the PMTCT service coverage can be explained by the disparity in ANC use associated with income; and the higher the disparity in ANC use, the lower the PMTCT service (P<0.05). The findings suggest that achieving the ambitious plan of zero new HIV infections among children while keeping their mothers alive will require on-going PMTCT/ANC service integration and ensuring that programs reach women who are most in need; specifically those in the poorest income categories.

Maternal health service disparities across incomes and implications on prevention of mother-to-child transmission service coverage: current context in Sub-Saharan Africa

About 69% of people living with HIV globally and over 90% of the children who acquired HIV infection are in Sub-Saharan Africa. Despite this, promising results have been observed, especially over the last decade ­ for example, a 25% decline in new HIV infections as compared to 2001 and a 38% decline in the number of children newly infected by HIV in 2012 as compared to 2009. However, the Global Plan and the Global Fast-Track Commitments of eliminating new HIV infections among children require addressing impediments to service expansion. In this regard, this paper attempts to draw attention to the extent to which disparities across income in using antenatal care (ANC) services may constrain the prevention of mother-to-child transmission (PMTCT) service expansion in Sub-Saharan Africa. The analysis is based on ANC service coverage data from Demographic and Health Surveys conducted between 2008 and 2015 in 31 Sub-Saharan African countries; and PMTCT coverage data from UNAIDS datasets released in 2016. Our analysis found that women in the highest wealth quintile are about three times more likely to frequently use ANC services (at least four visits) as compared to those in the lowest wealth quintile (95%CI: 1.7-5.7, P<0.0001). A regression analysis shows that one-quarter of the PMTCT service coverage can be explained by the disparity in ANC use associated with income; and the higher the disparity in ANC use, the lower the PMTCT service (P<0.05). The findings suggest that achieving the ambitious plan of zero new HIV infections among children while keeping their mothers alive will require on-going PMTCT/ANC service integration and ensuring that programs reach women who are most in need; specifically those in the poorest income categories

James Bond and Global Health Diplomacy.

In the 21st Century, distinctions and boundaries between global health, international politics, and the broader interests of the global community are harder to define and enforce than ever before. As a result, global health workers, leaders, and institutions face pressing questions around the nature and extent of their involvement with non-health endeavors, including international conflict resolution, counter-terrorism, and peace-keeping, under the global health diplomacy (GHD) paradigm.