State-Based Marketplaces Outperform Federally-Facilitated Marketplaces

In response to regulatory changes at the federal level, states that run their own marketplaces have taken steps to stabilize their individual markets. In this comparison of state-based and federally-facilitated marketplaces from 2016-2018, we find that SBMs had slower premium increases (43% vs. 75%), and fewer carrier exits, than FFMs. The total population participating in FFMs declined by 10%, while the enrolled population in SBMs remained largely stable, increasing by 2%. We find that the performance of the ACA marketplaces varies by state and appears to cluster around marketplace types

Networks in ACA Marketplaces are Narrower for Mental Health Care Than for Primary Care

In 2016, ACA marketplace plans offered provider networks that were far narrower for mental health care than for primary care. On average, plan networks included 24 percent of all primary care providers and 11 percent of all mental health care providers in a given market. Just 43 percent of psychiatrists and 19 percent of nonphysician mental health providers participate in any network. These findings raise important questions about network sufficiency, consumer choice, and access to mental health care in marketplace plans

Racial Disparities in Geographic Access to Primary Care in Philadelphia

Although Philadelphia has an adequate supply of primary care providers overall, spatial analysis shows wide variation across neighborhoods, with stark racial disparities. This study identifies six low-access areas within the city that warrant attention

EcoHIV infection of mice establishes latent viral reservoirs in T cells and active viral reservoirs in macrophages that are sufficient for induction of neurocognitive impairment

Suppression of HIV replication by antiretroviral therapy (ART) or host immunity can prevent AIDS but not other HIV-associated conditions including neurocognitive impairment (HIV-NCI). Pathogenesis in HIV-suppressed individuals has been attributed to reservoirs of latent-inducible virus in resting CD4+ T cells. Macrophages are persistently infected with HIV but their role as HIV reservoirs in vivo has not been fully explored. Here we show that infection of conventional mice with chimeric HIV, EcoHIV, reproduces physiological conditions for development of disease in people on ART including immunocompetence, stable suppression of HIV replication, persistence of integrated, replication-competent HIV in T cells and macrophages, and manifestation of learning and memory deficits in behavioral tests, termed here murine HIV-NCI. EcoHIV established latent reservoirs in CD4+ T lymphocytes in chronically-infected mice but could be induced by epigenetic modulators ex vivo and in mice. In contrast, macrophages expressed EcoHIV constitutively in mice for up to 16 months; murine leukemia virus (MLV), the donor of gp80 envelope in EcoHIV, did not infect macrophages. Both EcoHIV and MLV were found in brain tissue of infected mice but only EcoHIV induced NCI. Murine HIV-NCI was prevented by antiretroviral prophylaxis but once established neither persistent EcoHIV infection in mice nor NCI could be reversed by long-acting antiretroviral therapy. EcoHIV-infected, athymic mice were more permissive to virus replication in macrophages than were wild-type mice, suffered cognitive dysfunction, as well as increased numbers of monocytes and macrophages infiltrating the brain. Our results suggest an important role of HIV expressing macrophages in HIV neuropathogenesis in hosts with suppressed HIV replication

Antimalarial Therapy Selection for Quinolone Resistance among Escherichia coli in the Absence of Quinolone Exposure, in Tropical South America

BACKGROUND: Bacterial resistance to antibiotics is thought to develop only in the presence of antibiotic pressure. Here we show evidence to suggest that fluoroquinolone resistance in Escherichia coli has developed in the absence of fluoroquinolone use. METHODS: Over 4 years, outreach clinic attendees in one moderately remote and five very remote villages in rural Guyana were surveyed for the presence of rectal carriage of ciprofloxacin-resistant gram-negative bacilli (GNB). Drinking water was tested for the presence of resistant GNB by culture, and the presence of antibacterial agents and chloroquine by HPLC. The development of ciprofloxacin resistance in E. coli was examined after serial exposure to chloroquine. Patient and laboratory isolates of E. coli resistant to ciprofloxacin were assessed by PCR-sequencing for quinolone-resistance-determining-region (QRDR) mutations. RESULTS: In the very remote villages, 4.8% of patients carried ciprofloxacin-resistant E. coli with QRDR mutations despite no local availability of quinolones. However, there had been extensive local use of chloroquine, with higher prevalence of resistance seen in the villages shortly after a Plasmodium vivax epidemic (p<0.01). Antibacterial agents were not found in the drinking water, but chloroquine was demonstrated to be present. Chloroquine was found to inhibit the growth of E. coli in vitro. Replica plating demonstrated that 2-step QRDR mutations could be induced in E. coli in response to chloroquine. CONCLUSIONS: In these remote communities, the heavy use of chloroquine to treat malaria likely selected for ciprofloxacin resistance in E. coli. This may be an important public health problem in malarious areas

The Retail Food Environment in Relation to Socio-economic Characteristics, Weight Status and Diabetes

The food environment is drawing increasing attention as an important population-level determinant of diet, obesity and related health outcomes. Using retail food data sourced from a commercial database, we examined several dimensions of the local retail food environment in relation to area socio-economic characteristics, and weight status and diabetes risk among adult residents of three urban regions in southern Ontario. The first study showed that local access to different types of food retail was patterned by level of neighbourhood material deprivation. More deprived neighbourhoods generally provided better access to stores and restaurants of all types, including those selling more or less healthful foods. These patterns were partially explained by urban form factors. Relative access to unhealthy food retailers (as a proportion of all outlets) showed little variation by level of neighbourhood material deprivation. In the second study, we found that measures of absolute and relative availability of different types of restaurants (volume and proportion) within walking distance of residential areas had differential effects on the weight status of local residents. We also identified a novel interaction between absolute and relative restaurant measures, whereby exposure to a higher proportion of fast-food relative to all restaurants was directly related to excess weight, particularly in areas with high volumes of fast-food restaurants (e.g. odds ratio for obesity=2.55 in areas with 5+ fast-food restaurants, 95% confidence interval: 1.55-4.17, across the interquartile range). The third study showed a similar synergistic effect between absolute and relative dimensions of fast-food restaurant exposure in relation to the development of diabetes. Among younger adults (20-65 years), a greater proportion of fast-food restaurants was directly associated with incident diabetes after adjustment for individual- and area-level covariates, but only in areas with high volumes of fast-food outlets (hazard ratio=1.79, 95% confidence interval: 1.03-3.12, across the interquartile range). No significant associations were observed in areas with low volumes of fast food or among older adults. This dissertation contributes to a better understanding of how different aspects of the retail food environment relate to health, which may help to guide the design of programs and policies to create healthier and more equitable food environments.Ph.D