Preferences for Alternative Care Modalities Among French Adults With Chronic Illness

IMPORTANCE: The COVID-19 pandemic led to the implementation of alternative care modalities (eg, teleconsultations and task shifting) that will continue to be implemented in parallel to traditional care after the pandemic. An ideal balance between alternative and traditional care modalities is unknown. OBJECTIVES: To quantify the ideal postpandemic balance between alternative and traditional care modalities among patients with chronic illness and to qualify the circumstances in which patients consider it appropriate to replace traditional care with alternative care. DESIGN, SETTING, AND PARTICIPANTS: This survey study invited 5999 adults with chronic illness in ComPaRe, a French nationwide e-cohort of adults with chronic conditions who volunteer their time to participate in research projects, to participate in this study, which was performed from January 27 to February 23, 2021. MAIN OUTCOMES AND MEASURES: Participants rated the ideal proportion at which they would use 3 alternative care modalities instead of the traditional care equivalent on a 0% to 100% scale (with 0% indicating using alternative care modalities for none of one's future care and 100% indicating using alternative care modalities for all of one's future care) of their overall future care: (1) teleconsultations, (2) online symptom-checkers to react to new symptoms, and (3) remote monitoring to adapt treatment outside consultations. The median ideal proportion of alternative care use was calculated. Perceived appropriate circumstances in which each alternative modality could replace traditional care were collected with open-ended questions. Analyses were performed on a weighted data set representative of patients with chronic illness in France. RESULTS: Of the 5999 invited individuals, 1529 (mean [SD] age, 50.3 [14.7] years; 1072 [70.1%] female) agreed to participate (participation rate, 25.5%). Participants would choose teleconsultations for 50.0% of their future consultations (IQR, 11.0%-52.0%), online symptom-checkers over contacting their physician for 22.0% of new symptoms (IQR, 2.0%-50.0%), and remote monitoring instead of consultations for 52.3% of their treatment adaptations (IQR, 25.4%-85.4%). Participants reported 67 circumstances for which replacing traditional with alternative care modalities was considered appropriate, including 31 care activities (eg, prescription renewal and addressing acute or minor complaints), 25 patient characteristics (eg, stable chronic condition and established patient-physician relationship), and 11 required characteristics of the alternative care modalities (eg, quality assurance). CONCLUSIONS AND RELEVANCE: Results of this survey study suggest that after the pandemic, patients would choose alternative over traditional care for 22% to 52% of the time across different care needs. Participants proposed 67 criteria to guide clinicians in replacing traditional care with alternative care. These findings provide a guide for redesigning care in collaboration with patients after the pandemic

JMIR Res Protoc

BACKGROUND: Effective antiretroviral therapy has greatly reduced HIV-related morbidity and mortality, dramatically changing the demographics of the population of people living with HIV. The majority of people living with HIV in France are well cared for insofar as their HIV infection is concerned but remain at risk for age-associated comorbidities. Their long-term, potentially complex, and growing care needs make the routine, longitudinal assessment of health-related quality of life and other patient-reported outcomes of relevance in the current treatment era. OBJECTIVE: We aim to describe the development of a Web-based electronic patient-reported outcomes system for people living with HIV linked to the ANRS CO3 Aquitaine cohort's data capture and visualization system (ARPEGE) and designed to facilitate the electronic collection of patient-reported data and ultimately promote better patient-physician communication and quality of care (both patient satisfaction and health outcomes). METHODS: Participants who meet the eligibility criteria will be invited to engage with the Web-based electronic patient-reported outcomes system and provided with the information necessary to create a personal patient account. They will then be able to access the electronic patient-reported outcomes system and complete a set of standardized validated questionnaires covering health-related quality of life (World Health Organization's Quality of Life Instrument in HIV infection, named WHOQOL-HIV BREF) and other patient-reported outcomes. The information provided via questionnaires will ultimately be presented in a summary format for clinicians, together with the patient's HIV care history. RESULTS: The prototype of the Web-based electronic patient-reported outcome system will be finalized and the first 2 formative research phases of the study (prototyping and usability testing) will be conducted from December 2017 to May 2018. We describe the sequential processes planned to ensure that the proposed electronic patient-reported outcome system is ready for formal pilot testing, referred to herein as phases 1a and 1b. We also describe the planned pilot-testing designed to evaluate the acceptability and use of the system from the patient's perspective (phase 2). CONCLUSIONS: As the underlying information technology solution, ARPEGE, has being developed in-house, should the feasibility study presented here yield promising results, the panel of services provided via the proposed portal could ultimately be expanded and used to experiment with health-promoting interventions in aging people living with HIV in hospital-based care or adapted for use in other patient populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03296202; https://clinicaltrials.gov/ct2/show/NCT03296202 (Archived by WebCite at http://www.webcitation.org/6zgOBArps). REGISTERED REPORT IDENTIFIER: RR1-10.2196/9439

Improving Newborn Survival in Southern Tanzania (INSIST) trial; community-based maternal and newborn care economic analysis.

Despite health systems improvements in Tanzania, gaps in the continuum of care for maternal, newborn and child health persist. Recent improvements have largely benefited those over one month of age, leading to a greater proportion of under-five mortality in newborns. Community health workers providing home-based counselling have been championed as uniquely qualified to reach the poorest. We provide financial and economic costs of a volunteer home-based counselling programme in southern Tanzania. Financial costs of the programme were extracted from project accounts. Ministry of Health and Social Welfare costs associated with programme implementation were collected based on staff and project monthly activity plans. Household costs associated with facility-based delivery were also estimated based on exit interviews with post-natal women. Time spent on the programme by implementers was assessed by interviews conducted with volunteers and health staff. The programme involved substantial design and set-up costs. The main drivers of set-up costs were activities related to volunteer training. Total annualized costs (design, set-up and implementation) amounted to nearly US$300 000 for financial costs and just over US$400 000 for economic costs. Volunteers (n = 842) spent just under 14 hours per month on programme-related activities. When volunteer time was valued under economic costs, this input amounted to just under half of the costs of implementation. The economic consequences of increased service use to households were estimated at US$36 985. The intervention cost per mother-newborn pair visited was between US$12.60 and US$19.50, and the incremental cost per additional facility-based delivery ranged from US$85.50 to US$137.20 for financial and economic costs (with household costs). Three scale-up scenarios were considered, with the financial cost per home visit respectively varying from$1.44 to $3.21 across scenarios. Cost-effectiveness compares well with supply-side initiatives to increase coverage of facility-based deliveries, and the intervention would benefit from substantial economies of scale

The Search for Higgs particles at high-energy colliders: Past, Present and Future

I briefly review the Higgs sector in the Standard Model and its minimal Supersymmetric extension, the MSSM. After summarizing the properties of the Higgs bosons and the present experimental constraints, I will discuss the prospects for discovering these particle at the upgraded Tevatron, the LHC and a high-energy $e^+e^-$ linear collider. The possibility of studying the properties of the Higgs particles will be then summarized.Comment: 28 pages, latex, 15 figures, talk at WHEPP VII, Allahabad, Indi

Cohort profile:Collaboration of Observational HIV Epidemiological Research Europe (COHERE) in EuroCoord

Many questions about the long-term effects of combination antiretroviral therapy (cART) on clinical 3 outcomes in people living with HIV (PLWH) and their impact on health systems remain unanswered. The 4 Collaboration of Observational HIV Epidemiological Research Europe (COHERE) was formed in 2005 to 5 pool and harmonize existing longitudinal data on people living with HIV in Europe, to answer key 6 research questions that could not be addressed adequately by individual cohorts. Key research 7 questions include long-term prognosis, rare outcomes, and variations across patient groups, settings 8 and health systems. COHERE uses the HIV Cohorts Data Exchange Protocol, a standardized and validated 9 method of data structure and transfer, to compile data from over 40 cohorts of PLWH residing in 10 Europe, representing 331 481 individuals, including 2808 children (<13), representing 2 135 896 person- 11 years of follow-up. COHERE compiles data on clinical characteristics, antiretroviral therapy and other 12 medications, HIV seroconversion, opportunistic infections, laboratory results and socio demographic 13 data. External collaborators interested in conducting a project in COHERE should submit a project 14 proposal to the Regional Coordinating Centres in Bordeaux and Copenhagen for review by COHERE’s 15 governing bodies (see www.cohere.org for further information)

Withholding Primary Pneumocystis Pneumonia Prophylaxis in Virologically Suppressed Patients With Human Immunodeficiency Virus: An Emulation of a Pragmatic Trial in COHERE

BACKGROUND: Using data from the COHERE collaboration, we investigated whether primary prophylaxis for pneumocystis pneumonia (PcP) might be withheld in all patients on antiretroviral therapy (ART) with suppressed plasma human immunodeficiency virus (HIV) RNA (≤400 copies/mL), irrespective of CD4 count. METHODS: We implemented an established causal inference approach whereby observational data are used to emulate a randomized trial. Patients taking PcP prophylaxis were eligible for the emulated trial if their CD4 count was ≤200 cells/µL in line with existing recommendations. We compared the following 2 strategies for stopping prophylaxis: (1) when CD4 count was >200 cells/µL for >3 months or (2) when the patient was virologically suppressed (2 consecutive HIV RNA ≤400 copies/mL). Patients were artificially censored if they did not comply with these stopping rules. We estimated the risk of primary PcP in patients on ART, using the hazard ratio (HR) to compare the stopping strategies by fitting a pooled logistic model, including inverse probability weights to adjust for the selection bias introduced by the artificial censoring. RESULTS: A total of 4813 patients (10 324 person-years) complied with eligibility conditions for the emulated trial. With primary PcP diagnosis as an endpoint, the adjusted HR (aHR) indicated a slightly lower, but not statistically significant, different risk for the strategy based on viral suppression alone compared with the existing guidelines (aHR, .8; 95% confidence interval, .6-1.1; P = .2). CONCLUSIONS: This study suggests that primary PcP prophylaxis might be safely withheld in confirmed virologically suppressed patients on ART, regardless of their CD4 count.European Network of HIV/AIDS Cohort Studies to Coordinate at European and International Level Clinical Research on HIV/AID

Impact of CD4 and CD8 dynamics and viral rebounds on loss of virological control in HIV controllers

Objective: HIV controllers (HICs) spontaneously maintain HIV viral replication at low level without antiretroviral therapy (ART), a small number of whom will eventually lose this ability to control HIV viremia. The objective was to identify factors associated with loss of virological control. Methods: HICs were identified in COHERE on the basis of \ue2\u89\ua55 consecutive viral loads (VL) \ue2\u89\ua4500 copies/mL over \ue2\u89\ua51 year whilst ART-naive, with the last VL \ue2\u89\ua4500 copies/mL measured \ue2\u89\ua55 years after HIV diagnosis. Loss of virological control was defined as 2 consecutive VL &gt;2000 copies/mL. Duration of HIV control was described using cumulative incidence method, considering loss of virological control, ART initiation and death during virological control as competing outcomes. Factors associated with loss of virological control were identified using Cox models. CD4 and CD8 dynamics were described using mixed-effect linear models. Results: We identified 1067 HICs; 86 lost virological control, 293 initiated ART, and 13 died during virological control. Six years after confirmation of HIC status, the probability of losing virological control, initiating ART and dying were 13%, 37%, and 2%. Current lower CD4/CD8 ratio and a history of transient viral rebounds were associated with an increased risk of losing virological control. CD4 declined and CD8 increased before loss of virological control, and before viral rebounds. Discussion: Expansion of CD8 and decline of CD4 during HIV control may result from repeated low-level viremia. Our findings suggest that in addition to superinfection, other mechanisms, such as low grade viral replication, can lead to loss of virological control in HICs

Qualité de vie des personnes vivant avec le VIH : Mesure, déterminants et axes de prise en charge : Conception, recherches préliminaires et première année de mise en œuvre de la sous-étude QuAliV dans la cohorte ANRS CO3 Aquitaine

HIV has become a chronic disease in France. Nevertheless, HIV and associated inflammation, the effects of antiretroviral exposure, the high prevalence of modifiable risk factors for age-related diseases (e.g. smoking) and the effects of other viral co-infections together with social and economic vulnerability make the quality of life of people living with HIV (PLWH) an ongoing concern. French clinical guidelines have urged providers to address PLWH’s health as defined by the World Health Organisation. To take on this challenge, we designed an electronic module for the collection of patient-reported outcome linked the ANRS Aquitaine cohort’s data capture and visualisation system. The proposed solution relies on validated questionnaires and its content is based on current clinical guidelines on HIV management. The questionnaires’ psychometric properties, administration method/mode, and length were evaluated and paper-based instruments adapted following the International Society for Pharmacoeconomics and Outcomes Research’s guidance. Two rounds of usability evaluations were conducted first in research staff and the PLWH. We asked participants to complete a set of tasks using the ‘think aloud’ method and respond to the System Usability Scale (SUS). Input from experts/investigators and subsequently patients was used to improve features of the system. We calculated a summary score and defined “success” a priori as a usability score of 70. Experts reported average SUS scores of 65 ± 18.87 and patients reported average SUS scores of 85 ± 5.4 (p=0.032). To date, the collection of (electronic and paper) patient-reported outcomes, including health-related quality of life, is underway in five hospitals. Of those invited to participate (July 2018-May 2019), 90.5% (1,521/1,681) accepted, 7.1% (119/1,681) refused and 2.4% (41/1,681) were not eligible. Of those who accepted, 82% (1,246/1,521) were considered to have met the basic requirements of the newly designed solution whereas 18% (275/1,521) did not have a personal email address and/or a reliable Internet connection and were provided an identical paper questionnaire. We verified the psychometric properties of the WHOQOL-HIV BREF instrument, chosen to assess (health-related) quality of life in our population in a sample of 586 PLWH (aged 56 on average, 73% were male, 85% were of French origin, 99% were treated and 93% had an undetectable viral load). The French version of the WHOQOL-HIV BREF has acceptable measurement properties and its broad conceptualization of quality of life, going beyond physical and mental health, may be particularly useful in our population. On a scale of 4 (worst) to 20 (best), the personal belief domain had the highest average score (15.04 ± 3.35) and the lowest psychological health domain (13.70 ± 2.78). The most impaired facets (score of 1-5) were personal relationships (2.7 ± 1.25) and financial resources (2.9 ± 1.15). Women scored significantly lower than men on 12 of 29 facets, including the five HIV-specific facets. People born in North Africa or sub-Saharan Africa have lower scores in the environmental health domain than those born in France (13.19 ± 2.10 versus 14.52 ± 2.56, p<0.001). This work has been the first step in fostering a new relationship with those in care in the region. It has resulted in highlighting a number of areas that we feel need to be addressed in order to successfully develop new value-based models of care and social services which take into consideration and efficiently respond to PLWH’s global needs.L’infection par le VIH est devenue une maladie chronique en France. Néanmoins, le VIH et l'inflammation associée, les effets de l'exposition aux antirétroviraux, la prévalence élevée de facteurs de risque modifiables pour les maladies liées à l'âge, les effets d'autres co-infections virales couplés à la vulnérabilité sociale et économique font de la qualité de vie des personnes vivant avec le VIH (PVVIH) une préoccupation constante. Les recommandations de prise en charge incitent à prendre en compte la santé des PVVIH telle que définie par l'Organisation Mondiale de la Santé. Nous avons cherché à relever ce défi en concevant un module relié au système d’information de la Cohorte ANRS CO3 Aquitaine qui facilite le recueil de données rapportées par les patients (y compris la qualité de vie) par le biais d'instruments validés. Le contenu (composé de questionnaires courts et validés) du système est basé sur les recommandations thérapeutiques. Les propriétés psychométriques, la méthode et le mode d'administration ainsi que la longueur des questionnaires ont été évalués et des instruments papier ont été adaptés au format numérique selon les recommandations de l'International Society for Pharmacoeconomics and Outcomes Research. Les tests d'utilisabilité du nouveau module du système d’information se sont déroulés en deux cycles (1er auprès des experts et 2ème auprès des PVVIH). Nous avons demandé aux participants d'accomplir une série de tâches en utilisant la méthode « penser à voix haute » et de répondre à l'échelle de « System Usability Scale » (SUS). Nous avons calculé un score synthétique et défini a priori le « succès » comme un score d'utilisabilité de 70. Au premier cycle, les experts ont rapporté des scores SUS moyens de 65 ± 18,87 et les patients, au deuxième cycle, des scores SUS moyens de 85 ± 5,4 (p=0,032). A ce jour, le recueil (électronique et papier) de données rapportées par les patients, y compris la qualité de vie liée à la santé, est en cours dans cinq hôpitaux de la région Nouvelle Aquitaine. Parmi ceux qui ont été invités à participer (juillet 2018-mai 2019), 90,5% (1 521/1 681) ont accepté, 7,1 % (119/1 681) ont refusé et 2,4 % (41/1 681) étaient non- éligibles. Parmi ceux qui ont accepté, 82% (1246/1 521) ont été considérés comme ayant satisfait aux exigences de base du nouveau système d’information tandis que 18 % (275/1 521) n'avaient pas d’adresse courriel personnelle. Les propriétés métriques de l’instrument de mesure choisi pour évaluer la qualité de vie (liée à la santé) dans notre population ont été ensuite évaluées sur un échantillon de 586 PVVIH, âgées de 56 ans en moyenne. 73 % étaient des hommes, 85 % étaient d'origine française, 99% étaient sous antirétroviraux et 93 % avaient une charge virale indétectable. La version française du WHOQOL-HIV BREF a des propriétés de mesure acceptables et sa conceptualisation large de la qualité de vie (au-delà de la santé physique et mentale) peut s'avérer particulièrement utile dans notre population. Sur une échelle de 4 à 20, le domaine des croyances personnelles avait le score moyen le plus élevé (15,04 ± 3,35) et le domaine de la santé psychologique le plus faible (13,70 ± 2,78). Les aspects (score de 1 à 5) les plus altérés étaient les relations personnelles (2,7 ± 1,25) et les ressources financières (2,9 ± 1,15).[...] Cette nouvelle démarche a été la première étape dans l'établissement d'un nouveau rapport avec les personnes prises en charge dans la région. Elle a permis de mettre en lumière des domaines qui, selon nous, doivent être particulièrement ciblés afin de développer avec succès de nouveaux modèles de soins et de services sociaux qui tiennent compte des besoins globaux des PVVIH et y répondent efficacemen

Quality of life of people living with HIV : Measurement, determinants and priorities for care : Conception, formative research, and the first year of inclusions in the QuAliV ancillary study of the ANRS CO3 Aquitaine cohort.

L’infection par le VIH est devenue une maladie chronique en France. Néanmoins, le VIH et l'inflammation associée, les effets de l'exposition aux antirétroviraux, la prévalence élevée de facteurs de risque modifiables pour les maladies liées à l'âge, les effets d'autres co-infections virales couplés à la vulnérabilité sociale et économique font de la qualité de vie des personnes vivant avec le VIH (PVVIH) une préoccupation constante. Les recommandations de prise en charge incitent à prendre en compte la santé des PVVIH telle que définie par l'Organisation Mondiale de la Santé. Nous avons cherché à relever ce défi en concevant un module relié au système d’information de la Cohorte ANRS CO3 Aquitaine qui facilite le recueil de données rapportées par les patients (y compris la qualité de vie) par le biais d'instruments validés. Le contenu (composé de questionnaires courts et validés) du système est basé sur les recommandations thérapeutiques. Les propriétés psychométriques, la méthode et le mode d'administration ainsi que la longueur des questionnaires ont été évalués et des instruments papier ont été adaptés au format numérique selon les recommandations de l'International Society for Pharmacoeconomics and Outcomes Research. Les tests d'utilisabilité du nouveau module du système d’information se sont déroulés en deux cycles (1er auprès des experts et 2ème auprès des PVVIH). Nous avons demandé aux participants d'accomplir une série de tâches en utilisant la méthode « penser à voix haute » et de répondre à l'échelle de « System Usability Scale » (SUS). Nous avons calculé un score synthétique et défini a priori le « succès » comme un score d'utilisabilité de 70. Au premier cycle, les experts ont rapporté des scores SUS moyens de 65 ± 18,87 et les patients, au deuxième cycle, des scores SUS moyens de 85 ± 5,4 (p=0,032). A ce jour, le recueil (électronique et papier) de données rapportées par les patients, y compris la qualité de vie liée à la santé, est en cours dans cinq hôpitaux de la région Nouvelle Aquitaine. Parmi ceux qui ont été invités à participer (juillet 2018-mai 2019), 90,5% (1 521/1 681) ont accepté, 7,1 % (119/1 681) ont refusé et 2,4 % (41/1 681) étaient non- éligibles. Parmi ceux qui ont accepté, 82% (1246/1 521) ont été considérés comme ayant satisfait aux exigences de base du nouveau système d’information tandis que 18 % (275/1 521) n'avaient pas d’adresse courriel personnelle. Les propriétés métriques de l’instrument de mesure choisi pour évaluer la qualité de vie (liée à la santé) dans notre population ont été ensuite évaluées sur un échantillon de 586 PVVIH, âgées de 56 ans en moyenne. 73 % étaient des hommes, 85 % étaient d'origine française, 99% étaient sous antirétroviraux et 93 % avaient une charge virale indétectable. La version française du WHOQOL-HIV BREF a des propriétés de mesure acceptables et sa conceptualisation large de la qualité de vie (au-delà de la santé physique et mentale) peut s'avérer particulièrement utile dans notre population. Sur une échelle de 4 à 20, le domaine des croyances personnelles avait le score moyen le plus élevé (15,04 ± 3,35) et le domaine de la santé psychologique le plus faible (13,70 ± 2,78). Les aspects (score de 1 à 5) les plus altérés étaient les relations personnelles (2,7 ± 1,25) et les ressources financières (2,9 ± 1,15).[...] Cette nouvelle démarche a été la première étape dans l'établissement d'un nouveau rapport avec les personnes prises en charge dans la région. Elle a permis de mettre en lumière des domaines qui, selon nous, doivent être particulièrement ciblés afin de développer avec succès de nouveaux modèles de soins et de services sociaux qui tiennent compte des besoins globaux des PVVIH et y répondent efficacementHIV has become a chronic disease in France. Nevertheless, HIV and associated inflammation, the effects of antiretroviral exposure, the high prevalence of modifiable risk factors for age-related diseases (e.g. smoking) and the effects of other viral co-infections together with social and economic vulnerability make the quality of life of people living with HIV (PLWH) an ongoing concern. French clinical guidelines have urged providers to address PLWH’s health as defined by the World Health Organisation. To take on this challenge, we designed an electronic module for the collection of patient-reported outcome linked the ANRS Aquitaine cohort’s data capture and visualisation system. The proposed solution relies on validated questionnaires and its content is based on current clinical guidelines on HIV management. The questionnaires’ psychometric properties, administration method/mode, and length were evaluated and paper-based instruments adapted following the International Society for Pharmacoeconomics and Outcomes Research’s guidance. Two rounds of usability evaluations were conducted first in research staff and the PLWH. We asked participants to complete a set of tasks using the ‘think aloud’ method and respond to the System Usability Scale (SUS). Input from experts/investigators and subsequently patients was used to improve features of the system. We calculated a summary score and defined “success” a priori as a usability score of 70. Experts reported average SUS scores of 65 ± 18.87 and patients reported average SUS scores of 85 ± 5.4 (p=0.032). To date, the collection of (electronic and paper) patient-reported outcomes, including health-related quality of life, is underway in five hospitals. Of those invited to participate (July 2018-May 2019), 90.5% (1,521/1,681) accepted, 7.1% (119/1,681) refused and 2.4% (41/1,681) were not eligible. Of those who accepted, 82% (1,246/1,521) were considered to have met the basic requirements of the newly designed solution whereas 18% (275/1,521) did not have a personal email address and/or a reliable Internet connection and were provided an identical paper questionnaire. We verified the psychometric properties of the WHOQOL-HIV BREF instrument, chosen to assess (health-related) quality of life in our population in a sample of 586 PLWH (aged 56 on average, 73% were male, 85% were of French origin, 99% were treated and 93% had an undetectable viral load). The French version of the WHOQOL-HIV BREF has acceptable measurement properties and its broad conceptualization of quality of life, going beyond physical and mental health, may be particularly useful in our population. On a scale of 4 (worst) to 20 (best), the personal belief domain had the highest average score (15.04 ± 3.35) and the lowest psychological health domain (13.70 ± 2.78). The most impaired facets (score of 1-5) were personal relationships (2.7 ± 1.25) and financial resources (2.9 ± 1.15). Women scored significantly lower than men on 12 of 29 facets, including the five HIV-specific facets. People born in North Africa or sub-Saharan Africa have lower scores in the environmental health domain than those born in France (13.19 ± 2.10 versus 14.52 ± 2.56, p<0.001). This work has been the first step in fostering a new relationship with those in care in the region. It has resulted in highlighting a number of areas that we feel need to be addressed in order to successfully develop new value-based models of care and social services which take into consideration and efficiently respond to PLWH’s global needs