Human rights in health systems frameworks: what is there, what is missing and why does it matter?

Global initiatives and recent G8 commitments to health systems strengthening have brought increased attention to factors affecting health system performance. While equity concerns and human rights language appear often in the global health discourse, their inclusion in health systems efforts beyond rhetorical pronouncements is limited. Building on recent work assessing the extent to which features compatible with the right to health are incorporated into national health systems, we examine how health systems frameworks have thus far integrated human rights concepts and human rights-based approaches to health in their conceptualisation. Findings point to the potential value of the inclusion of human rights in these articulations to increase the participation or involvement of clients in health systems, to broaden the concept of equity, to bring attention to laws and policies beyond regulation and to strengthen accountability mechanisms

A scientific synthesis of marine protected areas in the United States: status and recommendations

Marine protected areas (MPAs) are a key tool for achieving goals for biodiversity conservation and human well-being, including improving climate resilience and equitable access to nature. At a national level, they are central components in the U.S. commitment to conserve at least 30% of U.S. waters by 2030. By definition, the primary goal of an MPA is the long-term conservation of nature; however, not all MPAs provide the same ecological and social benefits. A U.S. system of MPAs that is equitable, well-managed, representative and connected, and includes areas at a level of protection that can deliver desired outcomes is best positioned to support national goals. We used a new MPA framework, The MPA Guide, to assess the level of protection and stage of establishment of the 50 largest U.S. MPAs, which make up 99.7% of the total U.S. MPA area (3.19 million km2). Over 96% of this area, including 99% of that which is fully or highly protected against extractive or destructive human activities, is in the central Pacific ocean. Total MPA area in other regions is sparse – only 1.9% of the U.S. ocean excluding the central Pacific is protected in any kind of MPA (120,976 km2). Over three quarters of the non-central Pacific MPA area is lightly or minimally protected against extractive or destructive human activities. These results highlight an urgent need to improve the quality, quantity, and representativeness of MPA protection in U.S. waters to bring benefits to human and marine communities. We identify and review the state of the science, including focal areas for achieving desired MPA outcomes and lessons learned from places where sound ecological and social design principles come together in MPAs that are set up to achieve national goals for equity, climate resilience, and biodiversity conservation. We recommend key opportunities for action specific to the U.S. context, including increasing funding, research, equity, and protection level for new and existing U.S. MPAs

Diabetic cardiomyopathy

Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery disease, which leads to heart failure in diabetic patients. Epidemiological and clinical trial data have confirmed the greater incidence and prevalence of heart failure in diabetes. Novel echocardiographic and MR (magnetic resonance) techniques have enabled a more accurate means of phenotyping diabetic cardiomyopathy. Experimental models of diabetes have provided a range of novel molecular targets for this condition, but none have been substantiated in humans. Similarly, although ultrastructural pathology of the microvessels and cardiomyocytes is well described in animal models, studies in humans are small and limited to light microscopy. With regard to treatment, recent data with thiazoledinediones has generated much controversy in terms of the cardiac safety of both these and other drugs currently in use and under development. Clinical trials are urgently required to establish the efficacy of currently available agents for heart failure, as well as novel therapies in patients specifically with diabetic cardiomyopathy

Late presentation to HIV/AIDS care in Brazil among men who self-identify as heterosexual

ABSTRACT OBJECTIVE To analyze the factors associated with late presentation to HIV/AIDS services among heterosexual men. METHODS Men infected by HIV who self-identified as heterosexual (n = 543) were included in the study. Descriptive, biivariate and logistic regression analyses were performed to evaluate the factors associated with late presentation (defined as individuals whose first CD4 count was <350 cells/mm3) in the study population. RESULTS The prevalence of late presentation was 69.8%. The multivariate logistic analysis showed testing initiated by the provider (ORadjusted 3.75; 95%CI 2.45&#8211;5.63) increased the odds of late presentation. History of drug use (ORadjusted 0.59; 95%CI 0.38&#8211;0.91), history of having sexually transmitted infections (ORadjusted 0.64; 95%CI 0.42&#8211;0.97), and having less education (ORadjusted 0.63; 95%CI 0.41&#8211;0.97) were associated with a decreased odds of LP. CONCLUSIONS Provider initiated testing was the only variable to increase the odds of late presentation. Since the patients in this sample all self-identified as heterosexual, it appears that providers are not requesting they be tested for HIV until the patients are already presenting symptoms of AIDS. The high prevalence of late presentation provides additional evidence to shift towards routine testing and linkage to care, rather than risk-based strategies that may not effectively or efficiently engage individuals infected with HIV

Revisiting the use of condoms in Brazil

ABSTRACTIntroduction:It is known that a single prevention strategy is not enough to control multiple HIV epidemics around the world and in Brazil. However, it is not only necessary to recognize the importance of condoms as part of the policy of HIV/AIDS prevention but also discuss its limits. In this article, we aim to investigate the use of condoms in Brazil, draw critical reflections, and understand how they can once again be highlighted in Brazil's prevention strategy going forward.Methods:A narrative review of literature was conducted using keywords in PubMed. Reports from national surveys that guide the epidemiological and behavioral surveillance of the Brazilian Ministry of Health were also included.Results:A total of 40 articles and 3 reports were included in the review and 11 intervention studies to promote the condom use; the main findings were as follows: 1) Despite the increase in national studies on sexual behavior, little attention is given to the role of condom use; 2) There are few studies examining the factors associated with condom use among key populations such as men who have sex with men (MSM), female sex workers (FSW), drug users (DU), and transvestites and transexuals (TT), while substantial studies focus on adolescents and women; 3) Evidence suggests that a combination of interventions is more effective.Discussion:new prevention technologies must not lose sight of the critical importance of condoms, and efforts to reintroduce them should focus on the role of pleasure in addition to their potential to minimize the risk of HIV

Exploring differences in perceptions of gentrification, neighborhood satisfaction, social cohesion, and health among residents of two predominantly African American Pittsburgh neighborhoods (n = 60)

Abstract Background Gentrification often leads to changes in the social and physical environment of neighborhoods, which social capital theory has found are connected to aspects of resident health and wellbeing. A growing body of literature has explored the impact of gentrification on health and wellbeing of residents. The goal of this study is to qualitatively explore the ways in which gentrification may have impacted perceptions of neighborhood satisfaction, social cohesion, and health of neighborhood residents (n = 60) from two predominantly Black neighborhoods in Pittsburgh, Pennsylvania, one of which experienced Black gentrification during the study’s time period. This analysis is unique in its ability to capture experiences of residents who remained in their neighborhood throughout the course of the study, as well as those who moved away from their neighborhood. Methods Participants were randomly selected from a larger cohort enrolled in a quasi-experimental study and categorized by whether they lived in a census tract that gentrified, whether they owned or rented their home, and whether they moved from the neighborhood or remained in the same place of residence between 2011 and 2018. Phone interviews lasting approximately 30 min were conducted with participants and were audio recorded and transcribed verbatim. Participants were provided a $40 gift card for their time. Interview data were analyzed using a directed content approach, and Cohen’s Kappa was obtained (k = 0.924) to signal good inter-rater reliability. Results Results showed renters in gentrified census tracts overwhelmingly viewed gentrification trends as a negative change compared to homeowners. Overall, participants from gentrified census tracts reported being relatively satisfied with their neighborhood, though some suggested there were fewer resources in the neighborhood over time; felt their social cohesion had deteriorated over time; and more commonly reflected negative health changes over time. Conclusions These findings suggest that while gentrification can bring much needed improvements to neighborhoods, it can also bring other disruptive changes that affect the health and wellbeing of existing residents

“How am I going to live?”: exploring barriers to ART adherence among adolescents and young adults living with HIV in Uganda

Abstract Background Studies from sub-Saharan Africa (SSA) document how barriers to ART adherence present additional complications among adolescents and young adults living with HIV. We qualitatively explored barriers to ART adherence in Uganda among individuals age 14–24 to understand the unique challenges faced by this age group. Methods We conducted focus group (FG) discussions with Community Advisory Board members (n = 1), health care providers (n = 2), and male and female groups of adolescents age 14–17 (n = 2) and youth age 18–24 (n = 2) in Kampala, Uganda. FGs were transcribed verbatim and translated from Luganda into English. Two investigators independently reviewed all transcripts, developed a detailed codebook, achieved a pooled Cohen’s Kappa of 0.79 and 0.80, and used a directed content analysis to identify key themes. Results Four barriers to ART adherence emerged: 1) poverty limited adolescents’ ability to buy food and undercut efforts to become economically independent in their transition from adolescence to adulthood; 2) school attendance limited their privacy, further disrupting ART adherence; 3) family support was unreliable, and youth often struggled with a constant change in guardianship because they had lost their biological parents to HIV. In contrast peer influence, especially among HIV-positive youth, was strong and created an important network to support ART adherence; 4) the burden of taking multiple medications daily frustrated youth, often leading to so-called ‘drug holidays.’ Adolescent and youth-specific issues around disclosure emerged across three of the four barriers. Conclusions To be effective, programs and policies to improve ART adherence among youth in Uganda must address the special challenges that adolescents and young adults confront in achieving optimal adherence. For example, training on budgeting and savings practices could help promote their transition to financial independence. School staff could develop strategies to help students take their medications consistently and confidentially. While challenging to extend the range of services provided by HIV clinics, successful efforts will require engaging the family, peers, and larger community of health and educational providers to support adolescents and young adults living with HIV to live longer and healthier lives. Trial registration ClinicalTrials.gov Identifier: NCT02514356. Registered August 3, 2015