Shari Krishnaratne

Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review.

BackgroundResearch on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status.MethodsA total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality.ResultsEighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations.ConclusionsThese studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.

Communication about environmental health risks: A systematic review

BackgroundUsing the most effective methods and techniques for communicating risk to the public is critical. Understanding the impact that different types of risk communication have played in real and perceived public health risks can provide information about how messages, policies and programs can and should be communicated in order to be most effective. The purpose of this systematic review is to identify the effectiveness of communication strategies and factors that impact communication uptake related to environmental health risks.MethodsA systematic review of English articles using multiple databases with appropriate search terms. Data sources also included grey literature. Key organization websites and key journals were hand searched for relevant articles. Consultation with experts took place to locate any additional references.Articles had to meet relevance criteria for study design [randomized controlled trials, clinical controlled trials, cohort analytic, cohort, any pre-post, interrupted time series, mixed methods or any qualitative studies), participants (those in community-living, non-clinical populations), interventions (including, but not limited to, any community-based methods or tools such as Internet, telephone, media-based interventions or any combination thereof), and outcomes (reported measurable outcomes such as awareness, knowledge or attitudinal or behavioural change). Articles were assessed for quality and data was extracted using standardized tools by two independent reviewers. Articles were given an overall assessment of strong, moderate or weak quality.ResultsThere were no strong or moderate studies. Meta-analysis was not appropriate to the data. Data for 24 articles were analyzed and reported in a narrative format. The findings suggest that a multi-media approach is more effective than any single media approach. Similarly, printed material that offers a combination of information types (i.e., text and diagrams) is a more effective than just a single type, such as all text. Findings also suggest that factors influencing response to risk communications are impacted by personal risk perception, previous personal experience with risk, sources of information and trust in those sources.ConclusionsNo single method of message delivery is best. Risk communication strategies that incorporate the needs of the target audience(s) with a multi-faceted delivery method are most effective at reaching the audience.

Mass deworming to improve developmental health and wellbeing of children in low-income and middle-income countries: a systematic review and network meta-analysis

BACKGROUND Soil-transmitted helminthiasis and schistosomiasis, considered among the neglected tropical diseases by WHO, affect more than a third of the worlds population, with varying intensity of infection. We aimed to evaluate the effects of mass deworming for soil-transmitted helminths (with or without deworming for schistosomiasis or co-interventions) on growth, educational achievement, cognition, school attendance, quality of life, and adverse effects in children in endemic helminth areas. METHODS We searched 11 databases up to Jan 14, 2016, websites and trial registers, contacted authors, and reviewed reference lists. We included studies published in any language of children aged 6 months to 16 years, with mass deworming for soil-transmitted helminths or schistosomiasis (alone or in combination with other interventions) for 4 months or longer, that reported the primary outcomes of interest. We included randomised and quasi-randomised trials, controlled before-after studies, interrupted time series, and quasi-experimental studies. We screened in duplicate, then extracted data and appraised risk of bias in duplicate with a pre-tested form. We conducted random-effects meta-analysis and Bayesian network meta-analysis. FINDINGS We included 52 studies of duration 5 years or less with 1 108 541 children, and four long-term studies 8-10 years after mass deworming programmes with more than 160 000 children. Overall risk of bias was moderate. Mass deworming for soil-transmitted helminths compared with controls led to little to no improvement in weight over a period of about 12 months (0·99 kg, 95% credible interval [CrI] -0·09 to 0·28; moderate certainty evidence) or height (0·07 cm, 95% CrI -0·10 to 0·24; moderate certainty evidence), little to no difference in proportion stunted (eight fewer per 1000 children, 95% CrI -48 to 32; high certainty evidence), cognition measured by short-term attention (-0·23 points on a 100 point scale, 95% CI -0·56 to 0·14; high certainty evidence), school attendance (1% higher, 95% CI -1 to 3; high certainty evidence), or mortality (one fewer per 1000 children, 95% CI -3 to 1; high certainty evidence). We found no data on quality of life and little evidence of adverse effects. Mass deworming for schistosomiasis might slightly increase weight (0·41 kg, 95% CrI -0·20 to 0·91) and has little to no effect on height (low certainty evidence) and cognition (moderate certainty evidence). Our analyses do not suggest indirect benefits for untreated children from being exposed to treated children in the community. We are uncertain about effects on long-term economic productivity (hours worked), cognition, literacy, and school enrolment owing to very low certainty evidence. Results were consistent across sensitivity and subgroup analyses by age, worm prevalence, baseline nutritional status, infection status, impact on worms, infection intensity, types of worms (ascaris, hookworm, or trichuris), risk of bias, cluster versus individual trials, compliance, and attrition. INTERPRETATION Mass deworming for soil-transmitted helminths with or without deworming for schistosomiasis had little effect. For schistosomiasis, mass deworming might be effective for weight but is probably ineffective for height, cognition, and attendance. Future research should assess which subset of children do benefit from mass deworming, if any, using individual participant data meta-analysis. FUNDING Canadian Institutes of Health Research and WHO.

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

BACKGROUND Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade. METHODS We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence. FINDINGS From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories. INTERPRETATION There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods. FUNDING Bill & Melinda Gates Foundation.

Trends in socioeconomic inequalities in HIV prevalence among young people in seven countries in eastern and southern Africa.

Background In Eastern and Southern Africa, HIV prevalence was highest among higher socioeconomic groups during the 1990s. It has been suggested that this is changing, with HIV prevalence falling among higher-educated groups while stable among lower-educated groups. A multi-country analysis has not been undertaken. Methods We analysed data on socio-demographic factors and HIV infection from 14 nationally representative surveys of adults aged 15-24 (seven countries, two surveys each, 4-8 years apart). Sample sizes ranged from 2,408-12,082 (72,135 total). We used logistic regression to assess gender-stratified associations between highest educational level attended and HIV status in each survey, adjusting for age and urban/rural setting. We tested for interactions with urban/rural setting and age. Our primary hypothesis was that higher education became less of a risk factor for HIV over time. We tested for interaction between survey-year and the education-HIV association in each country and all countries pooled. Findings In Ethiopia and Malawi, HIV prevalence was higher in more educated women in both surveys. In Lesotho, Kenya and Zimbabwe, HIV prevalence was lower in higher educated women in both surveys. In Ethiopia, HIV prevalence fell among no and secondary educated women only (interaction p<0·01). Only among young men in Tanzania there was some evidence that the association between education and HIV changed over time (p=0·07). Pooled analysis found little evidence for an interaction between survey year and the education-HIV association among men (p=0·60) or women (p=0·37). Interpretation The pattern of prevalent HIV infection among young adults by level of education in different sub-Saharan African countries was heterogeneous. There was little statistical evidence that this pattern changed between 2003-5 and 2008-12. Explanations for the social epidemiology of HIV in Africa will need to account for time-trends and inter-country differences.

Changes in HIV prevalence among socioeconomic groups in eight African countries: analysis of sequential cross-sectional surveys

Abstract Background Across sub-Saharan Africa, HIV prevalence was highest among higher socioeconomic groups during the 1990s. Population-based data from Tanzania from 2003 to 2007 suggested that this pattern is changing, with HIV prevalence falling among higher-educated groups but remaining stable among those with lower levels of education, suggesting lower incidence in higher-educated groups over this period. A multi-country analysis has not previously been undertaken. Methods We collated data on sociodemographic factors and HIV infection from 16 nationally representative surveys of adults (aged 15–49 years) from Burkina Faso, Ethiopia, Malawi, Lesotho, Kenya, Rwanda, Tanzania, and Zimbabwe. Surveys were conducted 4–6 years apart; sample sizes ranged from 5357 to 29 812 (188 315 individuals total). We used logistic regression to assess gender-stratified associations between highest educational level attained and HIV status in each survey. We adjusted for age and urban/rural setting, and tested for interactions between education level, urban/rural setting, and age. Our primary hypothesis is that higher education level becomes less of a risk for HIV, or protective, over time; we report p values for the statistical interaction between education and survey year. Findings In Ethiopia, there is evidence that the association between HIV prevalence and higher education level was weaker and/or more protective in the second survey in young women (p=0·14) and all men (p=0·11). Similar patterns were observed in Malawian urban women (p=0·03) and rural men (p=0·02), Rwandan older men (p=0·16), Tanzanian men (p=0·07), and rural Zimbabwean women (p=0·07). In Burkina Faso, the risk associated with higher education levels increased (p=0·01) in older men. We found no other changes in association between education and prevalent HIV. Interpretation Changes in the social epidemiology of HIV across sub-Saharan Africa appear heterogeneous. In most cases, where there is evidence of changing association between education and HIV, education has become less risky, or protective, over time. We continue to explore the hypothesis that patterns may depend upon identifiable characteristics of a countrys HIV epidemic. Funding The study was supported through the STRIVE consortium by UKaid from the Department for International Development. However, the views expressed do not necessarily reflect the departments official policies.

Trials and tribulations: cross-learning from the practices of epidemiologists and economists in the evaluation of public health interventions.

Abstract The randomized controlled trial is commonly used by both epidemiologists and economists to test the effectiveness of public health interventions. Yet we have noticed differences in practice between the two disciplines. In this article, we propose that there are some underlying differences between the disciplines in the way trials are used, how they are conducted and how results from trials are reported and disseminated. We hypothesize that evidence-based public health could be strengthened by understanding these differences, harvesting best-practice across the disciplines and breaking down communication barriers between economists and epidemiologists who conduct trials of public health interventions.

Individual and community-level risk factors for Hiv stigma in 21 Zambian and South African communities: analysis of data from the Hptn071 (popart) study

Objective: To describe the prevalence and determinants of HIV stigma in 21 communities in Zambia and South Africa. Design: Analysis of baseline data from the HPTN 071 (PopART) cluster-randomized trial. HIV stigma data came from a random sample of 3859 people living with HIV. Community-level exposures reflecting HIV fears and judgements and perceptions of HIV stigma came from a random sample of community members not living with HIV (n = 5088), and from health workers (HW) (n = 851). Methods: We calculated the prevalence of internalized stigma, and stigma experienced in the community or in a healthcare setting in the past year. We conducted risk-factor analyses using logistic regression, adjusting for clustering. Results: Internalized stigma (868/3859, prevalence 22.5%) was not associated with sociodemographic characteristics but was less common among those with a longer period since diagnosis (P = 0.043). Stigma experienced in the community (853/3859, 22.1%) was more common among women (P = 0.016), older (P = 0.011) and unmarried (P = 0.009) individuals, those who had disclosed to others (P < 0.001), and those with more lifetime sexual partners (P < 0.001). Stigma experienced in a healthcare setting (280/3859, 7.3%) was more common among women (P = 0.019) and those reporting more lifetime sexual partners (P = 0.001) and higher wealth (P = 0.003). Experienced stigma was more common in clusters wherever community members perceived higher levels of stigma, but was not associated with the beliefs of community members or HW. Conclusion: HIV stigma remains unacceptably high in South Africa and Zambia and may act as barrier to HIV prevention and treatment. Further research is needed to understand its determinants.

Cost-Effectiveness of Interventions to Prevent HIV Acquisition

Because of the severe health consequences of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and the costs of lifelong treatment, inexpensive and effective HIV prevention is bound to be cost-effective. But what constitutes HIV prevention, and can it be affordable and effective? The use of condoms that cost a few cents and prevent a young adult from acquiring a chronic and fatal disease will, over time, be cost saving. Avoiding sex with someone who is infected with HIV/AIDS will be even more so. What can be done to get people to use condoms? What can be done to facilitate the avoidance of risky sexual encounters? Additional efficacious biomedical tools have become available, but similar questions persist: What can be done to get young women at risk to use oral truvada effectively as preexposure prophylaxis (PrEP) and to get young men at risk to be circumcised? The answers to these questions will determine what packages of prevention are essential, how much prevention programs should cost, and how cost-effective they can be. This chapter reviews current evidence about the efficacy, effectiveness, and costs of HIV/AIDS prevention products, programs, and approaches. HISTORY OF THE HIV/AIDS PANDEMIC AND PREVENTION INITIATIVES

Trends in Responses to DHS Questions Should Not Be Interpreted as Reflecting an Increase in "Anticipated Stigma" in Africa.

To the Editors:In sub-Saharan Africa, measurements of change in levels of HIV-related stigma have not been well reported. Years of data have been collected through the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys on responses to questions aimed at determining attitudes toward peop