BACKGROUND: Universal testing and treatment (UTT) for all people living with HIV has only been assessed under experimental conditions in cluster-randomised trials. The public health effectiveness of UTT policies on the HIV care cascade under real-world conditions is not known. We assessed the real-world effectiveness of universal HIV treatment policies that were implemented in Zambia on Jan 1, 2017. METHODS: We used data from Zambia's routine electronic health record system to analyse antiretroviral therapy (ART)-naive adults who newly enrolled in HIV care up to 1 year before and after the implementation of universal treatment (ie, Jan 1, 2016, to Jan 1, 2018) at 117 clinics supported by the Centre for Infectious Disease Research in Zambia. We used a regression discontinuity design to estimate the effects of implementing UTT on same-day ART initiation, ART initiation within 1 month, and retention on ART at 12 months (defined as clinic attendance 9-15 months after enrolment and at least 6 months on ART), under the assumption that patients presenting immediately before and after UTT implementation were balanced on both measured and unmeasured characteristics. We did an instrumental variable analysis to estimate the effect of same-day ART initiation under routine conditions on 12-month retention on ART. FINDINGS: 65 673 newly enrolled patients with HIV (40 858 [62·2%] female, median age 32 years [IQR 26-39], median CD4 count 287 cells per μL [IQR 147-466]) were eligible for inclusion in the analyses; 31 145 enrolled before implementation of UTT, and 34 528 enrolled after UTT. Implementation of universal treatment increased same-day ART initiation from 41·7% to 74·8% (risk difference [RD] 33·1%, 95% CI 30·5-35·7), ART initiation by 1 month from 69·6% to 87·0% (RD 17·4%, 15·5-19·3), and 12-month retention on ART from 56·2% to 63·3% (RD 7·1%, 4·3-9·9). ART initiation rates became more uniform across patient subgroups after implementation of universal treatment, but heterogeneity in 12-month retention on ART between subgroups was unchanged. Instrumental variable analyses indicated that same-day ART initiation in routine settings led to a 15·8% increase (95% CI 12·1-19·5) in 12-month retention on ART. INTERPRETATION: UTT policies implemented in Zambia increased the rapidity and uptake of ART, as well as retention on ART at 12 months, although overall retention on ART remained suboptimal. UTT policies reduced disparities in treatment initiation, but not 12-month retention on ART. Natural experiments reveal both the anticipated and unanticipated effects of real-world implementation and indicate the need for new strategies leveraging the short-term effects of UTT to cultivate long-term treatment success. FUNDING: National Institutes of Health.

Indicators for the measurement of programmes for the primary prevention of HIV are less aligned than indicators for HIV treatment, which results in a high burden of data collection, often without a clear vision for its use. As new evidence becomes available, the opportunity arises to critically evaluate the way countries and global bodies monitor HIV prevention programmes by incorporating emerging data on the strength of the evidence linking various factors with HIV acquisition, and by working to streamline indicators across stakeholders to reduce burdens on health-care systems. Programmes are also using new approaches, such as targeting specific sexual networks that might require non-traditional approaches to measurement. Technological advances can support these new directions and provide opportunities to use real-time analytics and new data sources to more effectively understand and adapt HIV prevention programmes to reflect population movement, risks, and an evolving epidemic.

Introduction: The workplace is a major source of exposure to secondhand smoke from combustible tobacco products. Smokefree workplace policies protect nonsmoking workers from secondhand smoke and help workers who smoke quit. This study examined changes in self-reported smokefree workplace policy coverage among U.S. workers from 2003 to 2010-2011. Methods: Data came from the 2003 (n = 74,728) and 2010-2011 (n = 70,749) waves of the Tobacco Use Supplement to the Current Population Survey. Among employed adults working indoors, a smokefree workplace policy was defined as a self-reported policy at the respondent's workplace that did not allow smoking in work areas and public/common areas. Descriptive statistics were used to assess smokefree workplace policy coverage at two timepoints overall, by occupation, and by state. Results: The proportion of U.S. workers covered by smokefree workplace policies increased from 77.7% in 2003 to 82.8% in 2010-2011 (p < .00001). The proportion of workers reporting smokefree workplace policy coverage increased in 21 states (p < .001) and decreased in two states (p < .001) over this period. In 2010-2011, by occupation, this proportion ranged from 74.3% for blue collar workers to 84.9% for white collar workers; by state, it ranged from 63.3% in Nevada to 92.6% in Montana. Conclusions: From 2003 to 2010-2011, self-reported smokefree workplace policy coverage among indoor adult workers increased nationally, and occupational coverage disparities narrowed. However, coverage remained unchanged in half of states, and disparities persisted across occupations and states. Accelerated efforts are warranted to ensure that all workers are protected by smokefree workplace policies. Implications: This study assessed changes in the proportion of indoor workers reporting being covered by smokefree workplace policies from 2003 to 2010-2011 overall and by occupation and by state, using data from the Tobacco Use Supplement to the Current Population Survey. The findings indicate that smokefree workplace policy coverage among U.S. indoor workers has increased nationally, with occupational coverage disparities narrowing. However, coverage remained unchanged in half of states, and disparities persisted across occupations and states. Accelerated efforts are warranted to ensure that all workers are protected by smokefree workplace policies.

The average retail price per pack of cigarettes is less than $6, which is substantially lower than the $10 per-pack target established in 2014 by the Surgeon General to reduce the smoking rate. We estimated the impact of three cigarette pricing scenarios on smoking prevalence among teens aged 12-17 years, young adults aged 18-25 years, and adults aged ≥26 years, by state: (1) $0.94 federal tax increase on cigarettes, as proposed in the fiscal year 2017 President’s budget; (2) $10 per-pack retail price, allowing discounts; and (3) $10 per-pack retail price, eliminating discounts. We conducted Monte Carlo simulations to generate point estimates of reductions in cigarette smoking prevalence by state. We found that each price scenario would substantially reduce cigarette smoking prevalence. A $10 per-pack retail price eliminating discounts could result in 637,270 fewer smokers aged 12-17 years; 4,186,954 fewer smokers aged 18-25 years; and 7,722,460 fewer smokers aged ≥26 years. Raising cigarette prices and eliminating discounts could substantially reduce cigarette smoking prevalence as well as smoking-related death and disease. © 2016, Association of Schools of Public Health. All rights reserved.

Exposure to secondhand smoke from burning tobacco products causes stroke, lung cancer, and coronary heart disease in adults. Children who are exposed to secondhand smoke are at increased risk for sudden infant death syndrome, acute respiratory infections, middle ear disease, more severe asthma, respiratory symptoms, and slowed lung growth. Secondhand smoke exposure contributes to approximately 41,000 deaths among nonsmoking adults and 400 deaths in infants each year. This report updates a previous CDC report that evaluated state smoke-free laws in effect from 2000-2010, and estimates the proportion of the population protected by comprehensive smoke-free laws. The number of states, including the District of Columbia (DC), with comprehensive smoke-free laws (statutes that prohibit smoking in indoor areas of worksites, restaurants, and bars) increased from zero in 2000 to 26 in 2010 and 27 in 2015. The percentage of the U.S. population that is protected increased from 2.72% in 2000 to 47.8% in 2010 and 49.6% in 2015. Regional disparities remain in the proportions of state populations covered by state or local comprehensive smoke-free policies, as no state in the southeast has a state comprehensive law. In addition, nine of the 24 states that lack state comprehensive smoke-free laws also lack any local comprehensive smoke-free laws. Opportunities exist to accelerate the adoption of smoke-free laws in states that lack local comprehensive smoke-free laws, including those in the south, to protect nonsmokers from the harmful effects of secondhand smoke exposure.

INTRODUCTION: Increasing tobacco excise taxes and implementing comprehensive smoke-free laws are two of the most effective population-level strategies to reduce tobacco use, prevent tobacco use initiation, and protect nonsmokers from secondhand smoke. We examined state laws related to smoke-free buildings and to cigarette excise taxes from 2000 through 2014 to see how implementation of these laws from 2000 through 2009 differs from implementation in more recent years (2010-2014). METHODS: We used legislative data from LexisNexis, an online legal research database, to examine changes in statewide smoke-free laws and cigarette excise taxes in effect from January 1, 2000, through December 31, 2014. A comprehensive smoke-free law was defined as a statewide law prohibiting smoking in all indoor areas of private work sites, restaurants, and bars. RESULTS: From 2000 through 2009, 21 states and the District of Columbia implemented comprehensive smoke-free laws prohibiting smoking in work sites, restaurants, and bars. In 2010, 4 states implemented comprehensive smoke-free laws. The last state to implement a comprehensive smoke-free law was North Dakota in 2012, bringing the total number to 26 states and the District of Columbia. From 2000 through 2009, 46 states and the District of Columbia implemented laws increasing their cigarette excise tax, which increased the national average state excise tax rate by $0.92. However, from 2010 through 2014, only 14 states and the District of Columbia increased their excise tax, which increased the national average state excise tax rate by $0.20. CONCLUSION: The recent stall in progress in enacting and implementing statewide comprehensive smoke-free laws and increasing cigarette excise taxes may undermine tobacco prevention and control efforts in the United States, undercutting efforts to reduce tobacco use, exposure to secondhand smoke, health disparities, and tobacco-related illness and death.

CONTEXT: Tobacco use is a leading cause of preventable death in the U.S. and around the world. Increasing tobacco price through higher taxes is an effective intervention both to reduce tobacco use in the population and generate government revenues. The goal of this paper is to review evidence on the economic impact of tobacco price increases through taxation with a focus on the likely healthcare cost savings and improvements in employee productivity. EVIDENCE ACQUISITION: The search covered studies published in English from January 2000 to July 2012 and included evaluations of national, state, and local policies to increase the price of any type of tobacco product by raising taxes in high-income countries. Economic review methods developed for The Guide to Community Preventive Services were used to screen and abstract included studies. Economic impact estimates were standardized to summarize the available evidence. Analyses were conducted in 2012. EVIDENCE SYNTHESIS: The review included eight modeling studies, with seven providing estimates of the impact on healthcare costs and three providing estimates of the value of productivity gains. Only one study provided an estimate of intervention costs. The economic merit of tobacco product price increases through taxation was determined from the overall body of evidence on per capita annual cost savings from a conservative 20% price increase. CONCLUSIONS: The evidence indicates that interventions that raise the unit price of tobacco products through taxes generate substantial healthcare cost savings and can generate additional gains from improved productivity in the workplace.

Electronic nicotine delivery systems (ENDS), including electronic cigarettes (e-cigarettes) and other devices such as electronic hookahs, electronic cigars, and vape pens, are battery-powered devices capable of delivering aerosolized nicotine and additives to the user. Experimentation with and current use of e-cigarettes has risen sharply among youths and adults in the United States. Youth access to and use of ENDS is of particular concern given the potential adverse effects of nicotine on adolescent brain development. Additionally, ENDS use in public indoor areas might passively expose bystanders (e.g., children, pregnant women, and other nontobacco users) to nicotine and other potentially harmful constituents. ENDS use could have the potential to renormalize tobacco use and complicate enforcement of smoke-free policies. State governments can regulate the sales of ENDS and their use in indoor areas where nonusers might be involuntarily exposed to secondhand aerosol. To learn the current status of state laws regulating the sales and use of ENDS, CDC assessed state laws that prohibit ENDS sales to minors and laws that include ENDS use in conventional smoking prohibitions in indoor areas of private worksites, restaurants, and bars. Findings indicate that as of November 30, 2014, 40 states prohibited ENDS sales to minors, but only three states prohibited ENDS use in private worksites, restaurants, and bars. Of the 40 states that prohibited ENDS sales to minors, 21 did not prohibit ENDS use or conventional smoking in private worksites, restaurants, and bars. Three states had no statewide laws prohibiting ENDS sales to minors and no statewide laws prohibiting ENDS use or conventional smoking in private worksites, restaurants, and bars. According to the Surgeon General, ENDS have the potential for public health harm or public health benefit. The possibility of public health benefit from ENDS could arise only if 1) current smokers use these devices to switch completely from combustible tobacco products and 2) the availability and use of combustible tobacco products are rapidly reduced. Therefore, when addressing potential public health harms associated with ENDS, it is important to simultaneously uphold and accelerate strategies found by the Surgeon General to prevent and reduce combustible tobacco use, including tobacco price increases, comprehensive smoke-free laws, high-impact media campaigns, barrier-free cessation treatment and services, and comprehensive statewide tobacco control programs.

Since its inception in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems.

Amid the global economic crisis, the President's Emergency Plan for AIDS Relief (PEPFAR) and other organizations have been pressed to do more with constrained resources to meet unmet needs in the worldwide HIV/AIDS pandemic. PEPFAR has approached this challenge through the development of an Impact and Efficiency Acceleration Plan, which includes improving the collection and use of economic and financial data, increasing the efficiency of HIV/AIDS program implementation, and collaborating with governments and multilateral organizations to maximize the impact of the resources provided by the United States. For example, by linking financial data with program outputs, PEPFAR was able to help its implementing partners in Mozambique reduce mean unit expenditures for people receiving antiretroviral treatment by 45 percent, from $265 to $145 per person, between 2009 and 2011. This article describes the plan's elements, provides examples of progress and challenges to its implementation, and assesses the prospects for further improvements in efficiency and impact.

Cost information is needed at multiple levels of health care systems to inform the public health response to HIV. To date, most attention has been paid to identifying the cost drivers of providing antiretroviral treatment, and these data have driven interventions that have been successful in reducing drug and human resource costs. The need for further cost information, especially for less well-studied areas such as HIV prevention, is particularly acute given global budget constraints and ongoing efforts to extract the greatest possible value from money spent on the response. Cost information can be collected from multiple perspectives and levels of the health care system (site, program, and national levels), and it is critical to choose the appropriate methodology in order to generate the appropriate information for decision-making. Organizations such as United States President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and other organizations are working together to bridge the divide between the fields of economics and HIV program implementation by accelerating the collection of cost data and building further local demand and capacity for their use. 2011 by Lippincott Williams & Wilkins.