Design, implementation, and monitoring of HIV service packages for people who inject drugs: An assessment of programs supported by the Global Fund in 46 countries.

BACKGROUND: People who inject drugs (PWID) are at higher risk of acquiring and transmitting HIV, accounting for an estimated 10% of HIV new infections globally. The World Health Organization (WHO) and other international agencies have clearly outlined the comprehensive package of services that should be available for PWID. METHODS: This paper summarizes the data and findings from the PWID service packages assessed in 15 countries across different regions. It also provides data on the design of PWID programs in a further 30 countries that identified PWID as a key population in their national HIV strategic documents. A mixed-method approach was used, including desk reviews, key informant interviews, site observations and group interviews with implementers and PWID focus groups. RESULTS: Design of service packages varied considerably between countries while many matched the WHO Comprehensive Package. Only 85% countries (39/46) included needle-syringe exchange programs (NSEP) and 76% included opioid agonist therapy (OAT). Only 17% countries included overdose management in their package design. Across the 46 countries assessed, the average coverage with defined prevention package was 40% among countries for which coverage figures could be derived. CONCLUSIONS: Despite some examples of client-based, high-quality services in challenging environments, few countries, which rely primarily on external donor support, are reaching the necessary coverage levels across the full range of PWID HIV prevention, testing and care services. Transition from donor to domestic funding to fund this element of the HIV responses in many countries presents a compelling case to prevent PWID from being further left behind.

Salt Intake and Risk of Disaster Hypertension Among Evacuees in a Shelter After the Great East Japan Earthquake.

This study investigated the association between salt intake and risk of disaster hypertension. We analyzed the data of surveys evaluating the health condition of evacuees in shelters after the Great East Japan Earthquake on April 30 and May 5, 2011. Among 272 subjects who completed the basic health condition questionnaire and underwent a medical examination, 158 (58%) had disaster hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg). Average estimated sodium intake assessed by spot urine was significantly associated with disaster hypertension (odds ratio per 1 g/d, 1.16; 95% CI, 1.05-1.30). When we defined the high risk factors for salt-sensitive hypertension as older age (≥65 years), obesity (body mass index, ≥25 kg/m2), chronic kidney disease, and diabetes mellitus, estimated sodium intake was found to be a risk factor for disaster hypertension in the total group (odds ratio per 1 g/d, 1.27; 95% CI, 1.12-1.43) and even in the group without prevalent hypertension before disaster (n=146; odds ratio per 1 g/d, 1.46; 95% CI, 1.19-1.79). There was an interaction between estimated sodium intake and disaster hypertension according to the presence or absence of high risk of salt-sensitive hypertension in the group without prevalent hypertension (P=0.03). Disaster hypertension conferred a risk of microalbuminuria (odds ratio, 3.00; 95% CI, 1.71-5.26; P<0.001). We conclude that increased estimated sodium intake was associated with disaster hypertension in evacuees after disaster. This association was noted in the population with high risk of salt-sensitive hypertension and without prevalent hypertension before natural disaster. Additionally, disaster hypertension was associated with subclinical organ damage.

Investing to end epidemics: the role of the Global Fund to control TB by 2030.

The Global Fund to fight AIDS, Tuberculosis and Malaria provides over three-quarters of all international financing towards TB programs with US$4.7 billion disbursed, supporting provision of treatment for 13.2 million patients with smear-positive TB and 210 000 patients with multidrug-resistant TB in over 100 countries since 2002. In 2013, the Global Fund launched a new funding model that, among others, is advancing strategic investments to maximize impact, addressing 'missing' TB cases, enhancing a synergistic response to TB/HIV dual epidemics, and building resilient and sustainable systems for health. A new Global Fund Strategy is under development through consultation with various stakeholders, with which the Global Fund will work to play a more catalytic role and foster innovations to end the TB epidemic.

Saving lives in health: global estimates and country measurement.

Daniel Low-Beer and colleagues provide a response from The Global Fund on the PLOS Medicine article by David McCoy and colleagues critiquing their lives saved assessment models. Please see later in the article for the Editors' Summary.

Re-invigorating Japan's commitment to global health: challenges and opportunities.

Over the past 50 years, Japan has successfully developed and maintained an increasingly equitable system of universal health coverage in addition to achieving the world's highest life expectancy and one of the lowest infant mortality rates. Against this backdrop, Japan is potentially in a position to become a leading advocate for and supporter of global health. Nevertheless, Japan's engagement with global health has not been outstanding relative to its substantial potential, in part because of government fragmentation, a weak civil society, and lack of transparency and assessment. Japan's development assistance for health, from both governmental and non-governmental sectors, has remained low and Japanese global health leadership has been weak. New challenges arising from changes in governance and global and domestic health needs, including the recent Great East Japan Earthquake, now provide Japan with an opportunity to review past approaches to health policy and develop a new strategy for addressing global and national health. The fragmented functioning of the government with regards to global health policy needs to be reconfigured and should be accompanied by further financial commitment to global health priorities, innovative non-governmental sector initiatives, increased research capacity, and investments in good leadership development as witnessed at the G8 Hokkaido Toyako Summit. Should this strategy development and commitment be achieved, Japan has the potential to make substantial contributions to the health of the world as many countries move toward universal coverage and as Japan itself faces the challenge of maintaining its own health system.

Rotavirus infections with multiple emerging genotypes in Sri Lanka.

Rotavirus diarrhea is an important cause of child mortality in developing countries, but studies on this diarrhea are scarce in Sri Lanka. A prospective study conducted in Sri Lanka on rotavirus infection among children in a hospital setting (n = 611) versus children residing in tsunami camps (n = 52) showed that prevalence of rotavirus infection was comparable, 21.9 and 20%, respectively. The hospital and camps were located in different districts. Analysis of the genotypes of 122 rotaviruses from the hospital and 12 from the camps indicated that G9P[8] was associated with 35 and 33%; G12P[8/nt] with 14.7 and 33%; G3P[8/4/nt] with 17 and 8% and G1P[8/4] with 6.5 and 16.7%. Rotaviruses with G2P[8/4/6] and G4P[8/4] were hospital-associated only, and some rotaviruses (9 and 8% from the hospital and the camps, respectively) were G- and P-nontypable. We conclude from the present study that multiple emerging genotypes were prevalent in Sri Lanka, and children in camps were at risk of developing diarrhea due to rotaviruses.

Knowledge, attitude, and practice (KAP) of HIV prevention and HIV infection risks among Congolese refugees in Tanzania.

Little is known about HIV infection risks and risk behaviours of refugees living in resource-scarce post-emergency phase camps in Africa. Our study at Nyarugusu Camp in Tanzania, covering systematically selected refugees (n = 1140) and refugees living with HIV/AIDS (PLWHA) (n = 182), revealed that the level of HIV risk of systematically selected refugees increased after displacement, particularly regarding the number having transactional sex for money or gifts, while radio broadcast messages are perceived to promote a base of risk awareness within the refugee community. While condoms are yet to be widely used in the camp, some refugees having transactional sex tended to undertake their own health initiatives such as using a condom, under the influence of peer refugee health workers, particularly health information team (HIT) members. Nevertheless, PLWHA were less faithful to one partner and had more non-regular sexual partners than the HIV-negative group. Our study revealed that community-based outreach by refugee health workers is conducive to risk behaviour prevention in the post-emergency camp setting. It is recommended to increase the optimal use of "radio broadcast messages" and "HIT," which can act as agents to reach out to wider populations, and to strengthen the focus on safer sex education for PLWHA; the aim being to achieve dual risk reduction for both refugees living with and without HIV/AIDS.

Possible prevalence and transmission of acute respiratory tract infections caused by Streptococcus pneumoniae and Haemophilus influenzae among the internally displaced persons in tsunami disaster evacuation camps of Sri Lanka.

OBJECTIVE: The objective of this prospective study was to investigate the status of acute respiratory tract infections caused by Haemophilus influenzae and Streptococcus pneumoniae in tsunami disaster evacuation camps. METHODS: Nasopharyngeal swabs (NP) of 324 internally displaced persons (IDP) in 3 different tsunami disaster evacuation camps of Sri Lanka were collected between March 18th and 20th, 2005, and analyzed for MIC, beta-lactamase production, serotypes, PCR and pulsed-field gel electrophoresis (PFGE). RESULTS: Many IDP had respiratory symptoms and the prevalence of cough and/or sputum was 84%, 70.5% and 64.7% in the three camps. Twenty-one H. influenzae from 20 IDP and 25 S. pneumoniae from 22 IDP were isolated from the NP. All H. influenzae isolates were nontypeable, and 5 were beta-lactamase producing. Seventeen pneumococci were susceptible, 5 showed intermediate resistance and 3 were fully resistant to penicillin G. Molecular analysis showed the 21 H. influenzae strains had 13 PFGE patterns and 25 pneumococci had 16 PFGE patterns. All 4 different PFGE patterns of H. influenzae strains were detected in a few IDP in camps 1 and 3, and 5 different PFGE patterns of serotype 3, 22A, 9A, 10A and 11A pneumococci were detected in a few IDP in camps 1 and 3. CONCLUSION: Our data indicate acute respiratory tract infections caused by various types of H. influenzae and S. pneumoniae appear to have been prevalent, some of which were potentially transmitted from person to person in tsunami disaster evacuation camps.

The dietary habits of non-asthmatic schoolchildren in Lhasa, Tibet.

The occurrence of asthma symptoms and food consumption frequencies in 13- to 14-year-old schoolchildren was investigated in Lhasa, Tibet (3,658 meters above sea level). A total of 99.2% of the schoolchildren reported that they had not experienced any wheezing during the prior 12 months. Among these students, more than 50% had consumed rice, meat, fruits, and vegetables at least three times per week in the preceding year. More than 70% of the non-asthmatic students rarely consumed margarine; 50% of these students rarely ate fast food; and 40% only occasionally ate fish during the prior 12 months. The dietary habits of the schoolchildren in Lhasa may have some potential beneficial roles in contributing to the low prevalence of asthma in this high altitude region.

The Okinawa Infectious Diseases Initiative.

At the Kyushu-Okinawa Group of Eight summit in 2000, Japan announced the Okinawa Infectious Diseases Initiative (IDI) and pledged to spend US$3 billion over a five year period to combat infectious and parasitic diseases in developing countries. The IDI has exceeded expectations, spending more than US$4 billion over four years. The IDI is a unique initiative with its own philosophical basis and specifically tailored interventions and measures that helped to initiate worldwide political and financial commitments in the fight against infectious diseases. Notably, it promoted partnerships among stakeholders and emphasized comprehensive and inter-sectoral approaches (i.e. coordination and collaboration between health and other sectors). It helped to create a new vision of what is possible in the global effort against communicable diseases and has been instrumental in shaping the changing environments of development assistance, poverty reduction and other trends to reduce the impact of infectious and parasitic diseases.

Who died as a result of the tsunami? Risk factors of mortality among internally displaced persons in Sri Lanka: a retrospective cohort analysis.

BACKGROUND: Describing adverse health effects and identifying vulnerable populations during and after a disaster are important aspects of any disaster relief operation. This study aimed to describe the mortality and related risk factors which affected the displaced population over a period of two and a half months after the 2004 Indian Ocean tsunami in an eastern coastal district of Sri Lanka. METHODS: A cross-sectional household survey was conducted in 13 evacuation camps for internally displaced persons (IDP). Information on all pre-tsunami family members was collected from householders, and all deaths which occurred during the recall period (77 to 80 days starting from the day of the tsunami) were recorded. The distribution of mortality and associated risk factors were analysed. Logistic regression modelling using the generalized estimating equations method was applied in multivariate analysis. RESULTS: Overall mortality rate out of 3,533 individuals from 859 households was 12.9% (446 deaths and 11 missing persons). The majority of the deaths occurred during and immediately after the disaster. A higher mortality was observed among females (17.5% vs. 8.2% for males, p < 0.001), children and the elderly (31.8%, 23.7% and 15.3% for children aged less than 5 years, children aged 5 to 9 years and adults over 50 years, respectively, compared with 7.4% for adults aged 20 to 29 years, p < 0.001). Other risk factors, such as being indoors at the time of the tsunami (13.8% vs. 5.9% outdoors, p < 0.001), the house destruction level (4.6%, 5.5% and 14.2% in increasing order of destruction, p < 0.001) and fishing as an occupation (15.4% vs. 11.2% for other occupations, p < 0.001) were also significantly associated with increased mortality. These correlations remained significant after adjusting for the confounding effects by multivariate analysis. CONCLUSION: A significantly high mortality was observed in women and children among the displaced population in the eastern coastal district of Sri Lanka who were examined by us. Reconstruction activities should take into consideration these changes in population structure.

Timing of mortality among internally displaced persons due to the tsunami in Sri Lanka: cross sectional household survey.

OBJECTIVE: To describe the distribution of mortality among internally displaced persons during two and a half months after the Indian Ocean tsunami, 2004. DESIGN: Cross sectional household survey with retrospective cohort analysis of mortality. SETTING: Camps for internally displaced persons due to the tsunami in an eastern coastal district of Sri Lanka. PARTICIPANTS: 3533 people from 859 households accommodated in 13 camps. MAIN OUTCOME MEASURES: All cause death and number of missing people. RESULTS: 446 deaths and 11 missing people were reported after the 2004 tsunami, of which most (99%) occurred on the day of the tsunami or within three days thereafter. No deaths were reported for the two and a half month period starting one week after the tsunami. CONCLUSIONS: Most mortality after the 2004 tsunami occurred within the first few days of the disaster and was low in the study area.

Anaemia, iron deficiency and vitamin A status among school-aged children in rural Kazakhstan.

OBJECTIVES: To investigate the prevalence of anaemia and iron deficiency and vitamin A status among school-aged children in rural Kazakhstan and identify factors associated with anaemia in this population. DESIGN: A cross-sectional design. SETTING: School-aged children in rural Kazakhstan. SUBJECTS: Socio-economic and anthropometric information was collected from 159 school-aged children living in the Kzyl-Orda region of Kazakhstan. Blood samples were collected and the concentrations of haemoglobin (Hb), serum iron, serum ferritin (SF), erythrocyte protoporphyrin (EP), serum retinol and beta-carotene, total iron binding capacity (TIBC), transferrin saturation (TS) and other haematological indices were measured. RESULTS: Among the 159 children, the prevalence of anaemia and iron deficiency defined by the multiple criteria model (SF, TS and EP) was 27% and 13%, respectively. Nine per cent had iron-deficiency anaemia and 21% had serum retinol value < 1.05 micromol l(-1). Mean SF and serum iron concentrations and TS were significantly lower in anaemic children than in their non-anaemic peers, while TIBC and EP were significantly higher in children with anaemia. Hb was significantly correlated with serum iron and retinol concentrations. Serum retinol and SF concentrations and mean corpuscular volume were significantly correlated with Hb by multiple regression analysis. CONCLUSIONS: Anaemia among school-aged children in rural Kazakhstan appears to be related to iron indices and vitamin A status.

Associations between nondipping of nocturnal blood pressure decrease and cardiovascular target organ damage in strictly selected community-dwelling normotensives.

BACKGROUND: In hypertensives, nondippers are more likely than dippers to suffer silent, as well as overt, hypertensive target organ damage. In this study, we investigated whether a nondipper status was associated with target organ damage in normotensives. METHODS: We performed ambulatory blood pressure (BP) monitoring, echocardiography, and carotid ultrasonography and measured natriuretic peptides and urinary albumin (UAE) in 74 normotensive subjects with the following criteria: 1) clinical BP <140/90 mm Hg; 2) average 24-h ambulatory BP <125/80 mm Hg. RESULTS: The left ventricular mass index (LVMI) and the relative wall thickness (RWT) measured by echocardiography were greater in nondippers than dippers (LVMI: 103 +/- 26 v 118 +/- 34 g/m(2), P <.05; RWT: 0.38 +/- 0.07 v 0.43 +/- 0.09, P <.01). Plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were higher in nondippers than dippers (ANP: 14 +/- 10 v 36 +/- 63 pg/mL, P <.01; BNP: 16 +/- 12 v 62 +/- 153 pg/mL, P <.05). There were no significant differences in UAE and intima-media thickness measured by carotid ultrasonography. CONCLUSIONS: Normotensive nondipping may not reflect renal damage, but may have a predominant effect on cardiac damage. Nondipping of nocturnal BP seems to be a determinant of cardiac hypertrophy and remodeling, and may result in a cardiovascular risk independent of ambulatory BP levels in normotensives.