Predicted and observed impacts of COVID-19 lockdowns: two Health Impact Assessments in Scotland and Wales.

Health Impact Assessment is a key approach used internationally to identify positive or negative impacts of policies, plans and proposals on health and well-being. In 2020, HIAs were undertaken in Scotland and Wales to identify the potential health and well-being impacts of the 'stay at home' and physical distancing measures implemented at the start of the coronavirus disease (COVID-19) pandemic. There is sparse evidence evaluating whether the impacts predicted in HIAs occur following policy implementation. This paper evaluates the impacts anticipated in the COVID-19 HIAs against actual observed trends. The processes undertaken were compared and predicted impacts were tabulated by population groups and main determinants of health. Routine data and literature evidence were collated to compare predicted and observed impacts. Nearly all health impacts anticipated in both HIAs have occurred in the direction predicted. There have been significant adverse impacts through multiple direct and indirect pathways including loss of income, social isolation, disruption to education and services, and psychosocial effects. This research demonstrates the value of prediction in impact assessment and fills a gap in the literature by comparing the predicted impacts identified within the HIAs with observed trends. Post-COVID-19 recovery should centre health and well-being within future policies and decisions. Processes like HIA can support this as part of a 'health in all policies' approach to improve the health and well-being of populations.

Health Impact Assessment (HIA) is an approach used to identify positive or negative impacts of policies, plans and proposals on health and well-being. In 2020, HIAs were undertaken in Scotland and Wales to identify the potential health and well-being impacts of the 'stay at home' and physical distancing measures (commonly called 'lockdown') which were put in place at the start of the COVID-19 pandemic. This paper evaluates whether these assessments were correct in their predictions. It finds that most of the health impacts anticipated in both assessments have occurred. These include significant impacts on income, employment and mental health. Using HIAs can help policymakers to take full account of these wider impacts on health and develop policies that benefit health and health equity.

Using health impact assessment (HIA) to understand the wider health and well-being implications of policy decisions: the COVID-19 'staying at home and social distancing policy' in Wales.

BACKGROUND: Health Impact Assessment (HIA) is promoted as a decision-informing tool by public health and governmental agencies. HIA is beneficial when carried out as part of policy development but is also valuable as a methodology when a policy is being implemented to identify and understand the wider health and well-being impacts of policy decisions, particularly when a decision needs to be taken rapidly to protect the population. This paper focusses on a HIA of the 'Staying at Home and Social Distancing Policy' or 'lockdown' in response to the COVID-19 pandemic in Wales conducted by the Welsh national public health institute. It describes the process and findings, captures the learning and discusses how the process has been used to better understand the wider health and well-being impacts of policy decisions beyond direct health harm. It also examines the role of public health institutes in promoting and using HIA. METHODS: A HIA was conducted following a standard HIA five step process. A literature review was undertaken alongside 15 qualitative semi-structured interviews with key stakeholders, and relevant health and demographic data were collated. The results were triangulated and analysed to form a holistic assessment of the policy decision and its impacts. RESULTS: A wide range of major health and well-being impacts of the lockdown in Wales were identified across the determinants of health, which included positive and negative social, economic, environmental and mental well-being impacts beyond the impact on direct health. Populations affected included children and young people, those on low incomes and women as well as those whose health has been directly impacted by COVID-19 such as older people. The work highlighted the benefit that HIA can bring in emphasizing impacts which can inform policy and shared learning with others. CONCLUSION: HIA is a largely underused tool to understand the impact of policy and political decisions, particularly when a decision has been taken at speed. This case study highlights how HIA provide evidence and information for advocacy and further work by public health institutes, health agencies and policy makers.

The social value of investing in public health across the life course: a systematic scoping review.

BACKGROUND: Making the case for investing in public health by illustrating the social, economic and environmental value of public health interventions is imperative. Economic methodologies to help capture the social value of public health interventions such as Social Return on Investment (SROI) and Social Cost-Benefit Analysis (SCBA) have been developed over past decades. The life course approach in public health reinforces the importance of investment to ensure a good start in life to safeguarding a safe, healthy and active older age. This novel review maps an overview of the application of SROI and SCBA in the existing literature to identify the social value of public health interventions at individual stages of the life course. METHODS: A systematic scoping review was conducted on peer-reviewed and grey literature to identify SROI and SCBA studies of public health interventions published between January 1996 and June 2019. All primary research articles published in the English language from high-income countries that presented SROI and SCBA outputs were included. Studies were mapped into stages of the life course, and data on the characteristics of the studies were extracted to help understand the application of social value methodology to assess the value of public health interventions. RESULTS: Overall 40 SROI studies were included in the final data extraction, of which 37 were published in the grey literature. No SCBA studies were identified in the search. Evidence was detected at each stage of the life course which included; the birth, neonatal period, postnatal period and infancy (n = 2); childhood and adolescence (n = 17); adulthood (main employment and reproductive years) (n = 8); and older adulthood (n = 6). In addition, 7 studies were identified as cross-cutting across the life course in their aims. CONCLUSION: This review contributes to the growing evidence base that demonstrates the use of social value methodologies within the field of public health. By mapping evidence across stages of the life course, this study can be used as a starting point by public health professionals and institutions to take forward current thinking about moving away from traditional economic measures, to capturing social value when investing in interventions across the life course.

Does continuous trusted adult support in childhood impart life-course resilience against adverse childhood experiences - a retrospective study on adult health-harming behaviours and mental well-being.

BACKGROUND: Adverse childhood experiences (ACEs) including child abuse and household problems (e.g. domestic violence) increase risks of poor health and mental well-being in adulthood. Factors such as having access to a trusted adult as a child may impart resilience against developing such negative outcomes. How much childhood adversity is mitigated by such resilience is poorly quantified. Here we test if access to a trusted adult in childhood is associated with reduced impacts of ACEs on adoption of health-harming behaviours and lower mental well-being in adults. METHODS: Cross-sectional, face-to-face household surveys (aged 18-69 years, February-September 2015) examining ACEs suffered, always available adult (AAA) support from someone you trust in childhood and current diet, smoking, alcohol consumption and mental well-being were undertaken in four UK regions. Sampling used stratified random probability methods (n = 7,047). Analyses used chi squared, binary and multinomial logistic regression. RESULTS: Adult prevalence of poor diet, daily smoking and heavier alcohol consumption increased with ACE count and decreased with AAA support in childhood. Prevalence of having any two such behaviours increased from 1.8% (0 ACEs, AAA support, most affluent quintile of residence) to 21.5% (≥4 ACEs, lacking AAA support, most deprived quintile). However, the increase was reduced to 7.1% with AAA support (≥4 ACEs, most deprived quintile). Lower mental well-being was 3.27 (95% CIs, 2.16-4.96) times more likely with ≥4 ACEs and AAA support from someone you trust in childhood (vs. 0 ACE, with AAA support) increasing to 8.32 (95% CIs, 6.53-10.61) times more likely with ≥4 ACEs but without AAA support in childhood. Multiple health-harming behaviours combined with lower mental well-being rose dramatically with ACE count and lack of AAA support in childhood (adjusted odds ratio 32.01, 95% CIs 18.31-55.98, ≥4 ACEs, without AAA support vs. 0 ACEs, with AAA support). CONCLUSIONS: Adverse childhood experiences negatively impact mental and physical health across the life-course. Such impacts may be substantively mitigated by always having support from an adult you trust in childhood. Developing resilience in children as well as reducing childhood adversity are critical if low mental well-being, health-harming behaviours and their combined contribution to non-communicable disease are to be reduced.

Foucault, surveillance, and carbon monoxide testing within stop-smoking services.

Health professionals have adopted proactive testing for early evidence of disease. Researchers have identified that this leads to enumerated understandings and shapes behavior in productive ways. Smoking-cessation advisors regularly test clients for carbon monoxide (CO), but client views of this had not previously been explored. We interviewed 23 clients of a United Kingdom-based stop-smoking service regarding their experiences of CO testing. The majority of participants were successful quitters. We used ATLAS.ti 7 as a data-management tool during structured qualitative analysis. Our findings reveal that clients believed the results of their CO tests. Many became enumerated in their understanding, and thus placed themselves in a hierarchy with other members of their group. Almost all clients found that knowing their CO test score was motivating. We conclude that additional research is needed to understand the experiences of CO testing among clients who do not quit.

Determining the Public Health Impact of Climate Change: A National Study Using a Health Impact Assessment Approach in Wales.

Objective: Climate change is recognised as the biggest threat to global health of the 21st century and impacts on health and wellbeing through a range of factors. Due to this, the need to take action in order to protect population health and wellbeing is becoming ever more urgent. Methods: In 2019, Public Health Wales carried out a comprehensive mixed-method Health Impact Assessment (HIA) of climate change. Unlike other risk assessments, it appraised the potential impact of climate change on health and inequalities in Wales through participatory workshops, stakeholder consultations, systematic literature reviews and case studies. Results: The HIA findings indicate potential impacts across the wider determinants of health and wellbeing. For example, air quality, excess heat/cold, flooding, economic productivity, infrastructure, and community resilience. A range of impacts were identified across population groups, settings, and geographical areas. Conclusion: These findings can inform decision-makers to prepare for climate change plans and policies using an evidence-informed approach. The work has demonstrated the value of a HIA approach by mobilising a range of evidence through a transparent process, resulting in transferrable learning for others.

The social return on investment of physical activity and nutrition interventions-a scoping review.

Introduction: Scarcity of resources and mounting pressures on health systems make it critical to evaluate new and existing public health interventions related to physical activity and nutrition. The Social Return on Investment (SROI) framework has gained prominence for capturing traditional variables such as economic costs and returns, as well as wider beneficial social and environmental outcomes. A scoping review was conducted to present the existing evidence on the SROI of physical activity and nutrition interventions, demonstrating the wider benefits of these interventions. Methodology: Existing peer-reviewed evidence and grey literature was collated to identify physical activity and nutrition interventions that were evaluated using the SROI framework between January 1996 up until February 2022. Only literature published in the English language, interventions that were conducted in high-income countries were considered for inclusion. Study information and economic data was entered into a pre-prepared data extraction sheet and eligible studies were quality assessed using a 12-point quality assessment framework for SROI studies. Results: This review identified a total of 21 SROI studies, with only four deriving from peer-reviewed literature sources. In total, 18 studies evaluated physical activity interventions, one study was purely focused on nutrition, whereas the two remaining studies presented a mix of physical activity and nutrition. The majority of studies derived from the United Kingdom (n = 16) with very few of the studies published prior to 2010 (n = 1). In total, four studies were classified as low quality based on the 12-point quality assessment framework used for this review. Outcomes of the relevant studies show that the benefits of these interventions have added value to families, communities and the wider environments of the target groups. Conclusion: This scoping review is adding to research conducted to understand the wider value of public health interventions such as physical activity and nutrition interventions using the SROI framework. This is important so that the development and implementation of public health interventions have the greatest value to people and society, which also benefits decision-makers to effectively and sustainably allocate scarce resources.

Social Return on Investment (SROI) of mental health related interventions-A scoping review.

Background: There is a growing recognition of the need to effectively assess the social value of public health interventions through a wider, comprehensive approach, capturing their social, economic and environmental benefits, outcomes and impacts. Social Return on Investment (SROI) is a methodological approach which incorporates all three aspects for evaluating interventions. Mental health problems are one of the leading causes of ill health and disability worldwide. This study aims to map existing evidence on the social value of mental health interventions that uses the SROI methodology. Methods: A scoping evidence search was conducted on Medline, PubMed, Google Scholar and relevant gray literature, published in English between January 2000 and March 2021 to identify studies which capture the SROI of mental health interventions in high- and middle-income countries. Studies that reported mental health outcomes and an SROI ratio were included in this review. The quality of included studies was assessed using Krlev's 12-item quality assessment framework. Results: The search identified a total of 435 records; and 42 of them with varying quality met the study inclusion criteria. Most of the included studies (93%) were non-peer reviewed publicly available reports, predominantly conducted in the United Kingdom (88%); and majority (60%) of those studies were funded by charity/non-for-profit organizations. Out of 42 included studies, 22 were targeted toward individuals experiencing mental health problems and the remainder 20 were targeted to vulnerable groups or the general population to prevent, or reduce the risk of poor mental health. Eighty-one percent of included studies were graded as high quality studies based on Krlev's 12-item quality assessment framework. The reported SROI ratios of the included studies ranged from £0.79 to £28.00 for every pound invested. Conclusion: This scoping review is a first of its kind to focus on SROI of mental health interventions, finding a good number of SROI studies that show a positive return on investment of the identified interventions. This review illustrates that SROI could be a useful tool and source of evidence to help inform policy and funding decisions for investment in mental health and wellbeing, as it accounts for the wider social, economic and environmental benefits of public health interventions. More SROI research in the area of public health is needed to expand the evidence base and develop further the methodology.

Exploring the social value of Public Health Institutes: An international scoping survey and expert interviews.

Introduction: Making the case for investing in preventative public health by illustrating not only the health impact but the social, economic and environmental value of Public Health Institutes is imperative. This is captured by the concept of Social Value, which when measured, demonstrates the combined intersectoral value of public health. There is currently insufficient research and evidence to show the social value of Public Health Institutes and their work across the life course, population groups and settings, in order to make the case for more investment. Methods: During July 2021, a quantitative online self-administered questionnaire was conducted across international networks. Semi-structured interviews were also carried out with nine representatives to gain a deeper understanding. A thematic analysis was undertaken on the data collected. Results: In total, 82.3% (n = 14) were aware of the terminology of social value and 58.8% (n = 10) were aware of the economic method of Social Return on Investment. However, only two Institutes reported capturing social and community impacts within their economic analysis and only 41.2% (n = 7) currently capture or measure the social value of their actions. Interviews and survey responses indicate a lack of resources, skills and buy-in from political powers. Finally, 76.5% (n = 12) wanted to do more to understand and measure wider outcomes and impact of their actions. It was noted this can be achieved through enhancing political will, developing a community of best practice and tools. Conclusion: This research can inform future work to understand how to measure the holistic social value of Public Health Institutes, in order to strengthen institutional capacity and impact, as well as to achieve a more equitable society, and a more sustainable health system and economy, making the case for investing in public health, as we recover from COVID-19.

Facilitators, Barriers and Views on the Role of Public Health Institutes in Promoting and Using Health Impact Assessment-An International Virtual Scoping Survey and Expert Interviews.

Public health institutes have an important role in promoting and protecting the health and well-being of populations. A key focus of such institutes are the wider determinants of health, embracing the need to advocate for 'Health in All Policies' (HiAP). A valuable tool to support this is the health impact assessment. This study aims to support public health institutes to advocate more successfully for the use of health impact assessments and HiAP in order to promote and protect health, well-being and equity. During July 2021, a quantitative online survey was undertaken across international networks with 17 valid responses received. Semi-structured interviews were also administered with nine expert representatives and analysed thematically. In total, 64.7% (n = 11) of survey respondents were aware of health impact assessments and 47.1% (n = 8) currently conducted health impact assessments. It was noted that there are differing approaches to HIAs, with a need for a clear set of standards. Barriers to use included lack of knowledge, training and resources. Overall, 64.7% (n = 11) of survey respondents would like to do more to develop knowledge and capacity around health impact assessments. The results from this study can serve as a platform to help build knowledge, networks and expertise, to help support a 'Health in All Policies' approach and address inequalities which exist in all societies.

Toward an economy of wellbeing: The economic impact of the Welsh healthcare sector.

Population health and wellbeing is both a result, as well as a driver, of economic development and prosperity on global, European, national and sub-national (local) levels. Wales, one of the four United Kingdom (UK) nations, has shown a long-term commitment to sustainable development and achieving prosperity for all, providing a good example of both national and sub-national level, which can be useful for other European countries and regions. In this paper, the economic importance of the healthcare sector to the Welsh economy is explored. We use a large number of data sources for the UK and Welsh economy to derive an economic model for 2017. We estimate output, income, employment, value-added, and import multipliers of the healthcare sector. Results suggest that the healthcare sector has an above average contribution in four explored economic aspects of the Welsh economy (output, income, employment, value-added), according to its impact on the surrounding economic ecosystem. Also, it is below average regarding leaking through imports. The multipliers' values offer empirical evidence when deciding on alternative policy actions. Such actions can be used as a stimulus for encouraging regional development and post-COVID economic recovery. Our study refers to the Welsh healthcare sector's economic impact as a whole. Therefore, we suggest investigating the economic impact of individual healthcare providers in the future.

'Health in All Policies'-A Key Driver for Health and Well-Being in a Post-COVID-19 Pandemic World.

Policy in all sectors affects health, through multiple pathways and determinants. Health in all policies (HiAP) is an approach that seeks to identify and influence the health and equity impacts of policy decisions, to enhance health benefits and avoid harm. This usually involves the use of health impact assessment or health lens analysis. There is growing international experience in these approaches, and some countries have cross-sectoral governance structures that prioritize the assessment of the policies that are most likely to affect health. The fundamental elements of HiAP are inter-sectoral collaboration, policy influence, and holistic consideration of the range of health determinants affected by a policy area or proposal. HiAP requires public health professionals to invest time to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity. With commitment, political will and tools such as the health impact assessment, it provides a powerful approach to integrated policymaking that promotes health, well-being, and equity. The COVID-19 pandemic has raised the profile of public health and highlighted the links between health and other policy areas. This paper describes the rationale for, and principles underpinning, HiAP mechanisms, including HIA, experiences, challenges and opportunities for the future.

Adult support during childhood: a retrospective study of trusted adult relationships, sources of personal adult support and their association with childhood resilience resources.

BACKGROUND: Adverse childhood experiences (ACEs) can affect health and well-being across the life course. Resilience is an individual characteristic that is known to help negate the effect of adversities and potentially transform toxic stress into tolerable stress. Having access to a trusted adult during childhood is critical to helping children build resiliency. Here, we aim to understand the relationship between always having access to trusted adult support and childhood resilience resources, and examine which sources of personal adult support and the number of sources of adult support, best foster childhood resilience. METHODS: A Welsh national cross-sectional retrospective survey (n = 2497), using a stratified random probability sample. Data were collected via face-to-face interviews at participants' places of residence by trained interviewers. Analyses use chi-square and binary logistic regression methods. Outcome measures were childhood resilience resources, access to an always-available trusted adult, and sources of personal adult support. RESULTS: Prevalence of access to an always-available trusted adult decreased with increasing number of ACEs from 86.6% of individuals with no ACEs, to 44.4% of those with four or more ACEs (≥ 4). In addition, for those experiencing ≥ 4 ACEs, individuals with no access to a trusted adult were substantially less likely than those with access, to report childhood resilience resources. For example, for individuals with ≥ 4 ACEs, those with access to an always-available trusted adult were 5.6 times more likely to have had supportive friends and 5.7 times more likely to have been given opportunities to develop skills to succeed in life, compared to those with no access to a trusted adult. When looking at sources of personal adult support, resilience levels increased dramatically for those individuals who had either one parent only or two parents as sources of support, in comparison to those without parental support. CONCLUSIONS: Analyses here suggest strong relationships between elements of childhood resilience, constant access to trusted adults and different sources of personal adult support. While the eradication of ACEs remains unlikely, actions to strengthen childhood access to trusted adults may partially ease immediate harms and protect future generations.

Process, Practice and Progress: A Case Study of the Health Impact Assessment (HIA) of Brexit in Wales.

Health impact assessment (HIA) is a systematic and flexible tool, which is advocated by the World Health Organisation as a method through which to consider the impact of policies on the health and well-being of a population, and the inequalities that may arise because of it. In 2018, the HIA support unit in Wales carried out a comprehensive and unique HIA on the impact of Brexit in Wales. The aims were to understand the differential impacts that Brexit would have on the health and well-being of the population and to provide evidence to inform decision makers across a range of public bodies. It followed a five-step process for HIA and utilised a wide range of evidence sources and health intelligence including both quantitative and qualitative evidence. This paper reflects on the process of carrying out the HIA and the methods used. It discusses the stages of the HIA, and shares the findings and reflections of implementation which will be beneficial to other HIA practitioners and policy makers. It does not concentrate on the findings of the HIA in detail, but focusses on what worked and any challenges encountered. It has been used to progress the practice of HIA in Wales and demonstrates the value of HIA as a method to inform and influence complex decisions.

Health Impact and Social Value of Interventions, Services, and Policies: A Methodological Discussion of Health Impact Assessment and Social Return on Investment Methodologies.

Introduction: Assessing the positive and negative impact of policies, services and interventions on health and well-being is of great importance to public health. Health Impact Assessment (HIA) and Social Return on Investment (SROI) are established methodologies which assess potential effects on health and well-being, including social, economic and environmental factors, indicating synergies, and cross-over in their approach. Within this paper, we explore how HIA and SROI could complement each other to capture and account for the impact and social value of an assessed intervention or policy. Methods: A scoping review of academic and gray literature was undertaken to identify case studies published between January 1996 and April 2019 where HIA and SROI methodologies have been used to complement each other previously. Semi-structured interviews were carried out with nine international experts from a range of regulatory and legislative contexts to gain a deeper understanding of past experiences and expertise of both HIA and SROI. A thematic analysis was undertaken on the data collected. Results: The scoping review identified two published reports on scenarios where HIA and SROI have both been used to assess the same intervention. Results from the interviews suggest that both methods have strengths as standalone methodologies. HIAs were noted to be well-structured in their approach, assessing health and well-being in its broadest context. SROI was noted to add value by monetizing social value, as well as capturing the social and environmental impact. Similarities of the two methods was suggested as their strong emphasis on stakeholder engagement and common shared principles. When questioned how the two methods could complement each other in practice, our results indicate the benefits of using HIA as an initial exploration of impact, potentially using SROI subsequently to monetarize social value. Conclusion: HIA and SROI have many synergies in their approaches. This research suggests potential benefits when used in tandem, or combining the methods to assess impact and account for social value. Further research is needed to understand the implications of this in practice, and to understand how the results of the two methods could be used by decision-makers.

Do emotions related to alcohol consumption differ by alcohol type? An international cross-sectional survey of emotions associated with alcohol consumption and influence on drink choice in different settings.

OBJECTIVES: To examine the emotions associated with drinking different types of alcohol, explore whether these emotions differ by sociodemographics and alcohol dependency and whether the emotions associated with different drink types influence people's choice of drinks in different settings. DESIGN: International cross-sectional opportunistic survey (Global Drug Survey) using an online anonymous questionnaire in 11 languages promoted through newspapers, magazines and social media from November 2015 to January 2016. STUDY POPULATION: Individuals aged 18-34 years who reported consumption of beer, spirits, red and white wine in the previous 12 months and were resident in countries with more than 200 respondents (n=21 countries; 29 836 respondents). MAIN OUTCOME MEASURES: Positive and negative emotions associated with consumption of different alcoholic beverages (energised, relaxed, sexy, confident, tired, aggressive, ill, restless and tearful) over the past 12 months in different settings. RESULTS: Alcoholic beverages vary in the types of emotions individuals report they elicit, with spirits more frequently eliciting emotional changes of all types. Overall 29.8% of respondents reported feeling aggressive when drinking spirits, compared with only 7.1% when drinking red wine (p<0.001). Women more frequently reported feeling all emotions when drinking alcohol, apart from feelings of aggression. Respondents' level of alcohol dependency was strongly associated with feeling all emotions, with the likelihood of aggression being significantly higher in possible dependent versus low risk drinkers (adjusted OR 6.4; 95% CI 5.79 to 7.09; p<0.001). The odds of feeling the majority of positive and negative emotions also remained highest among dependent drinkers irrespective of setting. CONCLUSION: Understanding emotions associated with alcohol consumption is imperative to addressing alcohol misuse, providing insight into what emotions influence drink choice between different groups in the population. The differences identified between sociodemographic groups and influences on drink choice within different settings will aid future public health practice to further comprehend individuals' drinking patterns and influence behaviour change.

Five years' real-life experience with raltegravir in a large HIV centre.

Raltegravir was the first licensed integrase inhibitor. Real-life experience is informative and complements trial data. We therefore evaluated raltegravir use in adults in a large HIV treatment centre. From pharmacy and departmental HIV database records, we identified all adults taking ≥1 dose of raltegravir from first availability to the end of November 2012. Data were collected using a standardised case report form. Two hundred and fifteen individuals provided 502 patient-years (median 2.6 years/person) of raltegravir use. Of 215 individuals, 166 (77%) were male, median age 43 years; 189 (88%) were antiretroviral therapy (ART)-experienced and 26 (12%) ART-naive, with median baseline CD4 counts of 324 and 54 cells/µL, respectively. Of ten individuals using once-daily raltegravir, four, with good adherence remained virologically suppressed after a median 28 months, four stopped against medical advice, one stopped to simplify and one failed virologically. In hepatitis co-infection, 35 individuals (92 patient-years) took raltegravir without evidence of hepatotoxicity. Six women started raltegravir during pregnancy for intensification (5/6) or switch for tolerability without complications. Of ten individuals stopping raltegravir after virological failure, 2/4 with successful sequencing showed resistance. Raltegravir appears safe and effective, without evidence of toxicity above that in published trials, including in pregnancy and co-infections. Once-daily dosing seems effective where adherence is good.