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Evidence on the implementation of health systems strengthening (HSS) interventions is scarce. Donors need this information to prioritise investments and lobby for continued financial support. To develop a deeper understanding of the implementation dynamics of robust HSS interventions, we retrospectively compared five USAID-supported projects in the Dominican Republic, Ethiopia, Kazakhstan, Rwanda, and Zambia. A document review and key informant interviews ( n  = 44) were conducted, coded, and analysed in each of the five cases using an integrated implementation framework. The framework was organised by four phases of implementation. For the pre-condition phase, data-driven HSS interventions were nested in a range of political contexts and with differing levels of financial support. In pre-implementation, cases relied on diverse teams that created a data-informed, inclusive, and transparent project ethos for implementation. Implementation was located at multiple tiers of the health system, used interventions as catalysts for government initiatives, supported governance/accountability initiatives, and responded nimbly to contextual changes in the implementation climate. There was less evidence of maintenance and evolution but all cases were designed with an eye towards sustainability. This research yields important insights about the dynamics of HSS, identifying ways donors can better support countries to achieve universal health coverage.

This paper presents results from a study conducted to compare the relative effectiveness of three strategies - alternate venue testing (AVT), the social network strategy (SNS), and partner counseling and referral services (PCRS; standard care) - for reaching and motivating previously undiagnosed, African-American men who have sex with men (AA MSM) to be tested for HIV. Data were collected between June 2008 and February 2010 at a gay-identified, community-based organization (CBO) serving AA MSM in Washington, DC. Men were eligible to participate if they were 18-64 years old, self-identified as black or African-American, were biologically male, and self-reported oral or anal sex with a man in the past six months. Fisher's exact test of independence was used to assess differences in demographics, testing history, HIV status and sexual behaviors across the three strategies. The final sample included 470 men who met all eligibility requirements. There were no statistically significant differences in HIV positivity rates across the three strategies. However, relative to standard care, the SNS, and (to a lesser degree) the AVT strategies were more successful in recruiting men that had never been tested. Additionally, the results indicate that each strategy recruited different subgroups of men. Specifically, heterosexually identified men and men who reported engaging in unprotected sex were most likely to be recruited via SNS. Bisexually identified men and older men were most likely to be recruited via AVT or SNS, while standard care tended to reach greater proportions of young men and homosexually identified men. These findings suggest that a combination of strategies may be the best approach for engaging African-American MSM in HIV testing.

Vietnam's HIV epidemic has been driven by injection drug use, with HIV prevalence among injection drug users (IDUs) of ~30%. Most IDUs are sexually active and may infect their female sexual partners (SPs). Male dominance in sexual decisions is deeply embedded in Vietnamese culture. There have been few HIV prevention interventions for SPs, who represent an important potential bridging population in the epidemic. We report findings from a baseline survey of SPs conducted in 2008 in Hanoi, Vietnam, where peer-based HIV prevention interventions targeting this population are now being implemented. The survey revealed HIV prevalence of 14% among SPs in Hanoi and only 27% reported condom use with their primary male partners half the time or more. About 69% of SPs were in serodiscordant or unknown HIV status relationships but condom use was not more frequent in these relationships than in concordant partnerships. Many SPs feared angry or violent responses if they requested condom use, problems that were even more likely in serodiscordant/unknown status relationships. SPs also reported limited prior access to HIV prevention services. Many SPs in Vietnam are at high risk for HIV and in need of HIV prevention interventions. However, to date, this population has been seriously underserved. Our interventions are in progress and results will be reported subsequently.

The aim of this study is to investigate adherence to highly active antiretroviral therapy (HAART) in persons living with HIV/AIDS (PLWHA) who are homeless or unstably housed. We evaluated homeless or unstably housed PLWHA (n=644) in three US cities were enrolled in the Housing and Health Study. Using baseline data and controlling for gender, race, age, and education, we examined associations between self-reported two- and Seven-day adherence and access to healthcare, mental health, substance use, and attitudes toward HIV medical therapy. Of the 644 participants, 358 (55%) were currently on HAART. For two-day adherence, 280 (78%) reported missing no prescribed doses (100% adherence), and for seven-day adherence, 291 (81%) reported > or =90% adherence. Logistic regression analyses indicated being younger, not having health insurance, and drug use were associated with missing > or =1 dose over the past two days. Scoring lower on SF-36 mental component summary scale and having greater risk of depression (CES-D) and stress (Perceived Stress Scale) were associated with poorer adherence for both two- and seven-day outcomes. Negative attitudes toward HIV treatment were also associated with lower adherence. Adherence to HIV medications in this population is similar to other groups. Coexisting problems of access to healthcare, higher risk of mental health problems, along with poorer attitudes toward treatment are associated with increased likelihood of missing doses. Comprehensive models of HIV care that include a continuum of medical and social services are essential for treating this population.

Background: Current guidelines recommend the use of pH monitoring to confirm the diagnosis of acid reflux in patients with a normal endoscopy. This analysis evaluated the financial impact of pH monitoring with the wireless pH capsule on a managed care organization (MCO) in the United States., Methods: A decision model was constructed to project total 1-year costs to manage GERD symptoms with and without the adoption of wireless pH capsules in a hypothetical MCO with 10 000 eligible adult enrollees, of whom 600 presented with GERD-like symptoms. Costs of GERD diagnosis, treatment, and symptom management for those in whom a GERD diagnosis was ruled out by pH monitoring were assessed. The incremental per-member-per-month (PMPM) and per-treated-member-per-month (PTMPM) costs were the primary outcomes. Data sources included literature, expert input, and standardized fee schedules., Results: An increase of 10 percentage points in the use of pH monitoring with wireless pH capsules yielded incremental PMPM and PTMPM costs of $0.029 and $0.481, respectively. The costs of proton pump inhibitor (PPI) therapy to the plan dropped to $236,363 from $238,086, while increases were observed in pH monitoring (from $16 739 to $21 973) and non-GERD therapy costs (from $1392 to $1740). The results were sensitive to the percentage of patients requiring repeat endoscopy before wireless pH monitoring and the cost of PPIs., Conclusions: Timely and increased use of pH monitoring as recommended in published guidelines leads to less unnecessary use of PPIs with a modest budgetary impact on health plans.

This paper presents findings from the assessment of a strategy aimed at improving case-finding and management of hypertension patients. Study findings suggest that providers' orientation to clinical guidelines, public information on hypertension risks, promotion of yearly blood pressure screening, and universal access to an outpatient drug benefit package, improve case-finding and management. In addition, training of providers at pilot sites resulted in a substantial and significant difference in patient care and health outcomes. Provider training and tools, especially focused on effective patient counselling, made a significant contribution to increased case-finding, patient adherence to prescribed drugs, reducing salt, and increasing regular exercise. However, further refinements are required to achieve the expected adherence of patients to medication and lifestyle advice. In the pilot area, we compared two samples of patients before and after the initiation of the intervention. We found an increase in the proportion of patients with blood pressure <140/90 mmHg, and a significant decrease in the proportion of patients with blood pressure > or =160/100 mmHg. The strategy involved the joint efforts of the Research Institute of Cardiology and Internal Diseases, Karaganda Drug Information Centre, Karaganda Oblast Health Department, Kazakhstan Association of Family Physicians, Almaty Postgraduate Institute for Physicians, and USAID ZdravPlus Project in Central Asia.

A pattern of serious injection drug user (IDU) driven HIV epidemics in Asia, with emerging evidence of generalization through heterosexual transmission, indicates the need for interventions focusing on both drug- and sex-related risk reduction. In a cross-border HIV prevention project for IDUs in northern Vietnam and southern China, peer educators disseminated risk reduction information to IDUs in the community and provided 20,000-25,000 sterile needles/syringes and 4,000-6,000 condoms per month. Since implementation of these interventions, the frequency of both injecting and sexual risk behaviours fell significantly, HIV prevalence among IDUs declined or stabilized, and HIV incidence dropped. There is official support for harm reduction interventions in both countries but this appears precarious in view of persistently powerful political and financial support for a law enforcement approach. Moreover, the simultaneous pursuit of inconsistent policies can have negative effects on the implementation of interventions. A harmonized and consistent policy environment is needed. Most of the evidence for efficacy of community-based HIV prevention comes from the developed world, but well-designed evaluations of such interventions in Asia and elsewhere in the developing world would have a better chance to influence policy decisions there. A synergistic approach to research, policy development, and service delivery is best calculated to achieve positive results in the struggle against HIV/AIDS in developing countries.

Purpose: The purpose of this study was to conduct a comprehensive and systematic literature review of the health-related quality of life (HRQL) burden of endometriosis in adults and adolescents., Methods: We conducted a systematic search and review of studies published between January 1999 and January 2006 using MEDLINE and relevant online resources. Search terms used included endometriosis, quality of life, burden of illness, psychology, and adolescent. We assessed: (1) the HRQL impact of endometriosis and related key symptoms; (2) the impact of specific pharmacologic and surgical treatments of endometriosis on HRQL; and (3) the presence and impact of endometriosis in adolescents., Results: Twenty relevant studies were identified and reviewed. Generic instruments most commonly used to assess HRQL in patients with endometriosis included the SF-36 and the SF-12. The EQ-5D was used to measure utilities. The Endometriosis Health Profile-30 (EHP-30) and its subset, the EHP-5, have been recently developed for use in endometriosis studies. Endometriosis was associated with significant impairments in pain, psychological functioning, and social functioning. Pharmacological and surgical treatments for endometriosis improved patients physical functioning, psychological functioning, vitality, pain level, and general health. Few studies used disease specific instruments to characterize the HRQL burden of endometriosis, addressed the HRQL impact of endometriosis-related infertility, and examined endometriosis in adolescents. Instruments specifically validated to measure HRQL in adolescents were not identified., Conclusions: Endometriosis impairs HRQL, especially in the domains of pain, psychological and social functioning. Therapies have been shown to alleviate symptoms and improve HRQL. Further research is warranted to evaluate the impact of endometriosis on HRQL in adolescents and the impact of infertility due to endometriosis on HRQL.

Objectives: Epidemiological data support an association between age-related macular degeneration (AMD) and cataract surgery that may be attributed to post-operative blue light exposure. By limiting the retina's blue light exposure, new blue-light filtering intraocular lenses (BLF IOLs) have the potential to reduce the development of AMD following cataract surgery. In the current economic healthcare environment, there is increased interest in the cost impact of new medical technologies. The objective of this analysis was to evaluate the cost impact of a BLF IOL versus a non-BLF IOL in cataract surgery., Methods: An economic model was developed to emulate three age-specific cohorts and to assess the clinical and economic outcomes over 5 years. Data from the published literature was supplemented with clinical expert opinion. Key literature inputs involved the risk of AMD after cataract surgery as well as laboratory and animal data on the effectiveness of the BLF IOL in reducing the risk of AMD. Clinical experts provided information on the management of AMD. Direct medical costs including the cost of the IOL, monitoring, and AMD prophylaxis and treatment were incorporated into the model. All costs were standardized to 2004 US dollars. Age-stratified sensitivity analyses were conducted., Results: In the BLF IOL group, the 5-year age-stratified incidence of AMD ranged from 0.58 to 9.23 per 100 eyes, compared with 1.69 to 24.55 per 100 eyes in the non-BLF IOL group. The incremental cost of the BLF was offset by reduced costs associated with averted AMD treatment. Estimated savings with BLF IOLs per 100 eyes were $4275, $29 997, and $111 734 in the 55 to 64 year-old, 65 to 74 year-old, and >or= 75-year-old cohorts, respectively; these findings remained robust throughout the sensitivity analyses., Conclusion: Limitations of this analysis include the lack of prospective clinical trial data that definitively demonstrate the efficacy of a BLF IOL in preventing AMD. Moreover, the efficacy data used to populate the model were derived from laboratory and animal studies. Thus, based on preliminary data, this study suggests that the economic benefits of implanting BLF IOLs during cataract surgery are observed in all patients over a 5-year timeframe although cost savings are greatest in patients >or= 75 years.

Purpose: Recent survey data have reported the incidence rate of needlestick injuries (NIs) and NIs which draw blood sustained by nurses caring for patients with diabetes in an in-patient hospital setting. The purpose of this study was to deduce the potential short-term annual economic impact resulting from such NI, and to project the potential national economic burden of NI among this population of health care workers (HCWs)., Methods: Data were obtained from a recently published, IRB-approved, Internet-based survey in which nurses routinely treating patients with diabetes self-reported outcomes of their experience with NI (N = 400). A micro-costing approach was adopted. Direct costs comprised post-exposure testing (PET) for infection, post-exposure health care services utilization, and NI-induced post-exposure prophylactic (PEP) drug utilization. Indirect costs were derived from missed workdays and associated lost productivity. These data were combined with data related to the national epidemiology and total incidence of NIs among HCWs and risk-associated populations to project the national burden., Results: Among 400 nurses, 110 sustained at least one NI in the past year, with 73 punctures drawing blood. The ensuing total short-term costs of these NIs were calculated to range from 25,896 US dollars to 36,066 US dollars. Indirect costs accounted for 44-62% of this total cost. Average short-term costs per NI ranged from 145 to 201 US dollars, and average short-term costs of NI per injured nurse ranged from 235 to 328 US dollars. Assuming mean values from published literature on the incidence and distribution of NI among nursing populations, an annual national burden of 65 million US dollars was calculated for costs in the immediate period following NI., Conclusions: These data suggest substantial economic burden immediately following NI on a national and individual hospital level occurring among acute-care nurses treating patients with diabetes. Long-term treatment costs would add to the overall economic burden.

Objective: To quantify the incidence and assess the risk of needlestick injury (NI) in nurses caring for patients with diabetes mellitus., Methods: A total of 400 nurses caring for patients with diabetes in 381 different hospitals throughout the United States over a period of at least 1 year voluntarily completed an Internet-based data collection instrument. The nurses self-reported comprehensive data on their experience with NI, focusing on those occurring within the past year. If respondents experienced multiple NI during this period, detailed data were collected on the most recent event., Results: Of the 400 nurses, 313 (78.3%) reported experiencing at least one NI, 110 (27.5%) reported at least one NI within the last 12 months, and 44 (40% of 110) reported multiple NI. Nearly two-thirds of these injuries (n = 73/110; 66.4%) were punctures that drew blood, resulting in one case of contracted hepatitis C. The cumulative annual incidence of NI events was 448 NI per 1000 nurses. Nurses reported the injury in adherence with existing regulations and policies in only 21.8% of the cases. Disposable syringes were involved in 88 (80%) of the NI events. In half of the injuries (n = 55), the needled device was equipped with a safety feature that was ineffective, primarily because it was not fully activated (n = 47/55; 85.5%) or it malfunctioned (n = 2-5; 3.6-9.1%). NI most commonly occurred while nurses were injecting insulin (n = 33; 30%). In the 2 weeks following their NI, 60.1% of nurses noted that they were more afraid of needled devices than before the injury and 41.8% felt anxious, depressed, or stressed. As a direct result of the NI, nurses missed 77 days of work., Conclusions: This study is the first to show the relatively high risk both of NI and of NI that draws blood among nurses injecting insulin with a disposable syringe and confirms previous incidence estimates of NI among nurses. Additionally, this study reveals significant post-NI emotional distress, suggests significant under-reporting of NI to hospital officials, and demonstrates the need for a more effective needle safety device.

Objectives: To quantify the direct medical costs associated with using vancomycin, as inpatient treatment, in methicillin-resistant Staphylococcus aureus infections, in four clinical indications: complicated skin and soft tissue infections (SSTI), bacteremia, infective endocarditis (IE), and hospital-acquired pneumonia (HAP)., Research Design and Methods: A decision-analytic model was constructed to evaluate the cost of administering intravenous vancomycin. Cost inputs included hospitalization, drug procurement, materials, preparation and administration, renal function and drug monitoring, treating adverse events, and treatment failure. Probabilities and lengths of stay and treatment were obtained from the literature, an antimicrobial therapy database and clinical expert opinion. Univariate and multivariate sensitivity analyses were conducted to confirm the robustness of the baseline scenario., Main Outcome Measures: The cost of using vancomycin in the four indications, including and excluding hospital cost., Results: Whereas the drug acquisition price of vancomycin 1g is US dollars 9.01 per dose, when all costs associated with using vancomycin were included, the cost per dose rose to US dollars 29-US dollars 43 per patient. Total costs per patient receiving multiple doses in a single course of treatment, excluding hospital room costs, were for SSTI, bacteremia, IE, and HAP,US dollars 779, US dollars 749, US dollars 2261, and US dollars 768, respectively. Total costs, including hospital length of stay, were for SSTI US dollars 23616, bacteremia US dollars 26446, IE US dollars 48925, and HAP US dollars 22493. In univariate analyses varying per diem hospital costs and length of stay had the greatest impact. Results of the multivariate analysis were comparable to the costs in the baseline scenario for all indications., Conclusions: This analysis highlights the importance of capturing all costs associated with using a drug and not simply focusing on drug acquisition cost. Future economic analyses should identify and account for the key cost burdens of a particular treatment to calculate its true cost.

This paper provides a brief discussion of the issues in examining "heavy" drug use in terms of a "career." This is an old paradigm in drug user research, and one that has produced some of the richest descriptions in the literature. It draws on the analytic approach developed to study other criminal activity in terms of "criminal careers" as well as the literature describing the variety of career "patterns" for substance users. Research into drug user careers is focused on the most serious, chronic substance users and examines the predictors of transition from lower level involvement to higher levels of involvement. Their use differs from that of experimental or social-recreational use in terms of its frequency and its significance in the user's life. The bibliography is divided into two general headings: research which described drug use careers and methodological issues in studying drug use careers. It ranges from classic narratives of the lives of drug users to discussions of the problems of trying to characterize accurately or to follow complex lives over time.

Many drug user treatment programs have difficulty recruiting, retaining, and successfully treating minority clients. Coupled with the fact that cultural diversity among clients is likely to increase, this consideration makes it critical that programs take steps to increase their responsiveness to minority clients. Among the steps which administrators and clinicians recommend that programs take are conducting a needs assessment; implementing special outreach approaches; hiring additional minority staff; providing staff training and education in cultural sensitivity; and identifying client cultural characteristics at intake.