Application of the HIV prevention cascade to identify, develop and evaluate interventions to improve use of prevention methods: examples from a study in east Zimbabwe

Introduction: The HIV prevention cascade could be used in developing interventions to strengthen implementation of efficacious HIV prevention methods, but its practical utility needs to be demonstrated. We propose a standardized approach to using the cascade to guide identification and evaluation of interventions and demonstrate its feasibility for this purpose through a project to develop interventions to improve HIV prevention methods use by adolescent girls and young women (AGYW) and potential male partners in east Zimbabwe. Discussion: We propose a six-step approach to using a published generic HIV prevention cascade formulation to develop interventions to increase motivation to use, access to and effective use of an HIV prevention method. These steps are as follows: (1) measure the HIV prevention cascade for the chosen population and method; (2) identify gaps in the cascade; (3) identify explanatory factors (barriers) contributing to observed gaps; (4) review literature to identify relevant theoretical frameworks and interventions; (5) tailor interventions to the local context; and (6) implement and evaluate the interventions using the cascade steps and explanatory factors as outcome indicators in the evaluation design. In the Zimbabwe example, steps 1-5 aided development of four interventions to overcome barriers to effective use of pre-exposure prophylaxis (PrEP) in AGYW (15-24 years) and voluntary medical male circumcision in male partners (15-29). For young men, prevention cascade analyses identified gaps in motivation and access as barriers to voluntary medical male circumcision uptake, so an intervention was designed including financial incentives and an education session. For AGYW, gaps in motivation (particularly lack of risk perception) and access were identified as barriers to PrEP uptake: an interactive counselling game was developed addressing these barriers. A text messaging intervention was developed to improve PrEP adherence among AGYW, addressing reasons underlying lack of effective PrEP use through improving the capacity (“skills”) to take PrEP effectively. A community-led intervention (community conversations) was developed addressing community-level factors underlying gaps in motivation, access and effective use. These interventions are being evaluated currently using outcomes from the HIV prevention cascade (step 6). Conclusions: The prevention cascade can guide development and evaluation of interventions to strengthen implementation of HIV prevention methods by following the proposed process

Idle hands are the devil’s tools: The geopolitics and geoeconomics of hunger

In current geopolitical and geoeconomic discourses, hunger is understood as both a threat to be contained, resulting in an often severe social and spatial localization of food insecurity, and a humanitarian problem to be solved through diffuse global flows of food and other aid. The resulting scalar tensions demonstrate the potentially contradictory alignment of geopolitics and geoeconomics within processes of globalization and neoliberalization. This article examines the geopolitical and geoeconomic place of hunger and the hungry through a critical analysis of the food-for-work (FFW) approach to combating hunger. FFW programs distribute food aid in exchange for labor, and have long been used to plan and deliver food aid. While debate continues as to whether and under what conditions FFW programs are socially and economically just, governments, international institutions, and NGOs tout them as a flexible and efficient way to deliver targeted aid, promote community development, and improve long-term prospects for economic development and food security. In the post-9/11 period, FFW programs are also cited as effective deterrents to terrorist recruitment strategies, while development and food security more broadly have been incorporated into national security strategies, especially but not only in the United States. The food-for-work approach attempts to resolve the scalar contradictions of hunger through the imposition of a labor requirement that disciplines the threat of the hungry while enforcing global connection. Case studies of FFW programs in Bangladesh, Ethiopia, and Indonesia illustrate this contradiction, and highlight the development and possible future of approaches to hunger under neoliberal geopolitics

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Clinical Outcomes of Paramyxovirus Infections in Lung Transplant Recipients Treated With Oral Ribavirin: A Two-Center Case Series

Objectives: Paramyxoviruses contribute to morbidity and mortality after lung transplant and are associated with bronchiolitis obliterans syndrome. Oral ribavirin has been used off-label for treatment of paramyxoviruses in immunosuppressed patients; however, data supporting its use for this purpose are lacking. Materials and Methods: We conducted a retrospective review to evaluate clinical outcomes of lung transplant recipients infected with paramyxoviruses and received treatment with oral ribavirin at 2 tertiary referral centers. Patients who were diagnosed with paramyxovirus infection by polymerase chain reaction testing between January 2011 and December 2014 and who received oral ribavirin were included. Clinical outcomes included pulmonary function testing, infection severity, and adverse events related to treatment. Results: Twenty-six patients were diagnosed with a paramyxovirus and received oral ribavirin. The changes in mean forced expiratory volume 1 second from preinfection to infection onset and from infection onset to postinfection were significant (1.79 +/- 0.13 to 1.61 +/- 0.12 Land 1.61 +/- 0.12L to 1.74 +/- 0.12 L;P= .0001). Similar results were seen in subgroup analysis when respiratory syncytial virus and parainfluenza infections were evaluated independently. Conclusions: Use of oral ribavirin for treatment of paramyxovirus infections in lung transplant recipients was safe and associated with recovery of lung function

Medicaid Enrollment among Elderly Medicare Beneficiaries: Individual Determinants, Effects of State Policy, and Impact on Service Use

OBJECTIVE: To better understand factors associated with Medicaid enrollment among low-income, community-dwelling elderly persons and to examine the effect of Medicaid enrollment on the use of health care services by elderly persons, taking into account selection in program participation. DATA SOURCES: 1996 Medicare Current Beneficiary Survey (MCBS) Access to Care and Cost and Use files. METHODS: Individual-level predictions of the probability of dual enrollment are obtained from equations that estimate jointly the residential status of Medicare beneficiaries (community versus institution) and the probability of Medicaid enrollment among community-dwelling eligible beneficiaries. Predicted values are then substituted into the service use equations, which are estimated via two-part models. PRINCIPAL FINDINGS: Less than half of all community-dwelling elderly persons with incomes at or below 100 percent of the Federal Poverty Level (FPL) were enrolled in Medicaid in 1996. Once selective enrollment was accounted for, there was limited evidence of a dual enrollment effect on service use. Although there were no effects of state Medicaid policy variables on the probability that beneficiaries lived in the community (as opposed to nursing homes), the effects of state's Medicaid generosity in home and community-based services had a sizeable and statistically significant effect on influencing the likelihood that eligible elderly persons enrolled in Medicaid. CONCLUSIONS: Our results provide compelling evidence that Medicaid participation can be influenced by state policy. The observation that “policy matters” provides new insights into how existing programs might reach a larger proportion of potentially eligible beneficiaries