HIV prevention in Mexican schools: prospective randomised evaluation of intervention.

OBJECTIVE: To assess effects on condom use and other sexual behaviour of an HIV prevention programme at school that promotes the use of condoms with and without emergency contraception. DESIGN: Cluster randomised controlled trial. SETTING: 40 public high schools in the state of Morelos, Mexico. PARTICIPANTS: 10 954 first year high school students. INTERVENTION: Schools were randomised to one of three arms: an HIV prevention course that promoted condom use, the same course with emergency contraception as back-up, or the existing sex education course. Self administered anonymous questionnaires were completed at baseline, four months, and 16 months. Students at intervention schools received a 30 hour course (over 15 weeks) on HIV prevention and life skills, designed in accordance with guidelines of the joint United Nations programme on HIV/AIDS. Two extra hours of education on emergency contraception were given to students in the condom promotion with contraception arm. MAIN OUTCOME MEASURES: Primary outcome measure was reported condom use. Other outcomes were reported sexual activity; knowledge and attitudes about HIV and emergency contraception; and attitudes and confidence about condom use. RESULTS: Intervention did not affect reported condom use. Knowledge of HIV improved in both intervention arms and knowledge of emergency contraception improved in the condom promotion with contraception arm. Reported sexual behaviour was similar in the intervention arms and the control group. CONCLUSION: A rigorously designed, implemented, and evaluated HIV education course based in public high schools did not reduce risk behaviour, so such courses need to be redesigned and evaluated. Addition of emergency contraception did not decrease reported condom use or increase risky sexual behaviour but did increase reported use of emergency contraception

Cost of AIDS care in Mexico: what are its main individual predictors?

BACKGROUND: The Mexican government is offering universal access to antiretroviral (ARV) drugs. The cost of doing so, despite aggressive price negotiation with the pharmaceutical industry, remains high. Even with a low prevalence, about 150,000 Mexicans are estimated to be living with HIV and will require ARV treatment. Estimating the resources needed to fund this gap should consider how patient and provider characteristics affect health care costs. METHODS: Using a sample of patients from 11 facilities in three Mexican cities representing a large proportion of AIDS patients in the country, we developed a fixed-effect model, which by controlling the facilities and individual heterogeneity estimates predicted costs using patient demographic and socioeconomic characteristics as well as physician training. RESULTS: The estimated model explains about 45% of the variation in costs. Additional education is significantly and positively associated with cost. Increasing age is also associated with higher costs. CONCLUSIONS: Socioeconomic status and demographic characteristics explain an important proportion of variation in care costs for AIDS, despite AIDS being such a heterogeneous disease. Such characteristics will need to be taken into account when resource needs are estimated. A priority-setting process considering the principles of equity in the fair distribution of resources is needed to help reduce the social burden of HIV/AIDS in Mexico

Access to condoms for female sex workers in Andhra Pradesh.

BACKGROUND: Condoms are an essential part of comprehensive HIV prevention and care programmes. We report the accessibility of male condoms for female sex workers (FSWs) and the associated characteristics that may play a major role in determining access to condoms for FSWs. METHODS: Confidential interviews of 6509 street- and home-based FSWs in 13 districts of the Indian state of Andhra Pradesh provided data on the number of paying clients and various aspects of access to free condoms and purchase of condoms. Access to condoms was defined as having ever obtained condoms either through free distribution or through purchase. Multivariate analyses were done separately for street- and home-based FSWs to describe correlates of their access to condoms. The requirement of condoms was assessed based on the number of paying clients during the past 15 days. RESULTS: Data on condom access were available for 6465 (99.3%) FSWs. A total of 2850 (44.1%; 95% CI: 36.2%-52.0%) reported accessing free condoms ever and 2336 (36.1%; 95% CI: 30.6%-41.6%) had purchased condoms ever (not mutually exclusive). The primary sources for condoms were non-governmental organization facilities (73.8%) and pharmacies (79.7%) for free and purchased condoms, respectively. A total of 3510 (54.3%; 95% CI: 48.5%-60.1%) FSWs reported no access to free or purchased condoms during the past 15 days, and this no access was significantly higher for those > 30 years of age, with no schooling, street-based FSWs, and with no participation in a FSW support group (p < 0.001 for each in univariate analysis). Participation in a FSW support group was the main predictor of access to free condoms for both types of FSWs during the past 15 days with multivariate analysis. Condom requirements during the past 15 days were met for 67.5% of FSWs who had accessed only free condoms and for 33.8% of those who had accessed only purchased condoms. CONCLUSIONS: One-fourth of FSWs had never accessed condoms, and a little over half of those who had ever accessed reported no access during the past 15 days. Condom requirements were not met for three-fifths of the FSWs. HIV prevention programmes need to Increase access to free condoms for FSWs in Andhra Pradesh as access to condoms is a necessary prerequisite for condom use

HIV prevention cost-effectiveness: a systematic review

BackgroundAfter more than 25 years, public health programs have not been able to sufficiently reduce the number of new HIV infections. Over 7,000 people become infected with HIV every day. Lack of convincing evidence of cost-effectiveness (CE) may be one of the reasons why implementation of effective programs is not occurring at sufficient scale. This paper identifies, summarizes and critiques the CE literature related to HIV-prevention interventions in low- and middle-income countries during 2005-2008.MethodsSystematic identification of publications was conducted through several methods: electronic databases, internet search of international organizations and major funding/implementing agencies, and journal browsing. Inclusion criteria included: HIV prevention intervention, year for publication (2005-2008), setting (low- and middle-income countries), and CE estimation (empirical or modeling) using outcomes in terms of cost per HIV infection averted and/or cost per disability-adjusted life year (DALY) or quality-adjusted life year (QALY).ResultsWe found 21 distinct studies analyzing the CE of HIV-prevention interventions published in the past four years (2005-2008). Seventeen CE studies analyzed biomedical interventions; only a few dealt with behavioral and environmental/structural interventions. Sixteen studies focused on sub-Saharan Africa, and only a handful on Asia, Latin America and Eastern Europe. Many HIV-prevention interventions are very cost effective in absolute terms (using costs per DALY averted), and also in country-specific relative terms (in cost per DALY measured as percentage of GDP per capita).ConclusionThere are several types of interventions for which CE studies are still not available or insufficient, including surveillance, abstinence, school-based education, universal precautions, prevention for positives and most structural interventions. The sparse CE evidence available is not easily comparable; thus, not very useful for decision making. More than 25 years into the AIDS epidemic and billions of dollars of spending later, there is still much work to be done both on costs and effectiveness to adequately inform HIV prevention planning

HIV testing among female sex workers in Andhra Pradesh, India.

Of 6648 female sex workers (FSW) in 13 districts of Andhra Pradesh state in India, only 7.9% reported having undergone HIV testing, and three-quarters of the rest were unwilling to undergo HIV testing in the future. The risk of HIV infection as a result of the non-use of condoms was higher among FSW who reported not having been tested and were also unwilling to get tested, and they also held significantly more negative beliefs about HIV/AIDS

Evolution of differences in clinical presentation across epidemic waves among patients with COVID-like-symptoms who received care at the Mexican Social Security Institute

BackgroundTimely monitoring of SARS-CoV-2 variants is crucial to effectively managing both prevention and treatment efforts. In this paper, we aim to describe demographic and clinical patterns of individuals with COVID-19-like symptoms during the first three epidemic waves in Mexico to identify changes in those patterns that may reflect differences determined by virus variants.MethodsWe conducted a descriptive analysis of a large database containing records for all individuals who sought care at the Mexican Social Security Institute (IMSS) due to COVID-19-like symptoms from March 2020 to October 2021 (4.48 million records). We described the clinical and demographic profile of individuals tested (3.38 million, 32% with PCR and 68% with rapid test) by test result (positives and negatives) and untested, and among those tested, and the changes in those profiles across the first three epidemic waves.ResultsIndividuals with COVID-19-like symptoms were older in the first wave and younger in the third one (the mean age for those positive was 46.6 in the first wave and 36.1 in the third wave; for negatives and not-tested, the mean age was 41 and 38.5 in the first wave and 34.3 and 33.5 in the third wave). As the pandemic progressed, an increasing number of individuals sought care for suspected COVID-19. The positivity rate decreased over time but remained well over the recommended 5%. The pattern of presenting symptoms changed over time, with some of those symptoms decreasing over time (dyspnea 40.6 to 14.0%, cough 80.4 to 76.2%, fever 77.5 to 65.2%, headache 80.3 to 78.5%), and some increasing (odynophagia 48.7 to 58.5%, rhinorrhea 28.6 to 47.5%, anosmia 11.8 to 23.2%, dysgeusia 11.2 to 23.2%).ConclusionDuring epidemic surges, the general consensus was that any individual presenting with respiratory symptoms was a suspected COVID-19 case. However, symptoms and signs are dynamic, with clinical patterns changing not only with the evolution of the virus but also with demographic changes in the affected population. A better understanding of these changing patterns is needed to improve preparedness for future surges and pandemics

Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza

Background In the spring of 2009, an outbreak of severe pneumonia was reported in conjunction with the concurrent isolation of a novel swine-origin influenza A (H1N1) virus (S-OIV), widely known as swine flu, in Mexico. Influenza A (H1N1) subtype viruses have rarely predominated since the 1957 pandemic. The analysis of epidemic pneumonia in the absence of routine diagnostic tests can provide information about risk factors for severe disease from this virus and prospects for its control. Methods From March 24 to April 29, 2009, a total of 2155 cases of severe pneumonia, involving 821 hospitalizations and 100 deaths, were reported to the Mexican Ministry of Health. During this period, of the 8817 nasopharyngeal specimens that were submitted to the National Epidemiological Reference Laboratory, 2582 were positive for S-OIV. We compared the age distribution of patients who were reported to have severe pneumonia with that during recent influenza epidemics to document an age shift in rates of death and illness. Results During the study period, 87% of deaths and 71% of cases of severe pneumonia involved patients between the ages of 5 and 59 years, as compared with average rates of 17% and 32%, respectively, in that age group during the referent periods. Features of this epidemic were similar to those of past influenza pandemics in that circulation of the new influenza virus was associated with an off-season wave of disease affecting a younger population. Conclusions During the early phase of this influenza pandemic, there was a sudden increase in the rate of severe pneumonia and a shift in the age distribution of patients with such illness, which was reminiscent of past pandemics and suggested relative protection for persons who were exposed to H1N1 strains during childhood before the 1957 pandemic. If resources or vaccine supplies are limited, these findings suggest a rationale for focusing prevention efforts on younger populations

Achieving the WHO/UNAIDS antiretroviral treatment 3 by 5 goal: what will it cost?

The "3 by 5" goal to have 3 million people in low and middle income countries on antiretroviral therapy (ART) by the end of 2005 is ambitious. Estimates of the necessary resources are needed to facilitate resource mobilisation and rapid channelling of funds to where they are required. We estimated the financial costs needed to implement treatment protocols, by use of country-specific estimates for 34 countries that account for 90% of the need for ART in resource-poor settings. We first estimated the number of people needing ART and supporting programmes for each country. We then estimated the cost per patient for each programme by country to derive total costs. We estimate that between US5.1 billion dollars and US5.9 billion dollars will be needed by the end of 2005 to provide ART, support programmes, and cover country-level administrative and logistic costs for 3 by 5