Eric Goosby

Recovery of function after hip fracture: The role of social supports.

Previous studies have found that social support may reduce mortality after myocardial infarction and reduce overall mortality among the elderly. To determine whether social support also influences the recovery of function among patients who have had hip fractures and to describe other potential predictors of recovery after hip fractures, 111 patients with hip fractures were interviewed and examined before discharge from the hospital. The functional status of surviving patients was assessed again 6 months later. Patients who had a greater number of social supports had more complete recovery of their prefracture level of function (r = .21; P = .04). This association was strongest for patients over 60 years old (r = .31; P = .006); among these patients, this association remained statistically significant after adjustment for other significant (P < .05) predictors of recovery: arm strength, mental status, and serum albumin. Additional studies should be done to test whether interventions to increase social supports can improve the recovery of function among elderly patients with hip fractures and other illnesses. In the meantime, health professionals should counsel elderly patients about the potential rehabilitative and preventive benefits of social supports.

Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola

Harvard Global Health Institute (Prof A Jha MD, S Moon PhD, L R Woskie MSc, J A Leigh MPH), Harvard T.H. Chan School of Public Health (Prof A K Jha, S Moon, L R Woskie, J A Leigh), and Harvard Kennedy School (S Moon), Harvard University, Boston, MA, USA; University of Edinburgh Medical School, Edinburgh (Prof D Sridhar DPhil); Duke Global Health Institute, Durham, NC, USA (M A Pate MD); Bill, Hillary & Chelsea Clinton Foundation, New York, NY, USA (C Clinton DPhil); Medecins Sans Frontieres, New York , NY, USA (S Delaunay MA); Campaign for Good Governance, Freetown, Sierra Leone (V Edwin MA); Action Contre La Faim International , Monrovia, Liberia (M Fallah PhD); Indiana University Maurer School of Law, Bloomington, IN, USA (Prof D P Fidler JD); Council on Foreign Relations, New York, NY, USA (L Garrett PhD); University of California, San Francisco, CA, USA (Prof E Goosby MD); Georgetown University, Washington, DC, USA (Prof L Gostin JD); Chatham House, London, UK (Prof D L Heymann MD); Simon Fraser University, Burnaby, BC, Canada (Prof K Lee DPhil); Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China (Prof G M Leung MD); Center for Strategic and International Studies, Washington DC, USA (J S Morrison PhD); AIDS Executive summary The west African Ebola epidemic that began in 2013 exposed deep inadequacies in the national and international institutions responsible for protecting the public from the far-reaching human, social, economic, and political consequences of infectious disease outbreaks. The Ebola epidemic raised a crucial question: what reforms are needed to mend the fragile global system for outbreak prevention and response, rebuild confi dence, and prevent future disasters? To address this question, the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine jointly launched the Independent Panel on the Global Response to Ebola. Panel members from academia, think tanks, and civil society have collectively reviewed the worldwide response to the Ebola outbreak. After diffi cult and lengthy deliberation, we concluded that major reforms are both warranted and feasible. The Panel’s conclusions off er a roadmap of ten interrelated recommendations across four thematic areas:

The Human Resources for Health Program in Rwanda — A New Partnership

The authors discuss the Human Resources for Health Program, which is working to improve the quality and quantity of health professionals in Rwanda by means of sustained collaborations with U.S. schools of medicine, nursing, dentistry, and public health.

The Chinese free antiretroviral treatment program: challenges and responses.

To respond to the HIV/AIDS epidemic in China, the National Center for AIDS/STD Control and Prevention established the Division of Treatment and Care in late 2001. The pilot for the National Free ART Program began in Henan Province in 2002, and the program fully began in 2003. Treatment efforts initially focused on patients infected through illicit blood and plasma donation in the mid-1990s and subsequently expanded to include HIV-infected injection drug users, commercial sex workers, pregnant women, and children. The National Free ART Database was established in late 2004, and includes data on current patients and those treated before 2004. Over 31 000 adult and pediatric patients have been treated thus far. Challenges for the program include integration of drug treatment services with ART, an under-resourced health care system, co-infections, stigma, discrimination, drug resistance, and procurement of second-line ART. The merging of national treatment and care, epidemiologic, and drug resistance databases will be critical for a better understanding of the epidemic, for earlier identification of patients requiring ART, and for improved patient follow-up. The Free ART Program has made considerable progress in providing the necessary care and treatment for HIV-infected people in China and has strong government support for continued improvement and expansion.

Defeating AIDS—advancing global health

After more than a decade of major achievements the AIDS response is at a crucial juncture both in terms of its immediate trajectory and its sustainability as well as its place in the new global health and development agendas. In May 2013 the UNAIDS-Lancet Commission -- a diverse group of experts in HIV health and development young people people living with HIV and affected communities activists and political leaders -- was established to investigate how the AIDS response could evolve in a new era of sustainable development. The UNAIDS-Lancet Commission has come together at a moment when the lessons of the AIDS response including its whole-of-society perspective can be informative and even transformational for other spheres of global health. The path to ending AIDS as a public health threat by 2030 as set out in this report should be a major part of the post-2015 development agenda. On the basis of our analysis and discussion we make the following seven key recommendations: Urgently escalate AIDS efforts get serious about HIV prevention and continue expanding access to treatment; Mobilise more resources spend efficiently and emphasise sustainability; Demand robust accountability transparency and better data; Forge new paths to uphold human rights and address criminalisation stigma and discrimination; Reinforce and renew leadership and engagement of people living with HIV; Invest in research and innovation in all facets of the AIDS response; and Promote more inclusive coherent and accountable governance for AIDS and health. In conclusion the question is no longer whether the fight against AIDS can be won; the only questions are: will it be won -- and when? The answers to these questions will eventually depend on the decisions made by leaders and institutions at all different levels in all sectors and parts of society and on the personal choices people make in their private lives. (Excerpts)

Public health and international drug policy.

The Johns Hopkins–Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug-control policy and to inform and encourage a central focus on public health evidence and outcomes in drug-policy debates, such as the important deliberations of the 2016 UNGASS on drugs. The Commission is concerned that drug policies are often coloured by ideas about drug use and dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug misuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, emphasised that drug use “is neither a medical condition, nor does it necessarily lead to drug dependence”. The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, and alcohol, for which the goal of social policy is to reduce potential harms.

Implementation science for the US President's Emergency Plan for AIDS Relief (PEPFAR).

Working with implementing organizations and governments in over 32 countries, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has contributed to the rapid acceleration of HIV treatment access, availability of care and support services, and HIV prevention interventions. In the first phase of PEPFAR, these activities were appropriately carried out in an emergency fashion with the goal of using available interventions to reduce mortality and alleviate suffering from HIV disease as quickly and effectively as possible. Many lessons have been learned through examination of programs, including simple evaluations and operations research. Commensurate with the emergency response, however, state-of-the-art monitoring, evaluation, and research methodologies were not fully integrated or systematically performed. In the second phase of PEPFAR, characterized by an increased emphasis on sustainability, programs must demonstrate value and impact to be prioritized within complex and resource-constrained environments. In this context, there is a greater demand to causally attribute outcomes to programs. Better attribution can be used to inform midcourse corrections in the scale-up of new interventions (eg, male circumcision) or to reevaluate investments in programs for which impact is less clear. To meet these demands, PEPFAR is adopting an implementation science (IS) framework to improve the development and effectiveness of its programs at all levels. IS is the study of methods to improve the uptake, implementation, and translation of research findings into routine and common practices (the ‘‘know-do’’ or ‘‘evidence to program’’ gap). For example, IS was used to evaluate the routine operational effectiveness of the South African National Prevention of Mother-to-Child Transmission Programme. Investigators explored the survival of HIV-free infants across program sites and identified specific sources of variation such as health system factors (eg, limited antenatal visits and lack of syphilis screening) and individual behaviors (eg, breastfeeding practices). By framing the problem through IS, the study revealed opportunities for improving program performance that could be translated into immediate solutions (eg, improving quality of care, infant feeding counseling). In this way, IS proved to be a valuable tool that was used not only to improve program effectiveness, but also to explain what worked, why, and under what circumstances. Although no less rigorous than biomedical research dictated by a static protocol with robust internal validity (ie, ‘‘proof-of-concept’’ research with a precisely defined and narrow objective), an IS approach represents a paradigmatic shift in emphasis to greater external validity. The IS scope is also broader, seeking to improve program effectiveness and optimize efficiency, including the effective transfer of interventions from one setting to another. The methods of IS facilitate making evidence-based choices between competing or combined interventions and improving the delivery of effective and costeffective programs.

Use of generic antiretroviral agents and cost savings in PEPFAR treatment programs.

CONTEXT One of the biggest hurdles to the rapid scale-up of antiretroviral therapy in the developing world was the price of antiretroviral drugs (ARVs). Modification of an existing US Food and Drug Administration (FDA) process to expedite review and approval of generic ARVs quickly resulted in a large number of FDA-tentatively approved ARVs available for use by the US Presidents Emergency Plan for AIDS Relief (PEPFAR). OBJECTIVE To evaluate the uptake of generic ARVs among PEPFAR-supported programs in Guyana, Haiti, Vietnam, and 13 countries in Africa, and changes over time in ARV use and costs. DESIGN, SETTING, AND PARTICIPANTS An annual survey from 2005 to 2008 of ARVs purchased in 16 countries by PEPFAR implementing and procurement partners (organizations using PEPFAR funding to purchase ARVs). MAIN OUTCOME MEASURES Drug expenditures, ARV types and volumes (assessed per pack, a 1-month supply), proportion of generic procurement across years and countries, and cost savings from generic procurement. RESULTS ARV expenditures increased from

The United States President's Emergency Plan for AIDS Relief: a story of partnerships and smart investments to turn the tide of the global AIDS pandemic.

116.8 million (2005) to

HIV Treatment As Prevention: How Scientific Discovery Occurred And Translated Rapidly Into Policy For The Global Response

202.2 million (2008); and procurement increased from 6.2 million to 22.1 million monthly packs. The proportion spent on generic ARVs increased from 9.17% (95% confidence interval [CI], 9.17%-9.18%) in 2005 to 76.41% (95% CI, 76.41%-76.42%) in 2008 (P < .001), and the proportion of generic packs procured increased from 14.8% (95% CI, 14.79%-14.84%) in 2005 to 89.33% (95% CI, 89.32%-89.34%) in 2008 (P < .001). In 2008, there were 8 PEPFAR programs that procured at least 90.0% of ARV packs in generic form; South Africa had the lowest generic procurement (24.7%; 95% CI, 24.6%-24.8%). Procurement of generic fixed-dose combinations increased from 33.3% (95% CI, 33.24%-33.43%) in 2005 to 42.73% (95% CI, 42.71%-42.75%) in 2008. Estimated yearly savings generated through generic ARV use were