Policy implications of demographic change: panel discussion: recent demographic achievements and the challenges ahead

The last century, the twentieth century, has been the most revolutionary, the most unparalleled in human history, in terms of demographic events, and it is likely to retain that distinction into the future.Demography ; Economic conditions

What do the Universal Test and Treat Trials tell us about the path to HIV epidemic control?

Introduction Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population‐based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub‐Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90‐90‐90 campaign. Discussion These three‐year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community‐based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient‐centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population‐level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub‐populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured. Conclusions These trials provide strong evidence that UTT inclusive of universal testing increases population‐level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub‐country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets

Assessment of Population-Based HIV RNA Levels in a Rural East African Setting Using a Fingerprick-Based Blood Collection Method

Background. Population-based human immunodeficiency virus type 1 (HIV-1) RNA levels (viral load [VL]) are proposed metrics for antiretroviral therapy (ART) program effectiveness. We estimated population-based HIV RNA levels using a fingerprick-based approach in a rural Ugandan community implementing rapid ART scale-up

Type I interferon autoantibodies are associated with systemic immune alterations in patients with COVID-19

Neutralizing autoantibodies against type I interferons (IFNs) have been found in some patients with critical coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the prevalence of these antibodies, their longitudinal dynamics across the disease severity scale, and their functional effects on circulating leukocytes remain unknown. Here, in 284 patients with COVID-19, we found type I IFN–specific autoantibodies in peripheral blood samples from 19% of patients with critical disease and 6% of patients with severe disease. We found no type I IFN autoantibodies in individuals with moderate disease. Longitudinal profiling of over 600,000 peripheral blood mononuclear cells using multiplexed single-cell epitope and transcriptome sequencing from 54 patients with COVID-19 and 26 non–COVID-19 controls revealed a lack of type I IFN–stimulated gene (ISG-I) responses in myeloid cells from patients with critical disease. This was especially evident in dendritic cell populations isolated from patients with critical disease producing type I IFN–specific autoantibodies. Moreover, we found elevated expression of the inhibitory receptor leukocyte-associated immunoglobulin-like receptor 1 (LAIR1) on the surface of monocytes isolated from patients with critical disease early in the disease course. LAIR1 expression is inversely correlated with ISG-I expression response in patients with COVID-19 but is not expressed in healthy controls. The deficient ISG-I response observed in patients with critical COVID-19 with and without type I IFN–specific autoantibodies supports a unifying model for disease pathogenesis involving ISG-I suppression through convergent mechanisms

Religious Fertility Differentials In Lebanon.

PhDDemographicsUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/180748/2/7619105.pd

Patient Function and the Value of Surgical Care for Kidney Cancer

PurposeFrailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery.Materials and methodsUsing linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30-day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures.ResultsOf 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10-1.36) or a geriatric event (OR 1.55, 95% CI 1.33-1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001).ConclusionsDuring kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care

Delayed anti-HCV antibody response in HIV-positive men acutely infected with HCV

<b>OBJECTIVE:</b> An epidemic of acute hepatitis C virus (HCV) infection among HIV-positive men who have sex with men is occurring in urban centers in Western Europe and the United States. Early diagnosis and treatment of HCV results in improved sustained virological response rates. This study compared the sensitivity of reverse transcriptase PCR (RT-PCR) versus antibody screening for the diagnosis of early HCV infection in HIV-positive patients and estimated the length of time from HCV infection to the development of anti-HCV antibodies.<p></p> <b>DESIGN:</b> Patients from the St Mary's Acute Hepatitis C Cohort (SMACC) were recruited retrospectively and prospectively between 2004 and 2008.<p></p> <b>METHODS:</b> Archived plasma samples, obtained at 1-3 monthly intervals for routine monitoring of HIV viral load were assayed retrospectively for HCV in order to assess the sensitivity of RT-PCR and enzyme-linked immunosorbent assay (ELISA).<p></p> <b>RESULTS:</b> Forty-three HIV-positive patients with early HCV infection were identified. The median CD4 cell count was 570 cells/microl. The median alanine transaminase at the time of the first positive HCV PCR was 65 IU/ml. At this time, 75% of patients had a negative HCV antibody test. Three months later, 37% of patients still had a negative result. After 9 months, 10% of patients had a negative test and 5% remained negative after 1 year.<p></p> <b>CONCLUSION/DISCUSSION:</b> Delayed seroconversion in HIV-positive individuals with acute HCV may result in delayed diagnosis and treatment. Where there is a clinical suspicion of recent HCV infection, for example, elevated alanine transaminase levels, HIV-infected patients should be screened for HCV RNA by RT-PCR