Health insurance for HIV prevention & treatment: predictors of health insurance enrollment among HIV+ women in Kenya

Background: The global push to achieve the 90-90-90 targets designed to end the HIV epidemic has called for the removing of policy barriers to prevention and treatment, and ensuring financial sustainability of HIV programs. Universal health insurance is one tool that can be used to this end. In sub-Saharan Africa, where HIV prevalence and incidence remain high, the use of health insurance to provide comprehensive HIV care is limited. This study looked at the factors that best predict social health insurance enrollment among HIV positive pregnant women using data from the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods: Cross-sectional clinical encounter data were extracted from the electronic medical records (EMR) at AMPATH. We used univariate and multivariate logistic regressions to estimate the predictors of health insurance enrollment among HIV positive pregnant women. The analysis was further stratified by HIV disease severity (based on CD4 cell count ) to test the possibility of differential enrollment given HIV disease state. Results: Approximately 7% of HIV infected women delivering at a healthcare facility had health insurance. HIV positive pregnant women who deliver at a health facility had twice the odds of enrolling in insurance [2.46 Adjusted Odds Ratio (AOR), Confidence Interval (CI) 1.24-4.87]. They were 10 times more likely to have insurance if they were lost to follow-up to HIV care during pregnancy [9.90 AOR; CI 3.42-28.67], and three times more likely to enroll if they sought care at an urban clinic [2.50 AOR; 95% CI 1.53-4.12]. Being on HIV treatment was negatively associated with health insurance enrollment [0.22 AOR; CI 0.10-0.49]. Stratifying the analysis by HIV disease severity while statistically significant did not change these results. Conclusions: The findings indicated that health insurance enrollment among HIV positive pregnant women was low mirroring national levels. Additionally, structural factors, such as access to institutional delivery and location of healthcare facilities, increased the likelihood of health insurance enrollment within this population. However, behavioral aspects, such as being lost to follow-up to HIV care during pregnancy and being on HIV treatment, had an ambiguous effect on insurance enrollment. This may potentially be because of adverse selection and information asymmetries. Further understanding of the relationship between insurance and HIV is needed if health insurance is to be utilized for HIV treatment and prevention in limited resource settings.Othe

Heterogeneous Impact of the "Seguro Popular" Program on the Utilization of Obstetrical Services in Mexico, 2001-2006: A Multinomial Probit Model with a Discrete Endogenous Variable

Objective: We evaluated the impact of Seguro Popular (SP), a program introduced in 2001 in Mexico primarily to finance health care for the poor. We studied the effect of SP on pregnant women's access to obstetrical services. Data: We analyzed the cross-sectional 2006 National Health and Nutrition Survey (ENSANUT), focusing on the responses of 3,890 women who delivered babies during 2001-2006 and whose households lacked employer-based health care coverage. Methods: We formulated a multinomial probit model that distinguished between three mutually exclusive sites for delivering a baby: a health unit accredited by SP; a clinic run by the Department of Health (Secretaria de Salud, or SSA); and private obstetrical care. Our model accounted for the endogeneity of the household's binary decision to enroll in the SP program. Results: Women in households that participated in the SP program had a much stronger preference for having a baby in a SP-sponsored unit rather than paying out of pocket for a private delivery. At the same time, participation in SP was associated with a stronger preference for delivering in the private sector rather than at a state-run SSA clinic. On balance, the Seguro Popular program reduced pregnant women's attendance at an SSA clinic much more than it reduced the probability of delivering a baby in the private sector. The impacts of the SP program at the individual and population levels varied with the woman's education and health, as well as the assets and location (rural versus urban) of the household. Conclusions: The SP program had a robust, significantly positive impact on access to obstetrical services. Our finding that women enrolled in SP switched from non-SP state-run facilities, rather than from out-of-pocket private services, is important for public policy and requires further exploration.

Diseño de una prensa de tornillo tipo expeller para la extracción de aceite vegetal virgen de la semilla de maíz, para uso comestible

Las características de las semillas de maíz y de maní y su alto contenido de aceite en sus paredes celulares permiten la obtención de aceite virgen bajo el método de prensado en frío. En el presente trabajo se hizo el diseño de una prensa tipo expeller, para la extracción de aceite de maíz y de maní con el propósito de generar un proceso de extracción que evite la degradación del material al ser sometido a un cambio de fase mediante la compresión del mismo; con la ayuda de un tornillo sin fin y un accionamiento. El prensado mecánico o de tipo expeller tiene sus inicios en el prensado que hacían los egipcios, los fenicios y los chinos, para producir un tipo de aceite y harina que se utilizaba para consumo humano y animal, mediante un equipo muy primitivo al cual llamaban “stump press”, que consistía en un tronco quemado con un palo pesado impulsado por un buey, que maceraba las semillas y así liberaba un poco del aceite. Desde los días de los imperios griegos y romanos y hasta el siglo 17 la prensa stump y sus equivalentes antiguos fueron modificados para imponer más presión sobre la semilla, con lo que el contenido de aceite después del prensado aumentaba. La prensa de husillo manual puede ser citada como un ejemplo de este desarrollo; la semilla vegetal era envuelta en algún tipo de tela y se coloca entre las placas de una prensa vertical, a continuación, un tornillo se utilizaba manualmente para imponer una presión sobre la semilla y así liberar la cantidad de aceite disponible en sus paredes celulares

An Instrumental Variable Evaluation of Antidepressant Use on Employment Among HIV-Infected Women Using Highly-Active Antiretroviral Therapy in the United States: 1996-2004

This paper examines the effect of antidepressant use on the likelihood of being employed among HIV-positive women receiving highly active antiretroviral therapy (HAART) in the United States from 1994 to 2004. We use instrumental variables to predict antidepressant use independently of outcomes; thus, addressing potential sources of bias -- more depressed women are more likely to receive antidepressant treatment, but they are also more likely to be unemployed. The results show that antidepressant use has a positive effect on the employment probability of women living with HIV. The proposed instrumental variables can be used to identify antidepressant use in the WIHS population. Among women receiving HAART, and controlling for individual and local area labor market characteristics, the use of antidepressants is associated with a higher probability of being employed.

Sexual behavior among orphaned adolescents in western Kenya: a comparison of institutional-and family-based care settings

Purpose: This study sought to assess whether risky sexual behaviors and sexual exploitation of orphaned adolescents differed between family-based and institutional care environments in Uasin Gishu County, Kenya. Methods: We analyzed baseline data from a cohort of orphaned adolescents aged 10–18 years living in 300 randomly selected households and 19 charitable children\u27s institutions. The primary outcomes were having ever had consensual sex, number of sex partners, transactional sex, and forced sex. Multivariate logistic regression compared these between participants in institutional care and family-based care while adjusting for age, sex, orphan status, importance of religion, caregiver support and supervision, school attendance, and alcohol and drug use. Results: This analysis included 1,365 participants aged ≥10 years: 712 (52%) living in institutional environments and 653 (48%) in family-based care. Participants in institutional care were significantly less likely to report engaging in transactional sex (adjusted odds ratio, .46; 95% confidence interval, .3–.72) or to have experienced forced sex (adjusted odds ratio, .57; 95% confidence interval, .38–.88) when controlling for age, sex, and orphan status. These associations remained when adjusting for additional variables. Conclusions: Orphaned adolescents living in family-based care in Uasin Gishu, Kenya, may be at increased risk of transactional sex and sexual violence compared to those in institutional care. Institutional care may reduce vulnerabilities through the provision of basic material needs and adequate standards of living that influence adolescents\u27 sexual risk-taking behaviors. The use of single items to assess outcomes and nonexplicit definition of sex suggest the findings should be interpreted with caution

The disproportionate burden of HIV and STIs among male sex workers in Mexico City and the rationale for economic incentives to reduce risks

Introduction: The objective of this article is to present the rationale and baseline results for a randomized controlled pilot trial using economic incentives to reduce HIV and sexually transmitted infection (STI) risk among male sex workers (MSWs) in Mexico City. Methods: Participants (n=267) were tested and treated for STIs (chlamydia, gonorrhoea, syphilis and HIV) and viral hepatitis (hepatitis B and C), received HIV and STI prevention education and were randomized into four groups: (1) control, (2) medium conditional incentive ($50/six months), (3) high conditional incentive ($75/six months) and (4) unconditional incentive ($50/six months). In the conditional arms, incentives were contingent upon testing free of new curable STIs (chlamydia, gonorrhoea and syphilis) at follow-up assessments. Results: Participants’ mean age was 25 years; 8$25 with a 35% higher payment for condomless sex. Conclusions: The findings suggest that economic incentives are a relevant approach for HIV prevention among MSWs, given the market-based inducements for unprotected sex. This type of targeted intervention seems to be justified and should continue to be explored in the context of combination prevention efforts

Improving Antiretroviral Therapy Adherence in Resource-Limited Settings at Scale: a Discussion of Interventions and Recommendations

INTRODUCTION: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. METHODS: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. RESULTS AND DISCUSSION: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. CONCLUSION: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS

Prevalence of Frailty in European Emergency Departments (FEED): an international flash mob study

Introduction Current emergency care systems are not optimized to respond to multiple and complex problems associated with frailty. Services may require reconfiguration to effectively deliver comprehensive frailty care, yet its prevalence and variation are poorly understood. This study primarily determined the prevalence of frailty among older people attending emergency care. Methods This cross-sectional study used a flash mob approach to collect observational European emergency care data over a 24-h period (04 July 2023). Sites were identified through the European Task Force for Geriatric Emergency Medicine collaboration and social media. Data were collected for all individuals aged 65 + who attended emergency care, and for all adults aged 18 + at a subset of sites. Variables included demographics, Clinical Frailty Scale (CFS), vital signs, and disposition. European and national frailty prevalence was determined with proportions with each CFS level and with dichotomized CFS 5 + (mild or more severe frailty). Results Sixty-two sites in fourteen European countries recruited five thousand seven hundred eighty-five individuals. 40% of 3479 older people had at least mild frailty, with countries ranging from 26 to 51%. They had median age 77 (IQR, 13) years and 53% were female. Across 22 sites observing all adult attenders, older people living with frailty comprised 14%. Conclusion 40% of older people using European emergency care had CFS 5 + . Frailty prevalence varied widely among European care systems. These differences likely reflected entrance selection and provide windows of opportunity for system configuration and workforce planning

THE EFFECT OF ANTIDEPRESSANTS ON THE LABOR MARKET OUTCOMES OF HIV-INFECTED PERSONS USING HIGHLY ACTIVE ANTIRETROVIRAL THERAPY IN THE UNITED STATES: 1996-2004

OBJECTIVE: To examine the association between antidepressant use and the likelihood of being employed among HIV-positive persons receiving highly active antiretroviral therapy (HAART). DATA SOURCES: Panel (longitudinal), semi-annual data (from 1996 to 2004) from the Women’s Interagency HIV Study (WIHS), a cohort study of 3,768 women in Bronx and Brooklyn (New York), Chicago (Illinois), Los Angeles and San Francisco (California), and Washington, D.C.; and the Multicenter AIDS Cohort Study (MACS), a cohort of 6,973 men in Baltimore (Maryland), Chicago (Illinois), Los Angeles (California), and Pittsburgh (Pennsylvania). METHODS: Regression analyses models of employment (linear, non-linear, and dynamic, under fixed and random effects assumptions), conditioning on the use of HAART at every prior calendar visit. The regressions control for: demographic characteristics (age, race, education); clinical indicators (CD4 cell count, viral load); physical and mental health summary measures (physical component of the SF-36 or quality of life index; and CES-D); and local area characteristics (unemployment rate, real weekly earnings, and employment ratios). Different measures of State Medicaid coverage for antidepressants are used as instrumental variables to predict antidepressant use independently of outcomes; thus, addressing potential sources of bias -- more depressed persons tend to receive antidepressant treatment, but they are also more likely to be unemployed. iii PRINCIPAL FINDINGS: The proposed instrumental variables can be used to identify antidepressant use in the WIHS population. Results show that antidepressant use has a positive effect on the employment probability of women living with HIV. Among women receiving HAART, and controlling for individual and local area labor market characteristics, use of antidepressants is associated with a higher probability of being employed. On the other hand, the proposed instruments do not perform well on the MACS sample. The treatment probability can be predicted only weakly. With the current instruments, we cannot find a positive effect of antidepressant use on employment for the participants in the MACS. CONCLUSIONS: Increasing efforts to improve screening, diagnosis, and treatment of depression in specific high-risk HIV positive populations, particularly low-income women, is warranted not only for the physical and mental health benefits, but also as an avenue to increase employment

THE EFFECT OF ANTIDEPRESSANTS ON THE LABOR MARKET OUTCOMES OF HIV-INFECTED PERSONS USING HIGHLY ACTIVE ANTIRETROVIRAL THERAPY IN THE UNITED STATES: 1996-2004

OBJECTIVE: To examine the association between antidepressant use and the likelihood of being employed among HIV-positive persons receiving highly active antiretroviral therapy (HAART). DATA SOURCES: Panel (longitudinal), semi-annual data (from 1996 to 2004) from the Women’s Interagency HIV Study (WIHS), a cohort study of 3,768 women in Bronx and Brooklyn (New York), Chicago (Illinois), Los Angeles and San Francisco (California), and Washington, D.C.; and the Multicenter AIDS Cohort Study (MACS), a cohort of 6,973 men in Baltimore (Maryland), Chicago (Illinois), Los Angeles (California), and Pittsburgh (Pennsylvania). METHODS: Regression analyses models of employment (linear, non-linear, and dynamic, under fixed and random effects assumptions), conditioning on the use of HAART at every prior calendar visit. The regressions control for: demographic characteristics (age, race, education); clinical indicators (CD4 cell count, viral load); physical and mental health summary measures (physical component of the SF-36 or quality of life index; and CES-D); and local area characteristics (unemployment rate, real weekly earnings, and employment ratios). Different measures of State Medicaid coverage for antidepressants are used as instrumental variables to predict antidepressant use independently of outcomes; thus, addressing potential sources of bias -- more depressed persons tend to receive antidepressant treatment, but they are also more likely to be unemployed. iii PRINCIPAL FINDINGS: The proposed instrumental variables can be used to identify antidepressant use in the WIHS population. Results show that antidepressant use has a positive effect on the employment probability of women living with HIV. Among women receiving HAART, and controlling for individual and local area labor market characteristics, use of antidepressants is associated with a higher probability of being employed. On the other hand, the proposed instruments do not perform well on the MACS sample. The treatment probability can be predicted only weakly. With the current instruments, we cannot find a positive effect of antidepressant use on employment for the participants in the MACS. CONCLUSIONS: Increasing efforts to improve screening, diagnosis, and treatment of depression in specific high-risk HIV positive populations, particularly low-income women, is warranted not only for the physical and mental health benefits, but also as an avenue to increase employment