The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

Background: Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited. Objectives: To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention. Data sources: All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014. Review methods: A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation. Results: Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from ‘goals and planning’ and ‘identity’ groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation. Limitations: There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity. Conclusions: Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention. Future work: There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity

Chronic disease care in primary health care facilities in rural South African settings

A THESIS Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2016Background: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs.MT201

Reconciling the irreconcilable? An application of economics to long-term fiscal sustainability of the HIV/AIDS response in Uganda

This Ph.D. aims to propose a pragmatic approach to the long-term fiscal sustainability of the HIV and HIV response in Uganda. It is motivated by the fact that whereas financing of the HIV response has been among the dominant economic development issues over the last years, it now faces an uncertain outlook. Using a mixed-methods research approach, this Ph.D.’s empirical, theoretical, and methodological contributions improve our understanding of the economics (and politics) of achieving fiscal sustainability of HIV responses. Empirically, I found that Uganda will not “end AIDS” by 2030 despite projected significant reductions in AIDS deaths and new HIV infections by 68% and 80% respectively between 2010 and 2030 under a scale-up strategy, the Fast-Track approach. From a fiscal perspective, the corresponding direct and indirect HIV-induced contingent fiscal liabilities range between 150% and 200% of GDP (in 2015 terms). To cope with these fiscal quasi-liabilities implied by the national HIV response, a novel analytical framework for achieving fiscal sustainability of HIV responses is proposed and, through a proof-of-concept, validated in this Ph.D. Theoretically informed and relying on a set of core principles, behavioral economics-inspired, explicit political analysis and, game-theoretic approaches, I empirically assess the likely evolution of future public spending and revenues through analytic policy simulations and conclude that the fiscal space created from applying this novel and pragmatic approach could meet the above-mentioned HIV-induced contingent fiscal liabilities estimated at US$ 24 billion by 2030. This Ph.D. also explores political economy considerations regarding long-term funding for the HIV response. This Ph.D. hopes to contribute to technically sound and politically achievable approaches to addressing HIV-related long-term fiscal challenges in Uganda and, more broadly, toward literature on the political economy of fiscal sustainability

Celebration Schedule 2015 (Friday)

Full presentation schedule for Celebration, Friday, May 1, 201

Rationalising health care provision under market incentives: experimental evidence from south Africa

Unnecessary medical treatments place a significant burden on health systems striving for universal health coverage (UHC). This thesis studies inappropriate treatment incentives in the private sector in South Africa, where plans to implement a national health insurance system (NHI) foresee the contracting of private physicians to deliver publicly-funded health care. Private providers are increasingly recognized as necessary partners for UHC success in many low-and-middle-income countries (LMIC). However, aligning the incentives of these actors with UHC and public health goals requires a better understanding of incentive effects in these settings. I conduct two field experiments with incognito standardized patients (SPs), to both evaluate appropriate care provision and experimentally vary the treatment incentives facing private physicians. First, I run a within-subject experiment with 89 private primary care physicians (GPs) in Johannesburg, to investigate the causal impact of improving patients’ financial protection (insurance cover) on physicians’ quality of care delivery. The results suggest that more insured patients receive a higher level of visible clinical effort, but a lower level of technical care quality – including a higher likelihood of inappropriate antibiotic treatment. Second, I use data from the same experiment to evaluate the impact of patient insurance on the quantity and costs of care. I find that more insured patients are more likely to receive unnecessary diagnostic tests and treatment procedures, and receive more and more expensive branded drugs, resulting in significantly higher care costs. The results on antibiotic treatment and drug treatment quantity and costs occurred despite the absence of any financial incentives attached to drug prescribing for GPs, which suggests the presence of alternative motives for physicians’ treatment decisions that might vary with patient insurance – including intrinsic or altruistic motives. Third, I explore the scope for leveraging such intrinsic motivations to improve physicians’ treatment choices. I conduct a randomized (between-subject) experiment with 80 GPs, to evaluate the impact of intrinsic, informational incentives from private performance audit and feedback (A&F) on physicians’ antibiotic treatment choices and care costs. The findings suggest that private A&F can significantly reduce the likelihood of inappropriate antibiotic treatment for common viral infections that present in primary care, without simultaneously reducing appropriate antibiotic use for bacterial infections or increasing other inappropriate drug treatments. However, improved performance on antibiotic use does not coincide with significantly lower treatment costs or any improvements in measured diagnostic effort or accuracy. There is indicative evidence that prescribing norms and perceived patient expectations may play an important role in mediating private physicians’ treatment choices in all three empirical chapters

HIV Testing

It can be said that now is the best time for everyone infected to become aware of their own HIV status. The state of the art in HIV management progressively reveals that antiretroviral treatment can prevent transmission, as well as chronic damage in the human body, if started early. Unfortunately, antiretrovirals are not widely available in many places, especially in developing countries. In these parts of the world, diagnosis of HIV infection must be kept in the agenda as a priority, in order to understand specific details of local epidemics and as an effort to interrupt the chain of HIV transmission

Analyst-driven development of an open-source simulation tool to address poor uptake of O.R. in healthcare

Computer simulation studies of health and care problems have been reported extensively in the academic literature, but the one-off research projects typically undertaken have failed to create an enduring legacy of widespread use by healthcare practitioners. Simulation and other modelling tools designed and developed to be used routinely have not fared much better either. Following a review of the literature and a survey of frontline analysts in the UK NHS, we found that one reason for this is because simulation tools have, to date, not been developed with the requirements of the end-user in the heart of the development process. Starting with a thorough needs assessment of NHS based healthcare analysts, this study outlines a set of practical design principles to guide development of simulation software tool for conducting patient flow simulation studies. The overall requirement is that patient flow be modelled over a number of inter-connected points of delivery while capturing the stochastic nature of patient arrivals and hospital length of stay, as well as the dynamic delays to patient discharge and transfer of care between different points of care delivery. In ensuring a cost-free solution that is both versatile and user-friendly, and coded in an increasingly popular language among the envisaged end users, the tool was implemented is the R programming language and software environment, with the user interface implemented in the interactive R-Shiny application. The talk will provide an overview of the project lifecycle including an illustrative example of an empirical simulation study concerning the centralisation of an acute stroke pathway

Antibody engineering & therapeutics, the annual meeting of the antibody society December 7-10, 2015, San Diego, CA, USA

The 26th Antibody Engineering & Therapeutics meeting, the annual meeting of The Antibody Society united over 800 participants from all over the world in San Diego from 6-10 December 2015. The latest innovations and advances in antibody research and development were discussed, covering a myriad of antibody-related topics by more than 100 speakers, who were carefully selected by The Antibody Society. As a prelude, attendees could join the pre-conference training course focusing, among others, on the engineering and enhancement of antibodies and antibody-like scaffolds, bispecific antibody engineering and adaptation to generate chimeric antigen receptor constructs. The main event covered 4 d of scientific sessions that included antibody effector functions, reproducibility of research and diagnostic antibodies, new developments in antibody-drug conjugates (ADCs), preclinical and clinical ADC data, new technologies and applications for bispecific antibodies, antibody therapeutics for non-cancer and orphan indications, antibodies to harness the cellular immune system, building comprehensive IgVH-gene repertoires through discovering, confirming and cataloging new germline IgVH genes, and overcoming resistance to clinical immunotherapy. The Antibody Society's special session focused on "Antibodies to watch" in 2016. Another special session put the spotlight on the limitations of the new definitions for the assignment of antibody international nonproprietary names introduced by the World Health Organization. The convention concluded with workshops on computational antibody design and on the promise and challenges of using next-generation sequencing for antibody discovery and engineering from synthetic and in vivo libraries

Track D Social Science, Human Rights and Political Science

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138414/1/jia218442.pd

PROGRAM and PROCEEDINGS THE NEBRASKA ACADEMY OF SCIENCES 1880-2017 Including the Nebraska Association of Teachers of Science (NATS) Division Nebraska Junior Academy of Sciences (NJAS) Affiliate and Affiliated Societies

FRIDAY, APRIL 21, 2017 7:30 a.m. REGISTRATION FOR ACADEMY, Lobby of Lecture wing, Olin Hall 8:00 Aeronautics and Space Science, Session A, Olin 249 Aeronautics and Space Science, Session B, Olin 224 Chemistry and Physics, Section A, Chemistry, Olin A Collegiate Academy, Biology, Session A, Olin B Collegiate Academy, Biology, Session B, Olin 112 Collegiate Academy, Chemistry and Physics, Session A, Olin 324 8:30 Biological and Medical Sciences, Session A, Smith Callen Conference Center 9:10 Aeronautics and Space Science, Poster Session, Olin 249 9:40 Applied Science and Technology, Olin 325 10:00 Chemistry and Physics, Physics, Section B, Planetarium 10:30 Aeronautics and Space Science, Poster Session, Olin 249 11:00 MAIBEN MEMORIAL LECTURE, OLIN B – Scholarship and Friend of Science Recipients also announced. 12:00 LUNCH, PATIO ROOM, STORY STUDENT CENTER Aeronautics Group, Sunflower Room 1:00 p.m. Anthropology, Olin 111 Biological and Medical Sciences, Session B, Smith Callen Conference Center Collegiate Academy, Biology, Session A, Olin B Collegiate Academy, Biology, Session B, Olin 112 Collegiate Academy, Chemistry and Physics, Session B, Olin 324 Earth Science, Olin 249 1:05 Applied Science and Technology, Olin 325 1:15 Teaching of Science and Math, Olin 224 Chemistry and Physics, Section A, Chemistry, Olin A 2:45 Environmental Sciences, Olin 249 4:30 BUSINESS MEETING, OLIN B Abstracts of papers 2016-2017 EXECUTIVE COMMITTEE 2016-2017 PROGRAM COMMITTEE 2016-2017 POLICY COMMITTEE FRIENDS OF THE ACADEMY FRIEND OF SCIENCE AWARD WINNERS FRIEND OF SCIENCE AWARD TO KACIE BAUM FRIEND OF SCIENCE AWARD TO TODD YOUNG Author Index 141 p