Reducing exposure to high levels of perfluorinated compounds in drinking water improves reproductive outcomes: evidence from an intervention in Minnesota.

BackgroundPer- and polyfluoroalkyl substances (PFASs) have been detected in drinking water supplies around the world and are the subject of intense regulatory debate. While they have been associated with several illnesses, their effects on reproductive outcomes remains uncertain.MethodsWe analyzed birth outcomes in the east Minneapolis-St. Paul metropolitan area from 2002 to 2011, where a portion of the population faced elevated exposure to PFASs due to long-term contamination of drinking water supplies from industrial waste disposal. Installation of a water filtration facility in the highly contaminated city of Oakdale, MN at the end of 2006 resulted in a sharp decrease in exposure to PFASs, creating a "natural experiment". Using a difference-in-differences approach, we compare the changes in birth outcomes before and after water filtration in Oakdale to the changes over the same period in neighboring communities where the treatment of municipal water remained constant.ResultsAverage birth weight and average gestational age were statistically significantly lower in the highly exposed population than in the control area prior to filtration of municipal water supply. The highly exposed population faced increased odds of low birth weight (adjusted odds ratio 1.36, 95% CI 1.25-1.48) and pre-term birth (adjusted odds ratio 1.14, 95% CI 1.09-1.19) relative to the control before filtration, and these differences moderated after filtration. The general fertility rate was also significantly lower in the exposed population (incidence rate ratio 0.73, 95% CI 0.69-0.77) prior to filtration and appeared to be rebounding post-2006.ConclusionsOur findings provide evidence of a causal relationship between filtration of drinking water containing high levels of exposure to PFASs and improved reproductive outcomes

HIV clinical stage progression of patients at 241 outpatient clinics in Democratic Republic of Congo: Disparities by gender, TB status and rurality

Background: HIV clinical care programs are increasingly cognizant of the importance of customizing services according to patients’ clinical stage progression (WHO\u27s four-tiered staging) and other risk assessments. Understanding factors associated with Persons Living with HIV (PLHIV) patients’ progression through the treatment cascade and clinical stages is essential for programs to provide patient-centered, evidence-based services. Methods and materials: To analyze patient characteristics associated with disease progression stages for PLHIV on antiretroviral therapy (ART), this quantitative study used data, from January 2014–June 2019, from 49,460 PLHIV on ART from 241 HIV/AIDS outpatient clinics in 23 health zones in Haut-Katanga and Kinshasa provinces, Democratic Republic of Congo. To assess bivariate and multivariate associations, we performed Chi-square and multinomial logistic regression. Results: Among PLHIV receiving ART, 4.4% were at stage 4, and 30.7% at stage 3. Those at the less severe stages 2 and 1 constituted 22.9% and 41.9%. After controlling for covariates, patients with no TB were significantly more likely than those with TB (p\u3c = .05) to be at stage 1, rather than 3 or 4 (adjusted odds ratio or AOR, 5.73; confidence interval or CI, 4.98–6.59). Other characteristics significantly associated with higher odds of being at stage 1 included being female (AOR, 1.35; CI, 1.29–1.42), and shorter duration on ART (vs. \u3e 40.37 months); for ART duration less than 3.23 months the AOR was 2.47, for 3.23–14.52 months duration the AOR was 2.60, and for 14.53–40.37 months duration the AOR was 1.77 (quartile cut points used). Compared to patients in urban health zones, those in rural (AOR, 0.32) and semi-rural health zones (AOR, 0.79) were less likely to be at stage 1. Conclusion: Significant and substantial variation in HIV clinical progression stage by geographic location and demographic characteristics existed, indicative of the need for targeted efforts to improve the effectiveness of HIV care. Patients with TB coinfection compared to those without coinfection had a much greater risk of being at stage 3 or 4, implying a need for customized approaches and clinical regimens for this high-risk population

Socioeconomic status and other factors associated with HIV status among OVC in Democratic Republic of Congo (DRC)

Background: Orphans and vulnerable children (OVC) are a high-risk group for HIV infection, particularly in Sub-Saharan Africa. Purpose: This study aims to portray the socioeconomic profile of OVC and examine the association of household and parent/guardian characteristics with the HIV status of OVC. Methods: For this quantitative retrospective study, we obtained data from ICAP/DRC for a total of 1,624 OVC from households enrolled for social, financial, and clinical services between January 2017 and April 2020 in two provinces of the Democratic Republic of Congo, Haut-Katanga and Kinshasa. We computed descriptive statistics for OVC and their parents\u27 or guardians\u27 characteristics. We used the chi-square test to determine bivariate associations of the predictor variables with the dichotomous dependent variable, HIV positivity status. To analyze the association between these independent variables and the dichotomous dependent variable HIV status after controlling for other covariates, we performed firth\u27s logistic regression. Results: Of the OVC included in this study, 18% were orphans, and 10.9% were HIV+. The chi-square analysis showed that among parents/guardians that were HIV+, a significantly lower proportion of OVC (11.7%) were HIV+ rather than HIV- (26.3%). In contrast, for parents/guardians with HIV- status, 9.0% of OVC were HIV-negative, and 11.7% of OVC were OVC+. The firth\u27s logistic regression also showed the adjusted odds of HIV+ status were significantly lower for OVC with parents/guardians having HIV+ status themselves (AOR, 0.335; 95% CI, 0.171–0.656) compared with HIV-negative parents/guardians. The adjusted odds of HIV+ status were significantly lower for OVC with a monthly household income of \u3c $30 (AOR, 0.421; 95$30. Conclusions: Our results suggest that, with the exception of a few household and parent/guardian characteristics, the risk of HIV+ status is prevalent across all groups of OVC within this study, which is consistent with the existing body of evidence showing that OVC are in general vulnerable to HIV infection. With a notable proportion of children who are single or double orphans in DRC, HIV+ OVC constitute a high-risk group that merits customized HIV services. The findings of this study provide data-driven scientific evidence to guide such customization of HIV services

Essays in Environmental Economics

Public initiative and referendum voting outcomes provide an opportune setting in which to study the demand for publicly provided goods and services, such as environmental quality and public education. In the first essay, I use census block group level voting outcomes on California statewide ballot propositions from 2006 to 2012 to test whether the relationship between voter support and income depends on a proposition's fiscal implications or the local availability of private substitutes. Support is modestly increasing in income when the proposition is associated with a regulatory change in the context of environmental protection. When propositions are tax or bond-funded, however, I find evidence of a convex or U-shaped relationship between median income and the share of votes in favor, consistent with the combined effects of a low tax burden on poor households and a low marginal utility of wealth among rich households. In the context of public education funding, I further find that the positive marginal effect of income at high income levels is moderated in block groups with greater availability of private substitutes, namely a greater density of nearby private schools.Individuals can express their preferences for public goods, and environmental protection in particular, both as voters by supporting regulation or as consumers by choosing favorable alternatives, thus providing a unique opportunity to compare consumer and voter behavior within the same individual and regarding the same issue. In the second essay, I examine the relationship between willingness to pay a premium for products that avoid a controversial technology associated with environmental risks or externalities, with willingness to vote in favor of a ban or mandatory labeling of the technology. Based on a survey on genetically modified food, I find that the majority of respondents make consumer and voter choices that can be explained by a standard utility maximization framework. However, certain respondent characteristics are correlated with inconsistent choice patterns. In particular, low-income voters appear to be overly supportive of regulation relative to their private willingness to pay. Voters who are uncertain about the safety of genetically modified food also tend to be more in favor of mandatory labeling than their consumer choices would imply. While the first two essays consider the relationship between income and demand for environmental protection at a micro level, there are also much broader implications of this relationship. At the country level, higher GDP is often associated with stricter pollution regulation, which may imply a disproportionate amount of production of pollution-intensive goods in less wealthy countries. The hypothesis that countries with relatively strict pollution regulation will be more likely to import pollution intensive goods from countries with weaker or absent regulation is intuitively appealing and has found moderate support in a number of empirical studies. While these studies focus on the regulation of manufacturing industries, the underlying theoretical argument applies equally to the agricultural sector. The third essay assesses whether cross-country differences in pesticide regulation can induce such "pollution haven'' effects. In particular, I estimate the impact of the international phaseout of methyl bromide on trade flows in agricultural products. I find robust evidence that cross-country differences in allowed methyl bromide usage affect trade flows, and show that the effect varies in magnitude and significance across commodities, largely in line with their baseline reliance on MeBr. The results do not suggest that countries granted exemptions from the phaseout for particular commodities, on the basis of such reliance, gained an unfair competitive advantage

Consequences of COVID-19 Crisis for Persons with HIV: The Impact of Social Determinants of Health

Background With the indiscriminate spread of COVID-19 globally, many populations are experiencing negative consequences such as job loss, food insecurity, and inability to manage existing medical conditions and maintain preventive measures such as social distancing and personal preventative equipment. Some of the most disadvantaged in the COVID-19 era are people living with HIV/AIDS and other autoimmune diseases. Discussion As the number of new HIV infections decrease globally, many subpopulations remain at high risk of infection due to lack of or limited access to prevention services, as well as clinical care and treatment. For persons living with HIV or at higher risk of contracting HIV, including persons who inject drugs or men that have sex with men, the risk of COVID-19 infection increases if they have certain comorbidities, are older than 60 years of age, and are homeless, orphaned, or vulnerable children. The risk of COVID-19 is also more significant for those that live in Low- and Middle-Income Countries, rural, and/or poverty-stricken areas. An additional concern for those living the HIV is the double stigma that may arise if they also test positive for COVID-19. As public health and health care workers try to tackle the needs of the populations that they serve, they are beginning to realize the need for a change in the infrastructure that will include more efficient partnerships between public health, health care, and HIV programs. Conclusion Persons living with HIV that also have other underlying comorbidities are a great disadvantage from the negative consequences of COVID-19. For those that may test positive for both HIV and COVID-19, the increased psychosocial burdens stemming from stress and isolation, as well as, experiencing additional barriers that inhibit access to care, may cause them to become more disenfranchised. Thus, it becomes very important during the current pandemic for these challenges and barriers to be addressed so that these persons living with HIV can maintain continuity of care, as well as, their social and mental support systems

HIV clinical stage progression of patients at 241 outpatient clinics in DRC: Disparities by gender, TB status and rurality

Presentation given at APHA Annual Meeting and Expo. Background: HIV clinical care programs are increasingly customizing services to patients’ clinical stage progression (WHO’s four-tiered staging). Understanding factors associated with Persons Living with HIV (PLHIV)’s stage progression is essential for patient-centered services. Methods: To analyze PLHIV on antiretroviral therapy (ART) patients’ characteristics associated with progression stages, we used data, from 1/2014--6/2019, from 49,460 ART patients from 241 outpatient clinics in 23 health zones in Haut-Katanga and Kinshasa provinces, Democratic Republic of Congo. Chi-square and multinomial logistic regression assessed bivariate and multivariate associations. Results: ART patients were stage 4 (4.4%) and stage 3 (30.7%), with less severe stages 2 (22.9%) and 1 (41.9%). After covariate control, patients without TB were more likely than those with TB (p40.37 months); for ART duration \u3c 3.23 months the AOR was 2.47, for 3.23-14.52 months it was 2.60, and for 14.53-40.37 months it was 1.77 (quartile cut-points used). Compared to patients in urban health zones, those in rural (AOR, 0.32) and semi-rural zones (AOR, 0.79) were less likely to be stage 1. Conclusion: Significant variations in progression stage by location and demographic characteristics are indicative of the need for targeted efforts to improve HIV care. TB/HIV co-infected patients’ great risk of being stage 3 or 4 implies a particular need for customized approaches for this population

TB-HIV Co-infection and Risk of Death, Loss to Follow Up, and Viral Load Suppression in Democratic Republic Of Congo

Presentation given at APHA Annual Meeting and Expo. Background: To provide efficient, equitable, patient-centered care to people living with HIV/AIDS (PLWH), this study analyzes two aspects of TB coinfection in PLWH: (a) variation in TB/HIV coinfection by demographic and clinical characteristics of patients; and (b) risks of negative outcomes among PLWH with TB coinfection compared to those without such coinfection. Methods: This quantitative study used data on 49,460 PLWH on ART from 241 HIV/AIDS clinics in two provinces of Democratic Republic of Congo, Haut-Katanga and Kinshasa. Chi-square and logistic regression analysis were performed. Results: TB coinfection existed in 3.6% of the patients. Significantly higher proportions of patients with TB/HIV coinfection were males (4.5% vs. 3.3%); new patients rather than transferred-in (3.7% vs. 1.6%) resided in the Kinshasa province rather than Haut-Katanga (4.0% vs. 2.7%) and were in an urban health zone (3.9%) and semi-rural (3.1%) rather than rural (1.2%) health zone. The logistic regression models showed that after controlling for other demographic and clinical variables, TB/HIV coinfection raised the risk of death (AOR, 2.26; CI, 1.94 to 2.64) and loss to follow up (AOR, 2.06; CI, 1.82 to 2.34). TB/HIV coinfection lowered the odds of viral load suppression below 1,000 copies per ml of blood (AOR, 0.58; CI, 0.46 TO 0.74). Conclusions: TB/HIV coinfection raises the risk of negative outcomes. HIV clinics in DRC and other African countries may consider these findings when customizing their interventions to improve HIV care and reduce disparities in PLWH

Disparities in HIV Clinical Stages Progression of Patients at Outpatient Clinics in Democratic Republic of Congo

Context: In this era of patient-centered care, it is increasingly important for HIV/AIDS care and treatment programs to customize their services according to patients’ clinical stage progression and other risk assessments. To enable such customization of HIV care and treatment delivery, the research evidence explaining factors associated with patients’ clinical stages is needed. Objectives: The primary objective of this study was to produce such scientific evidence by analyzing the most recent data for patients at outpatient clinics in the provinces of Kinshasa and Haut-Katanga and to examine the patient characteristics associated with WHO stages of disease progression. Methods: Using a quantitative retrospective cohort study design, we analyzed data from 49,460 people living with HIV (PLHIV) on antiretroviral therapy (ART) from 241 HIV/AIDS clinics located in Haut-Katanga and Kinshasa provinces of the Democratic Republic of Congo. We performed Chi-square and multinomial logistic regression analyses. Results: A small proportion (i.e., 4.4%) of PLHIV were at WHO’s clinical progression stage 4, whereas 30.7% were at clinical stage 3, another 22.9% at stage 2, and the remaining 41.9% were at stage 1, the least severe stage. After controlling for other demographic and clinical factors included in the model, the likelihood of being at stage 1 rather than stage 3 or 4 was significantly higher (at p ≤ 0.05) for patients with no tuberculosis (TB) than those with TB co-infection (adjusted odds ratio or AOR, 5.73; confidence interval or CI, 4.98–6.59). The odds of being at stage 1 were significantly higher for female patients (AOR, 1.35; CI, 1.29–1.42), and those with the shorter duration on ART (vs. greater than 40.37 months). Patents in rural health zones (AOR, 0.32) and semi-rural health zones (AOR, 0.79) were less likely to be at stage 1, compared to patients in urban health zones. Conclusions: Our study showed that TB co-infection raised the risk for PLHIV to be at the severe stages of clinical progression of HIV. Such variation supports the thesis that customized HIV management approaches and clinical regimens may be imperative for this high-risk population. We also found significant variation in HIV clinical progression stages by geographic location and demographic characteristics. Such variation points to the need for more targeted efforts to address the disparities, as the programs attempt to improve the effectiveness of HIV care and treatment. The intersectionality of vulnerabilities from HIV, TB, and COVID-19-related hardships has elevated the need for customized care and treatment even more in the COVID-19 er