Tara Horvath

The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-analysis

Firearms cause an estimated 31000 deaths annually in the United States (1). Data from the 16-state National Violent Death Reporting System indicate that 51.8% of deaths from suicide in 2009 (n= 9949) were firearm-related; among homicide victims (n= 4057), 66.5% were firearm-related. Most suicides (76.4%) occurred in the victims homes. Homicides also frequently occurred in the home, with 45.5% of male victims and 74.0% of female victims killed at home (2). Firearm ownership is more prevalent in the United States than in any other country; approximately 35% to 39% of households have firearms (3, 4), and 22% of persons report owning firearms. The annual rate of suicide by firearms (6.3 suicides per 100000 residents) is higher in the United States than in any other country with reported data, and the annual rate of firearm-related homicide in the United States (7.1 homicides per 100000 residents) is the highest among high-income countries (4). Results from ecological studies suggest that state restrictions on firearm ownership are associated with decreases in firearm-related suicides and homicides (5). Specific characteristics about storage and types of firearms seem to increase suicide risk. Firearms that are stored loaded or unlocked are more likely to be used than those that are unloaded or locked (6, 7), and adolescent suicide victims often use an unlocked firearm in the home (8). The apparent increased risk for suicide associated with firearms in the home is not unique to persons with a history of mental illness (7) and may be more of an indicator of the ease of impulsive suicide. Impulsiveness may be a catalyst in using a firearm to commit suicide and may also play a role in firearm-related homicide. Researchers have estimated higher odds of homicide victimization among women than men (9, 10). Because most homicide victims know their perpetrators (9), this finding may indicate an impulsive reaction to domestic disputes. To our knowledge, this is the first systematic review and meta-analysis to estimate the association between firearm accessibility and suicide or homicide victimization. Supplement. Original Version (PDF) Methods We used Cochrane Collaboration methods (11) throughout the review process. Data Sources and Searches We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and Web of Science without date, geographic, or language limitations. We also examined bibliographies of included articles to identify additional references. In addition, we searched the gray literature for papers related to firearms and suicide or homicide. The Appendix and Appendix Table 1 (both available at www.annals.org) present details of our search strategy and screening process. Appendix Table 1. Search Strategy Study Selection Study Design Study designs eligible for inclusion in our review were randomized, controlled trials; nonrandomized, controlled trials; pre- or postintervention evaluations; and observational studies (for example, cohort or casecontrol studies) if a comparator was available. Because we were concerned with the individual effects of firearm accessibility, we included only studies with individual-level data and excluded those with population-level data (for example, ecological studies). Types of Participants Participants were not restricted by age, sex, or country of residence. Types of Exposures Studies needed to assess whether firearms were available for all participants. In addition, included studies needed to assess outcomes between participants with and without access to firearms. Specifically, studies needed to compare firearm ownership or availability (that is, accessibility) with no firearm ownership or availability (that is, no accessibility) or provide adequate data to estimate the effect that firearms had on selected harms outcomes. Firearm accessibility could be defined as self- or proxy-reported or assumed from other types of exposure data (for example, firearm purchase records). Types of Outcome Measures The primary outcomes of interest were suicide or homicide victimization (that is, being a victim of homicide rather than a perpetrator). Data Extraction and Quality Assessment Two authors independently extracted relevant data into a standardized, prepiloted data extraction form. Assessment of Risk of Bias Two authors independently assessed the risk of bias for each study by using the NewcastleOttawa Scale (12, 13). We resolved disagreements by discussion or by involving the third author to adjudicate (Table 1 and Appendix Table 2). Table 1. Summary of Critical Appraisal of Included Studies Using the NewcastleOttawa Scale for Assessing the Quality of Observational Studies* Appendix Table 2. Detailed Risk of Bias Results Using the NewcastleOttawa Scale for Assessing Quality for Observational Studies Data Synthesis and Analysis When necessary, we calculated the odds ratio (OR) and 95% CI for dichotomous outcomes, although published adjusted estimates were preferentially used if provided in the report. We pooled data across studies and estimated summary effect sizes by using fixed- and random-effects models. The choice of model was determined by the significance of the maximum likelihood estimate of the heterogeneity parameter ( 2) (14). If the estimate of 2 did not significantly differ from 0, the fixed-effects model was used (14). We present 2 estimates of heterogeneitythe I 2 statistic and the coefficient. Estimates of the former are interpreted as the percentage of variability in effect estimates due to heterogeneity rather than chance, whereas the latter can be interpreted as the clinical heterogeneity as determined by the estimated SD of underlying effects across studies. Unlike the I 2 statistic, the coefficient does not change with the number of patients included in the studies in a meta-analysis (15). We used R, version 3.0.0 (R Foundation for Statistical Computing, Vienna, Austria), for statistical analyses. The coefficient was measured on the log OR scale. This review is registered in PROSPERO (CRD42013004469). Results Search Results The database searches yielded 6902 references (Figure 1). We removed 2929 duplicates and an additional 2881 clearly irrelevant references. We then identified 2382 records through gray-literature searches. We closely reviewed 3474 titles and abstracts. After this screening, we selected 70 articles for full-text review. We identified an additional 4 studies by cross-referencing bibliographies (1619). Overall, 16 observational studies met our inclusion criteria. The Appendix shows the disposition of studies excluded after full-text review. Figure 1. Summary of evidence search and selection. Fourteen of the included studies estimated the odds of suicide in the context of firearm accessibility (68, 10, 1625), and 6 studies estimated the odds of homicide victimization in this context (9, 10, 2224, 48). Four studies reported both outcomes (10, 2224). Study Characteristics Demographic Characteristics Persons who completed suicide (mean, 75% [range, 70% to 85%]) (68, 10, 1621, 23) and homicide victims (mean, 79% [range, 63% to 92%]) (9, 10, 23, 48) were more commonly men. Most persons who completed suicide were white (range, 78% to 98%) (6, 8, 10, 1619, 21, 23, 26), whereas most homicide victims were non-Hispanic black or another race (range, 47% to 88%) (9, 10, 23, 48). Four (28.6%) of the 14 suicide studies were among adolescents only (6, 8, 16, 17), and 10 (71.4%) were among adults only (7, 10, 1825). All studies of outcomes of homicide victimization were among adults only (9, 10, 2224, 48). Firearm Access Among 11 U.S. casecontrol studies using survey data, proportions of firearm access ranged from 62.7% to 75.4% among case patients and from 26.4% to 50.8% among controls participants. One non-U.S. study (20) used survey data to estimate the proportion of case patients (23.9%) and control participants (18.5%) with firearm access, and another non-U.S. study (25) assumed firearm access from military duty and estimated the proportion of case patients (41%) and control participants (17%) with access. Among U.S.-based studies with reported data, the proportion of completed suicides using a firearm ranged from 47% to 73% (6, 7, 10, 16, 17, 2124); 3 studies did not report adequate data (8, 18, 19). One nonU.S.-based study of civilians reported that 13% of suicides were completed using a firearm (20), whereas another non-U.S. study of military personnel reported that 52% of suicides were completed using a firearm (25). The proportion of homicides using a firearm ranged from 50% to 76% (13, 15, 2729). Studies of Suicide Eleven of 14 studies (78.6%) interviewed proxies to determine firearm accessibility among decedents or control participants (68, 10, 1621, 23), whereas 3 studies (21.4%) used firearm purchase records or military duty to determine accessibility among decedents or control participants (22, 24, 25) (Table 2). Twelve studies (85.7%) defined suicide as self-inflicted, intentional death by any means (6, 7, 10, 1623, 25), whereas 2 studies (14.3%) defined suicide as injury related only to firearms or firearm- or violence-related injury (8, 24). All suicides were reported consecutively or identified using death certificates. In casecontrol studies, various types of control participants were identified, such as inpatients who attempted suicide (14.3%) (16, 17), community or school control participants (42.9%) (68, 18, 20, 21), decedents from causes other than suicide (28.6%) (18, 19, 24, 25), participants in a national health survey (7.1%) (10), or living HMO-based control participants (7.1%) (22). Table 2. Characteristics of Included Studies of Suicide and Homicide Victimization Studies of Homicide Victimization Three of 6 studies (50.0%) interviewed proxies to determine firearm accessibility in the home of decedents or control participants (Table 1) (9, 10, 23). Two studies (33.0%) used firearm purchase records to determine firearm acc

Predicting treatment failure in adults and children on antiretroviral therapy: a systematic review of the performance characteristics of the 2010 WHO immunologic and clinical criteria for virologic failure.

Objective:We systematically reviewed the performance of 2010 WHO immunologic and clinical criteria for predicting virologic failure in HIV-infected patients on antiretroviral therapy (ART). Design:Systematic review. Methods:We used Cochrane Collaboration methods. We calculated unweighted sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of immunologic and clinical criteria for predicting virologic failure. Results:We identified 18 studies. Sixteen assessed immunologic criteria in adults; 12 defined virologic failure as a plasma viral load of more than 50 to more than 1000 copies/ml in adults, three as viral load at least 5000 copies/ml, and two as viral load more than 10 000 copies/ml; the sensitivity ranged from 16.8 to 54.9%, specificity from 82.9 to 95.5%, PPV from 15.0 to 38.8%, and NPV from 90.9 to 98.6%. Seven studies assessed clinical criteria to predict viral load of more than 50 to more than 1000 copies/ml; the sensitivity was 11.0%, specificity 90.5%, PPV 44.9%, and NPV 90.2%. Seven studies assessed clinical or immunologic criteria defining virologic failure as viral load of more than 50 to more than1000 copies/ml; their sensitivity was 26.6%, specificity 85.9%, PPV 49.4%, and NPV 91.1%. Four studies assessed immunologic criteria in children; three defined virologic failure as viral load at least 5000 copies/ml and one as viral load at least 400 copies/ml. The sensitivity ranged from 4.5 to 6.3%, specificity from 97.7 to 99.3%, PPV from 20.0 to 54.9%, and NPV from 85.5 to 91.8%. Conclusion:The 2010 WHO clinical and immunologic criteria are insensitive and have low PPV for predicting virologic failure. These data support the strong recommendation 2013 treatment guidelines that viral load testing be used to monitor for, diagnose, and confirm ART failure.

Antiretroviral Therapy for Prevention of HIV Transmission in HIV-Discordant Couples

CLINICAL QUESTION Does treating the HIV-infected partner in a serodiscordant couple reduce the risk of HIV transmission to the uninfected partner? BOTTOM LINE Compared with serodiscordant couples without treatment, couples in which the infected partner is treated with antiretroviral therapy have a lower risk of HIV transmission.

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization

Background:Current service delivery systems do not reach all people in need of antiretroviral therapy (ART). In order to inform the operational and service delivery section of the WHO 2013 consolidated antiretroviral guidelines, our objective was to summarize systematic reviews on integrating ART delivery into maternal, newborn, and child health (MNCH) care settings in countries with generalized epidemics, tuberculosis (TB) treatment settings in which the burden of HIV and TB is high, and settings providing opiate substitution therapy (OST); and decentralizing ART into primary health facilities and communities. Design:A summary of systematic reviews. Methods:The reviewers searched PubMed, Embase, PsycINFO, Web of Science, CENTRAL, and the WHO Index Medicus databases. Randomized controlled trials and observational cohort studies were included if they compared ART coverage, retention in HIV care, and/or mortality in MNCH, TB, or OST facilities providing ART with MNCH, TB, or OST facilities providing ART services separately; or primary health facilities or communities providing ART with hospitals providing ART. Results:The reviewers identified 28 studies on integration and decentralization. Antiretroviral therapy integration into MNCH facilities improved ART coverage (relative risk [RR] 1.37, 95% confidence interval [CI] 1.05–1.79) and led to comparable retention in care. ART integration into TB treatment settings improved ART coverage (RR 1.83, 95% CI 1.48–2.23) and led to a nonsignificant reduction in mortality (RR 0.55, 95% CI 0.29–1.05). The limited data on ART integration into OST services indicated comparable rates of ART coverage, retention, and mortality. Partial decentralization into primary health facilities improved retention (RR 1.05, 95% CI 1.01–1.09) and reduced mortality (RR 0.34, 95% CI 0.13–0.87). Full decentralization improved retention (RR 1.12, 95% CI 1.08–1.17) and led to comparable mortality. Community-based ART led to comparable rates of retention and mortality. Conclusion:Integrating ART into MNCH, TB, and OST services was often associated with improvements in ART coverage, and decentralization of ART into primary health facilities and communities was often associated with improved retention. Neither integration nor decentralization was associated with adverse outcomes. These data contributed to recommendations in the WHO 2013 consolidated antiretroviral guidelines to integrate ART delivery into MNCH, TB, and OST services and to decentralize ART.

Early initiation of antiretroviral therapy in HIV-infected adults and adolescents: a systematic review

Objectives:The objective of this review was to update evidence on when to initiate antiretroviral therapy (ART) to inform revision of the 2013 WHO guidelines for ART in low and middle-income countries. Design:A systematic review and meta-analysis. Methods:We comprehensively searchescohorts. Outcomes were mortality, clinical progression, virologic failure, immunologic recover, and severe adverse events. We pooled data across studies and estimated summary effect sizes. We graded the quality of evidence from the literature for each outcome. Results:We identified 24 studies; 3 were RCTs. Studies found reduced risk of mortality [1 RCT: hazard ratio 0.77, 95% confidence interval (CI) 0.34–1.76; 13 cohorts: relative risk (RR) 0.66, 95% CI 0.55–0.79], progression to AIDS or death (2 RCTs: RR 0.48, 95% CI 0.26–0.91; 9 cohorts: RR 0.70, 95% CI 0.40–1.24) and diagnosis of a non-AIDS-defining illness (1 RCT: RR 0.14, 95% CI 0.03–0.64; 1 cohort: RR 0.47, 95% CI 0.23–0.98), and an increased risk of grade 3/4 laboratory abnormalities in patients initiating ART at at least 350 cells/&mgr;l (1 RCT: RR 1.49, 95% CI 1.25–1.77). The quality of evidence was low or very low for clinical outcomes due to few events and imprecision, and high for adverse events. Conclusions:Our findings contributed to the evidence base for the revised 2013 WHO guidelines on ART, which recommend initiating ART at CD4+ T-cell counts of 350–500 cells/&mgr;l, but not above 500 cells/&mgr;l compared to initiating it later when CD4+ T-cell counts fall below 350 cells/&mgr;l.

Using GRADE methodology for the development of public health guidelines for the prevention and treatment of HIV and other STIs among men who have sex with men and transgender people

BackgroundThe World Health Organization (WHO) Department of HIV/AIDS led the development of public health guidelines for delivering an evidence-based, essential package of interventions for the prevention and treatment of HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM) and transgender people in the health sector in low- and middle-income countries. The objective of this paper is to review the methodological challenges faced and solutions applied during the development of the guidelines.MethodsThe development of the guidelines followed the WHO guideline development process, which utilizes the GRADE approach. We identified, categorized and labeled the challenges identified in the guidelines development process and described the solutions through an interactive process of in-person and electronic communication.ResultsWe describe how we dealt with the following challenges: (1) heterogeneous and complex interventions; (2) paucity of trial data; (3) selecting outcomes of interest; (4) using indirect evidence; (5) integrating values and preferences; (6) considering resource use; (7) addressing social and legal barriers; (8) wording of recommendations; and (9) developing global guidelines.ConclusionWe were able to successfully apply the GRADE approach for developing recommendations for public health interventions. Applying the general principles of the approach while carefully considering specific challenges can enhance both the process and the outcome of guideline development.

The sexually transmitted infections and HIV/AIDS Cochrane review groups

![Graphic][1] Accurate diagnosis, treatment and prevention of HIV and sexually transmitted infections (STIs) should be priorities for health systems around the world. Untreated or undertreated STIs can lead to infertility, cancer, chronic pelvic pain, and facilitate HIV transmission.1 New and existing treatments, tests and prevention strategies therefore need to be rigorously evaluated to assess their benefits and harms as this information is important for clinical decision-making and policy and guideline development. This editorial introduces the new Sexually Transmitted Infections Cochrane Review (STICR) group, which aims to support authors in summarising evidence about interventions and diagnostic tests used for genital tract infections. The Cochrane Collaboration focuses on developing and maintaining systematic reviews of healthcare interventions to allow well-informed decisions about healthcare.2 A systematic review is an assessment and evaluation of all research studies that examine a particular clinical problem,3 using explicit, pre-stated methods that reduce bias, thus providing more reliable findings from which conclusions can be drawn and decisions made.4 The Cochrane Database of Systematic Reviews forms the main part of the Cochrane Library, and has over 5000 reviews. According to Journal Citation Reports its impact factor for 2012 was 5.78,5 and more than 50% of the world has free access to the Cochrane Library.6 The STICR group is one of 52 groups of the Cochrane Collaboration. Its … [1]: /embed/inline-graphic-1.gif