The Cost of Providing Comprehensive HIV Services to Key Populations : An Analysis of the LINKAGES Program in Kenya and Malawi

Introduction: Timely data on HIV service costs are critical for estimating resource needs and allocating funding, but few data exist on the cost of HIV services for key populations (KPs) at higher risk of HIV infection in low- and middle-income countries. We aimed to estimate the total and per contact annual cost of providing comprehensive HIV services to KPs to inform planning and budgeting decisions. Methods: We collected cost data from the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program in Kenya and Malawi serving female and male sex workers, men who have sex with men, and transgender women. Data were collected prospectively for fiscal year (FY) 2019 and retrospectively for start-up activities conducted in FY2015 and FY2016. Data to estimate economic costs from the provider’s perspective were collected from LINKAGES headquarters, country offices, implementing partners (IPs), and drop-in centers (DICs). We used top-down and bottom-up cost estimation approaches. Results: Total economic costs for FY2019 were US$6,175,960 in Kenya and US$4,261,207 in Malawi. The proportion of costs incurred in IPs and DICs was 66% in Kenya and 42% in Malawi. The costliest program areas were clinical services, management, peer outreach, and monitoring and data use. Mean cost per contact was US$127 in Kenya and US$279 in Malawi, with a mean cost per contact in DICs and IPs of US$63 in Kenya and US$104 in Malawi. Conclusion: Actions undertaken above the service level in headquarters and country offices along with those conducted below the service level in communities, comprised important proportions of KP HIV service costs. The costs of pre-service population mapping and size estimation activities were not negligible. Costing studies that focus on the service level alone are likely to underestimate the costs of delivering HIV services to KPs

High-flow nasal cannula therapy for hypoxemic respiratory failure in patients with COVID-19.

INTRODUCTION: High-flow nasal cannula (HFNC) therapy in patients with hypoxemic respiratory failure due to COVID-19 is poorly understood and remains controversial. METHODS: We evaluated a large cohort of patients with COVID-19-related hypoxemic respiratory failure at the temporary COVID-19 hospital in Mexico City. The primary outcome was the success rate of HFNC to prevent the progression to invasive mechanical ventilation (IMV). We also evaluated the risk factors associated with HFNC success or failure. RESULTS: HFNC use effectively prevented IMV in 71.4% of patients [270 of 378 patients; 95% confidence interval (CI) 66.6-75.8%]. Factors that were significantly different at admission included age, the presence of hypertension, and the Charlson comorbidity index. Predictors of therapy failure (adjusted hazard ratio, 95% CI) included the comorbidity-age-lymphocyte count-lactate dehydrogenase (CALL) score at admission (1.27, 1.09-1.47; p < 0.01), Rox index at 1 hour (0.82, 0.7-0.96; p = 0.02), and no prior steroid treatment (0.34, 95% CI 0.19-0.62; p < 0.0001). Patients with HFNC success rarely required admission to the intensive care unit and had shorter lengths of hospital stay [19/270 (7.0%) and 15.0 (interquartile range, 11-20) days, respectively] than those who required IMV [104/108 (96.3%) and 26.5 (20-36) days, respectively]. CONCLUSION: Treating patients with HFNC at admission led to improvement in respiratory parameters in many patients with COVID-19

Impacts of the Tropical Pacific/Indian Oceans on the Seasonal Cycle of the West African Monsoon

The current consensus is that drought has developed in the Sahel during the second half of the twentieth century as a result of remote effects of oceanic anomalies amplified by local land–atmosphere interactions. This paper focuses on the impacts of oceanic anomalies upon West African climate and specifically aims to identify those from SST anomalies in the Pacific/Indian Oceans during spring and summer seasons, when they were significant. Idealized sensitivity experiments are performed with four atmospheric general circulation models (AGCMs). The prescribed SST patterns used in the AGCMs are based on the leading mode of covariability between SST anomalies over the Pacific/Indian Oceans and summer rainfall over West Africa. The results show that such oceanic anomalies in the Pacific/Indian Ocean lead to a northward shift of an anomalous dry belt from the Gulf of Guinea to the Sahel as the season advances. In the Sahel, the magnitude of rainfall anomalies is comparable to that obtained by other authors using SST anomalies confined to the proximity of the Atlantic Ocean. The mechanism connecting the Pacific/Indian SST anomalies with West African rainfall has a strong seasonal cycle. In spring (May and June), anomalous subsidence develops over both the Maritime Continent and the equatorial Atlantic in response to the enhanced equatorial heating. Precipitation increases over continental West Africa in association with stronger zonal convergence of moisture. In addition, precipitation decreases over the Gulf of Guinea. During the monsoon peak (July and August), the SST anomalies move westward over the equatorial Pacific and the two regions where subsidence occurred earlier in the seasons merge over West Africa. The monsoon weakens and rainfall decreases over the Sahel, especially in August.Peer reviewe

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Learning from the first wave of the COVID-19 pandemic: Comparing policy responses in Uruguay with 10 other Latin American and Caribbean countries

In response to the disproportionate impact of COVID-19 in Latin America and the Caribbean (LAC), a variety of public health and social actions have been implemented. Nevertheless, there have been disparities in the region\u27s pandemic responses, especially throughout the first six months of the pandemic, when Uruguay effectively curbed transmission. This research discusses aspects of pandemic responses that may have helped Uruguay outperform the other 10 LAC nations in its early years, including Argentina, Chile, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Panama, Paraguay, and Trinidad and Tobago. By forgoing strong border closures and movement restrictions and swiftly implementing a number of economic and social measures, Uruguay distinguished itself from the other studied countries\u27 early response attempts.The research shows how crucial it is to encourage adherence to public health interventions by putting strong social and economic safety nets in place to make compliance with the

Origin, impacts, and potential solutions to the fragmentation of the Mexican health system: a consultation with key actors

Abstract Background One of the central debates in health policy is related to the fragmentation of health systems. Fragmentation is perceived as a major obstacle to UHC. This article presents the results of a consultation with a group of actors of the Mexican policy arena on the origins and impacts of the fragmentation of the Mexican health system. Methods We used a consultation to nine key actors to collect thoughts on the fragmentation of the Mexican health system. The group included national and local decision makers with experience in health care issues and researchers with background in health systems and/or public policies. The sessions were recorded, transcribed verbatim and analyzed thematically. Results Participants defined the term ‘fragmentation’ as the separation of the various groups of the population based on characteristics which define their access to health care services. This is a core characteristic of health systems in Latin America (LA). In general, those affiliated to social security institutions have a higher per capita expenditure than those without social security, which translates into differential health benefits. According to the actors in this consultation, fragmentation is the main structural problem of the Mexican health system. Actors agreed that the best way to end fragmentation is through the creation of a universal health system. Defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. Conclusions First, health system fragmentation in Mexico has created problems of equity since different population groups have unequal access to public resources and different health benefits. Second, Mexico needs to move beyond the fragmentation of its health system and guarantee, through its financial integration, access to the same package of health services to all its citizens. Third, defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. Fourth, defragmentation of health systems is not an easy task because there are vested interests that oppose its implementation. Political strategies to meet the resistance of these groups are an essential component of any defragmentation plan

La pandemia en/desde Jujuy: reflexiones situadas

Acaso no podrí amos afirmar que la pandemia llego a nuestra sociedad mundial causando un pandemo - nium?. En cierto modo, ma s alla del juego de palabras, gran parte de nosotros lo sentimos así . Es claro, una pandemia, es una enfermedad que afecta a la sociedad. Perturba intensamente la cotidianeidad, las ocupaciones, y, en general, lo que en estos dí as an oramos como la “vida normal” de todos. Si contraemos una enfermedad ma s o menos aguda, todas nuestras actividades se ven afectadas, se desordenan. Cuando ello ocurre, pra cticamente debemos concentrarnos, casi con exclusividad, en superar la afeccio n con la ayuda de profesionales de la salud, cualquiera sea el abordaje disciplinario que nos resulte ma s adecuado y confiable. Así , del mismo modo, la pandemia afecta a toda la comunidad, a todas sus actividades. Y, en este caso tambie n la principal preocupacio n es superar la afeccio n. Entonces hay que buscar alternativas para el resto de las tareas, que deben transcurrir entre los estrechos ma rgenes que nos permiten tanto el cuidado personal como el social, ambos imprescindibles.Fil: Aramayo, Anahí. Universidad Nacional de Jujuy; ArgentinaFil: Lopez, Andrea Noelia. Universidad Nacional de Jujuy; ArgentinaFil: Díaz, Rodrigo Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades. Universidad Nacional de Jujuy. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades; ArgentinaFil: Astorga, Farid Diego. Universidad Nacional de Jujuy; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Assad, Lucas Gabriel. Universidad Nacional de Jujuy; ArgentinaFil: Hoyos, Gustavo Daniel. Universidad Nacional de Jujuy; ArgentinaFil: Balut, Jorgelina. No especifíca;Fil: Angulo Villán, Florencia Raquel. No especifíca;Fil: Brailovsky, Sofia Miriam. No especifíca;Fil: Carrizo, María José. No especifíca;Fil: Bustamante, Patricia. No especifíca;Fil: Jaled, Daniela Alejandra. No especifíca;Fil: Castillo, Silvina Ana Lia. No especifíca;Fil: Díaz, Enrique Antonio. No especifíca;Fil: Cieza, Fernanda. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; ArgentinaFil: Cuva, Cecilia Alejandra. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; ArgentinaFil: Rivas, Rosana Verónica. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; ArgentinaFil: Altea, Laura. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; ArgentinaFil: Garzon, Analia Soledad. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Mamani, Claudia. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; ArgentinaFil: Villarroel, Viviana Mabel. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; ArgentinaFil: Costas Frison, Celeste. No especifíca;Fil: Montenegro, Erica Maricel. No especifíca;Fil: Guzmán, Vilma Roxana. No especifíca;Fil: Donaire, Claudia. No especifíca;Fil: Herrera, Ana Soledad. No especifíca;Fil: Cardozo, Juana Griselda. No especifíca;Fil: Nieva, Nuria Noelia. No especifíca;Fil: Miranda , Ana Lía. Universidad Nacional de Jujuy; ArgentinaFil: Patagua, Patricia Evangelina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades. Universidad Nacional de Jujuy. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades; ArgentinaFil: Gomez, Carina Elizabeth. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades. Universidad Nacional de Jujuy. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades; ArgentinaFil: Bustamante, Patricia. Universidad Nacional de Jujuy; ArgentinaFil: Navarro Suárez, Camila. Universidad Nacional de Jujuy; ArgentinaFil: Yufra, Laura Cristina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades. Universidad Nacional de Jujuy. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades; ArgentinaFil: Massari, María Justina. Universidad Nacional de Jujuy; ArgentinaFil: Cortez, Carla Melisa. Universidad Nacional de Jujuy; ArgentinaFil: Rovetta, Ana Inés. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Química Biológica de la Facultad de Ciencias Exactas y Naturales. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Química Biológica de la Facultad de Ciencias Exactas y Naturales; ArgentinaFil: Zinger, Sabrina. Universidad Nacional de Jujuy; ArgentinaFil: Alba, Juan Pablo. Universidad Nacional de Jujuy; ArgentinaFil: Arrueta, Patricia Marisel. Universidad Nacional de Jujuy; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Constant, Juan. Universidad Nacional de Jujuy; ArgentinaFil: Gumiel, Silvina. Universidad Nacional de Jujuy; ArgentinaFil: Zazzarini, Susana. Universidad Nacional de Jujuy; ArgentinaFil: Valente, Verónica. Universidad Nacional de Jujuy; ArgentinaFil: Bergesio, Liliana del Carmen. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta; ArgentinaFil: González, Natividad María. Universidad Nacional de Jujuy. Facultad de Ciencias Económicas. Instituto de Investigaciones Económicas; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Nieva, Florencia Antonella. Universidad Nacional de Jujuy; ArgentinaFil: Callieri, Ivanna Gabriela. Universidad Nacional de Jujuy; ArgentinaFil: Montes, Elena Patricia. Universidad Nacional de Jujuy; ArgentinaFil: Civila Orellana, Fabiola Vanesa. Universidad Nacional de Jujuy; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Villarrubia Gómez, Álvaro Patricio. Universidad Nacional de Jujuy; ArgentinaFil: Quispe, Gloria. Universidad Nacional de Jujuy; ArgentinaFil: Cosme, María Cristina. Universidad Nacional de Jujuy; ArgentinaFil: Quispe, Ariadna Vanesa. Universidad Nacional de Jujuy; ArgentinaFil: Galián, Víctor Joel. Universidad Nacional de Jujuy; ArgentinaFil: Vazquez, Omar Eduardo. Universidad Nacional de Jujuy; ArgentinaFil: Cerpa, Daniela Soledad. Universidad Nacional de Jujuy; ArgentinaFil: Martínez, Luis Gustavo. Universidad Nacional de Jujuy; ArgentinaFil: Fernández, Laura Soledad. Universidad Nacional de Jujuy; ArgentinaFil: Tolaba, Gladys Sarai. Universidad Nacional de Jujuy; ArgentinaFil: Escalante, Norberto Oscar. Universidad Nacional de Jujuy; ArgentinaFil: Cazón, Mariela. Universidad Nacional de Jujuy; ArgentinaFil: Ugarte, María Adela. Universidad Nacional de Jujuy; ArgentinaFil: García Vargas, Alejandra. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta; ArgentinaFil: Gaona, Melina. Universidad Nacional de Quilmes. Departamento de Ciencias Sociales. Centro de Estudios de Historia, Cultura y Memoria; ArgentinaFil: Zubia, Gonzalo Federico. Universidad Nacional de Quilmes. Departamento de Ciencias Sociales. Centro de Estudios de Historia, Cultura y Memoria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Kulemeyer, Jorge Alberto. No especifíca;Fil: Pantoja, Rodrigo. No especifíca;Fil: Paz, María Elisa. No especifíca;Fil: Rivero, Ariel Rodolfo. No especifíca;Fil: Rocabado, Cecilia Inés. Universidad Nacional de Jujuy; ArgentinaFil: Villagra, Gabriela Soledad. Instituto de Ciencia y Tecnología Regional; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Rodríguez, Ana. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Ciencia y Tecnología Regional; ArgentinaFil: Adi Barrionuevo, Ana Carolina. Universidad Nacional de Jujuy; ArgentinaFil: Adi Barrionuevo, Irene. Universidad Nacional de Jujuy; ArgentinaFil: Aramayo, Natalia. Universidad Nacional de Jujuy; ArgentinaFil: Fernández, Gabriel. Universidad Nacional de Jujuy; ArgentinaFil: Morales, Miriam Mariana. Universidad Nacional de Jujuy. Instituto de Ecorregiones Andinas. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Instituto de Ecorregiones Andinas; ArgentinaFil: Rios, Natalia Fatima. Facultad Latinoamericana de Ciencias Sociales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Rocabado, Zaida Nadia. Universidad Nacional de Jujuy; ArgentinaFil: Sandoval, Cecilia. No especifíca;Fil: Soto, Mercedes. No especifíca;Fil: Osores, Noelia Andrea del Valle. No especifíca;Fil: Revollo, Jimena ;Citterio. No especifíca;Fil: Gutiérrez, Ivone Belén. Universidad Nacional de Jujuy; ArgentinaFil: Juste, Stella Maris. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades. Universidad Nacional de Jujuy. Unidad Ejecutora en Ciencias Sociales Regionales y Humanidades; ArgentinaFil: Vidal, José Fernando. Universidad Nacional de Jujuy; ArgentinaFil: Karasik, Gabriela Alejandra. Universidad Nacional de Jujuy. Facultad de Humanidades y Ciencias Sociales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta; ArgentinaFil: Bruce, Beatriz Maria. Universidad Nacional de Jujuy; Argentin

Factors influencing plasma transfusion practices in paediatric intensive care units around the world

Background and Objectives Plasma transfusions are a frequent treatment worldwide, but many studies have reported a wide variation in the indications to transfuse. Recently, an international paediatric study also showed wide variation in frequency in the use of plasma transfusions: 25% of the centres transfused plasma to >5% of their patients, whereas another 25% transfused plasma to <1% of their patients. The objective of this study was to explore the factors associated with different plasma transfusion practices in these centres. Materials and Methods Online survey sent to the local investigators of the 101 participating centres, in February 2016. Four areas were explored: beliefs regarding plasma transfusion, patients’ case‐mix in each unit, unit's characteristics, and local blood product transfusion policies and processes. Results The response rate was 82% (83/101). 43% of the respondents believed that plasma transfusions can arrest bleeding, whereas 27% believe that plasma transfusion can prevent bleeding. Centres with the highest plasma transfusion rate were more likely to think that hypovolaemia and mildly abnormal coagulation tests are appropriate indications for plasma transfusions (P = 0·02 and P = 0·04, respectively). Case‐mix, centre characteristics or local transfusion services were not identified as significant relevant factors. Conclusion Factors influencing plasma transfusion practices reflect beliefs about indications and the efficacy of transfusion in the prevention and management of bleeding as well as effects on coagulation tests. Educational and other initiatives to target these beliefs should be the focus of research