CONTEXT: Public health fellowship programs play a vital role in strengthening the workforce across state, tribal, local, and territorial (STLT) public health agencies. PROGRAM: The US Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS) and Laboratory Leadership Service (LLS) fellowships provide structured opportunities for trainees to be placed within STLT public health agencies, where they are intended to contribute directly to essential public health functions. Through these assignments, the objective is for trainees to gain practical experience while STLT public health agencies benefit from additional capacity and public health expertise. EVALUATION: Findings from a rapid evaluation showed that EIS and LLS trainees offer crucial support to STLT public health agencies' delivery of Foundational Public Health Services. The trainees also provide surge support during emergency response events, including infectious disease outbreaks and environmental toxins. DISCUSSION: Public health fellowships are a collaborative model of how federal programs can help alleviate longstanding public health workforce challenges, including difficulties recruiting, hiring, and retaining qualified professionals. Integration of trainees into STLT public health agency operations fosters knowledge transfer, strengthens local capabilities, and supports sustained delivery of public health services. Our findings provide additional evidence that public health fellowship programs can serve as essential support for the national public health workforce.

BACKGROUND: Respiratory syncytial virus (RSV) causes a large burden of illness among infants and young children, accounting for 50,000 hospitalizations annually in U.S. children under two years of age. RSV-related illness can require outpatient, emergency department, and hospitalized medical care contributing to significant medical and nonmedical economic burden. Further, the symptoms associated with RSV can reduce quality of life in children and their caregivers. Presently, the economic burden of RSV illness for children and their caregivers is largely unresearched. The objective of this study was to estimate the financial, time, and quality of life burdens associated with pediatric RSV illness for children and their caregivers. METHODS: Surveys were developed to measure the out-of-pocket costs, time costs, and caregiver quality of life associated with medically attended RSV illness. Caregivers of pediatric (age 0-17 years) patients with RSV illness seen at Michigan Medicine were invited by email and text message between October 2022 and June 2023 to complete the online surveys. RESULTS: Mean out-of-pocket medical costs for outpatient and emergency department (ED) visits were more than $500 per case. Mean out-of-pocket medical costs associated with hospitalizations, with an average length of stay of 6 days, were $1290 per case. Non-medical costs ranged from $83-$267 depending on health care service utilized. Mean time spent traveling, waiting, and receiving care in outpatient and ED settings was 9 h per case. Caregivers spent an average of 3.5 days caring for their non-hospitalized child with RSV illness and 11.6 days caring for their child who was hospitalized. Quality-adjusted life years (QALYs) lost for caregivers was 0.011-0.019. QALYs lost per episode for the sick child ranged between 0.0161 and 0.087 for outpatient episodes of illness and hospitalization, respectively. CONCLUSIONS: This study demonstrated the high financial burden and consequences to quality of life experienced by children with RSV illness and their caregivers, especially when the child was hospitalized due to their illness. Use of these findings will be valuable for evaluating the cost effectiveness of treatments and preventative measures from the perspective of caregivers, and understanding the complete economic burden of RSV illness.

BACKGROUND AND OBJECTIVES: Fungal infections cause substantial morbidity and mortality. Monitoring antifungal use is a foundational aspect of antifungal stewardship, particularly as new disease-causing fungi emerge and antifungal resistance spreads. We assessed recent patterns in systemic antifungal medication use among hospitalized patients within a diverse convenience sample of academic medical centres and community hospitals in the USA. METHODS: We conducted a multicentre retrospective cohort study using the Vizient(R) Clinical Data Base. We selected hospitalized patients who received >/=1 dose of systemic antifungal medication during 2018-23 and assessed antifungal days of therapy (DOT) per 1000 patient days. We stratified antifungal DOT by National Comprehensive Cancer Network (NCCN) cancer centre status to compare antifungal use at hospitals with an NCCN-designated cancer centre-some of which also include a main academic medical centre and non-cancer service lines-versus hospitals without an NCCN-designated cancer centre. RESULTS: Among 39 956 873 discharges from 412 hospitals, the proportion of patients who received any systemic antifungal was 4.5%; azoles (3.8%) were the most common antifungal class, followed by echinocandins (0.9%). Overall antifungal DOT were 53.7 per 1000 patient days (114.5 among 25 NCCN hospitals and 43.2 among 387 non-NCCN hospitals). CONCLUSIONS: Substantial antifungal use occurs among hospitalized patients, particularly among those with cancer. The growing population susceptible to fungal infections (e.g. transplants, cancer and other immunosuppressing conditions) warrants consideration of antifungal stewardship and evaluation of appropriateness of antifungal use in the context of increasing resistance.

INTRODUCTION: Significant differences exist in the risk of diabetes and diabetes-related complications by income level in the United States. We assessed 1) to what extent medical expenditures in total and by health service type differ by income levels, and 2) how demographic and socioeconomic factors and health status are associated with these differences. METHODS: Data from the 2017 through 2021 Medical Expenditure Panel Survey were analyzed to estimate annual per-person medical expenditures for adults with diabetes. These expenditures were categorized by service type (inpatient, outpatient, prescription, home health care services, emergency department, or other) and compared across income groups based on the federal poverty level (FPL): poor (<125% FPL), low (125% to <200% FPL), middle (200% to <400% FPL), and high (>/=400% FPL). One-way analysis of variance was used to test group differences, and a regression-based decomposition identified factors driving expenditure disparities. All expenditures were adjusted to 2021 US dollars. RESULTS: Mean total medical expenditures were significantly higher for the poor-income group compared with the low-income, middle-income, and high-income groups, though no significant differences were observed among the latter 3 groups. Prescription drugs and home health care services in the poor-income group accounted for most of this difference. Key factors associated with the higher expenditures in this group included elevated disability rates, poorer physical health status, and dual Medicaid-Medicare coverage. CONCLUSION: Adults with diabetes from the poorest households incurred the highest medical expenditures, largely driven by poor physical health and higher rates of disability. Reducing disability and improving health outcomes for this group may help lower their medical expenses.

BACKGROUND: Pneumonia causes high rates of hospitalization among adults living in long-term care (LTC) facilities and is a major cause of mortality in this population. Since 2014, pneumococcal conjugate vaccines (PCVs) have been recommended for U.S. adults aged ≥65 years; however, effectiveness of PCVs against all-cause pneumonia hospitalization among adults living in LTC remains unclear. METHODS: We used Medicare Fee-for-Service claims data to construct an open cohort of beneficiaries aged ≥65 years between September 2014 and December 2019. We estimated 13-valent PCV (PCV13) vaccine effectiveness (VE) by comparing rates of pneumonia hospitalization among PCV13-exposed and PCV13-unexposed time during LTC stays. Discrete-time logistic regression models with generalized estimating equations were used to estimate VE, incorporating time-varying exposures and covariates. RESULTS: Among 3,485,071 beneficiaries meeting the eligibility criteria, the proportion vaccinated with PCV13 increased from 1.1% to 52.7% during the study period. The characteristics of beneficiaries with shorter LTC stays differed from those with longer LTC stays: a lower proportion of beneficiaries aged ≥85 years (LTC stay ≤100 days vs >100 days: 38.5% vs. 48.2%), but a higher proportion with chronic medical conditions (71.4% vs 66.4%), immunocompromising conditions (36.6% vs. 25.2%), and recent hospitalizations (84.1% vs. 74.7%). VE of PCV13-only against all-cause pneumonia hospitalization was 3.8% (95% confidence interval 2.4%-5.2%) overall; 5.6% (3.9%-7.2%) for LTC stays ≤100 days and 0.3% (-2.1%- 2.77%) for LTC stays >100 days. CONCLUSIONS: PCV13 reduced the risk of pneumonia hospitalization among this population. Differences in beneficiary characteristics could explain differences in VE by length of LTC stay.

The adoption of the test and treat policy by the World Health Organization (WHO) in 2015 led to an unprecedented increase in the number of people living with HIV (PLHIV) enrolling into HIV treatment, thereby increasing the burden on HIV service delivery. To compensate, WHO endorsed the Differentiated Service Delivery (DSD) approach to reduce the burden on the health care system and therefore support attainment of the UNAIDS 95-95-95 goals by 2030. This study examined clinical outcomes among clients enrolled in the DSD models and examined health care worker and client experiences of the DSD approach. A client-level pre-post study was conducted in 14 Ministry of Health (MOH) facilities in Kisumu County from October 2014 - March 2021 to examine retention and viral load suppression (<1000 copies/mL) in a cohort of stable clients aged 20 years and above at three time points: immediately preceding DSD start (pre-DSD; 2014-2016), 12 months post-DSD implementation (midline), and 24 months post-DSD (endline). Focus group discussions (FGDs) were conducted to assess DSD experiences among a sample of adult clients and health care workers. Findings from the pre-post analysis showed a significant increase in retention at 12 months (99.2%) and 24 months (98.9%) compared to pre-DSD (86.4%; p < 0.001). The predominant themes shared by clients and healthcare workers in FGDs were high satisfaction with DSD due to the efficiency of services, improved staff attitudes, and reduced clinic workload. Clients also expressed a strong preference for facility-based models owing to perceived stigma and privacy concerns associated with community DSD models. This study provides important insights on the promising effectiveness of DSD models on sustained retention on ART and viral suppression and the acceptability of this modality for client-centered HIV care.

OBJECTIVES: Homelessness increased by 31% from 2022 to 2023 in Denver, Colorado. We surveyed people experiencing homelessness in Denver to evaluate their health conditions and service needs and to identify factors associated with new or worsening health conditions after housing loss. METHODS: From October 28 through November 15, 2023, we surveyed 356 people experiencing homelessness in Denver. We fit multivariable logistic regression models using backward-fitting procedures to identify factors associated with reporting new or worsening health conditions after housing loss. RESULTS: The mean (SD) age of participants was 46.0 (13.7) years, 227 (63.7%) reported physical health conditions, and 207 (58.1%) reported mental health conditions that were new or worsening after experiencing homelessness. Chronic pain (n = 61; 17.1%) and depression (n = 123; 34.6%) were the most reported conditions. Eye care (n = 131; 36.8%), dental care (n = 95; 26.7%), and pain management (n = 54; 15.2%) were among the top service needs. Self-rated health declined by 22% after housing loss, from 3.4 (good or very good) before experiencing homelessness to 2.7 (fair or good) at the time of the survey, with a larger decline among those experiencing unsheltered homelessness than among those who were sheltered (0.95 vs 0.57; P = .006). As compared with men, women had higher odds of reporting new or worsening health conditions, whether physical (adjusted odds ratio [AOR] = 1.93; 95% CI, 1.14-3.29) or mental (AOR = 2.14; 95% CI, 1.23-3.81). Experiencing violence was associated with reporting new or worsening mental health conditions (AOR = 2.01; 95% CI, 1.20-3.37) after housing loss. CONCLUSION: Targeted interventions are needed to address the unique needs of unhoused women and those experiencing unsheltered homelessness in Denver.

IMPORTANCE: The mandatory service of essential workers during the COVID-19 pandemic was associated with high job stress, increased SARS-CoV-2 exposure, and limited time for recovery following infection. Understanding outcomes for frontline workers can inform planning for future pandemics. OBJECTIVE: To compare patient-reported outcomes by employment type and SARS-CoV-2 status. DESIGN: Data from the INSPIRE registry, which enrolled COVID-positive and COVID-negative adults between 12/7/2020-8/29/2022 was analyzed. Patient-reported outcomes were collected quarterly over 18 months. SETTING: Participants were recruited across eight US sites. PARTICIPANTS: Employed INSPIRE participants who completed a short (3-month) and long-term (12-18 month) survey. EXPOSURE: SARS-CoV-2 index status and employment type (essential healthcare worker [HCW], essential non-HCW, and non-essential worker ["general worker"]). MAIN OUTCOMES AND MEASURES: PROMIS-29 (mental and physical health summary) and PROMIS Cognitive SF-CF 8a (cognitive function) scores were assessed at baseline, short-term (3-months), and long-term (12-18 months) timepoints using GEE modeling. RESULTS: Of the 1,463 participants: 53.5% were essential workers (51.4% HCWs, 48.6% non-HCWs) and 46.5% were general workers. Most associations between outcomes and employment type became non-significant after adjusting for sociodemographics, comorbidities, COVID-19 vaccination, and SARS-CoV-2 variant period. However, among COVID-negative participants, essential HCWs had higher cognitive scores at baseline (β: 3.91, 95% CI [1.32, 6.50]), short term: (β: 3.49, 95% CI: [0.80, 6.18]) and long-term: (β: 3.72, 95% CI: [0.98, 6.46]) compared to general workers. Among COVID-positive participants, essential non-HCWs had significantly worse long-term physical health summary scores (β:-1.22, 95% CI: [-2.35, -0.09]) compared to general workers. CONCLUSIONS AND RELEVANCE: Differences in outcomes by worker status were largely explained by baseline characteristics. However, compared to general workers, essential HCW status had higher cognitive function in the absence of SARS-CoV-2 infection at all timepoints, while essential non-HCWs were most vulnerable to poor recovery in long-term physical health following SARS-CoV-2 infection. Preparation efforts for future pandemics may consider enhanced protection and post-infection resources for frontline workers.

In the years following the COVID-19 pandemic, immunization coverage has declined among frontline post-acute and long-term care (PALTC) staff, such as nurses, certified nursing assistants, and kitchen staff. We took a novel approach to addressing these declines by engaging frontline staff in design of immunization-focused professional development by surveying a convenience sample of 200 frontline PALTC staff to understand their attitudes toward immunization and preferences for job-related education and training. Frontline staff reported being motivated to protect themselves and residents from illness but were skeptical about the ability of vaccines to do so. Many felt strongly that immunization is a personal choice and wanted objective and reliable information on vaccines. We used this learning to design a 45-minute in-service for frontline staff that presented information on the benefits and risks of recommended immunization for PALTC residents and staff in a neutral way that respected staff autonomy. Accompanying brief online training prepared supervisors to deliver the in-service and answer staff questions. To evaluate the training, we surveyed a separate convenience sample of supervisors at 3 PALTC facilities, and all positively evaluated the in-service materials and training. The core focus of this innovative approach is centered on trusted messengers sharing reliable and relevant vaccine information in respectful ways.

INTRODUCTION: The antiretroviral therapy (ART) initiation policy in Uganda recommends that ART is initiated on the same day of HIV diagnosis to those who do not have contraindications. We assessed determinants of retention in ART care at the first follow-up (FFU) after same-day ART initiation and retention in long-term care beyond the FFU visit. METHODS: We conducted a retrospective longitudinal analysis among persons living with HIV aged ≥18 years who initiated ART during April 2016-February 2021 after the inception of Uganda's Test-and-Treat ART policy, which states that 'all individuals diagnosed with HIV should initiate ART regardless of clinical stage CD4 count'. Missing the FFU after ART initiation (missing FFU) was defined as not returning for FFU within 1 month of ART initiation; loss to follow-up long-term (LTFU-LT) was defined as delaying more than 3 months to return for a scheduled ART drug refill after the FFU appointment. LTFU-LT time was defined as the time from the FFU visit date to the last follow-up visit date during the study period. We used log-binomial distributions to estimate unadjusted and adjusted relative risks (adjRRs) of missing FFU, and we used Cox proportional hazard models to estimate unadjusted and adjusted hazard ratios (adjHRs) for LTFU-LT. RESULTS: Overall, 8332 clients initiated ART on the same day of HIV diagnosis. Most were female (55%), aged 25-34 years (44%), resided in the semi-urban or rural district (41% and 41%, respectively) and had a median age of 25 years (IQR = 24-35). Overall, missing FFU was 15.1%. Increased likelihood/risk of missing FFU was seen in clients who initiated ART at outreach health service centres versus health facilities (adjRRs = 1.79, 95% CI = 1.6-2.0), in younger clients aged 18-24 years and 25-34 years versus ≥45 years [(adjRRs = 1.65, 95% CI = 1.3-2.0) and (adjRRs = 1.31, 95% CI = 1.1-1.6), respectively], and clients residing in agrarian districts versus fishing districts (adjRRs = 1.24, 95% CI = 1.1-1.4). Overall, the LTFU-LT rate was 25 clients/100 pys (95% CI = 23.9-25.9) and was associated with younger age (18-34 years versus ≥45 years, adjHRs = 1.77, 95% CI = 1.5-2.1), residence in semi-urban (adjHRs = 1.33, 95% CI = 1.2-1.5) or agrarian district (adjHRs = 1.30, 95% CI = 1.2-1.5) versus fishing-community district. CONCLUSION: Retention-strengthening strategies in tandem with same-day ART initiation efforts for younger clients and clients initiated on ART from mobile and outreach health service settings might improve HIV treatment retention. Best practices for retaining fishing-community clients might improve health outcomes if applied to agrarian and semi-urban communities.

INTRODUCTION: Differentiated service delivery (DSD) models aim to tailor health services delivery to clients' preferences and clinical characteristics while reducing the burden on health systems. In Uganda, DSD models developed for HIV care were adapted to the tuberculosis (TB) services context to mitigate disruptions from the COVID-19 pandemic and inform national efforts to improve TB care. METHODS: Beginning in April 2021, four facility-based and five community-based DSD models were implemented in 28 TB clinics in Kampala and Soroti Regions. All clients in the intensive (months 1-2) and continuation (months 3-6) phases of treatment were eligible. Client preference and clinician concurrence determined model choice. All models allowed TB medication dispensing intervals ranging from biweekly to multi-month dispensing (MMD; ≥ 2 months). Data abstracted in December 2022 from TB registers and DSD enrolment tracking tools at 21 of 28 implementing facilities were used to evaluate the intervention. The TB treatment success rate (i.e. proportion cured or who completed treatment, vs. those who died, failed, were lost-to-follow-up or had no recorded outcome) in the DSD cohort was compared to facilities' 2018-2019 results using Fischer's exact test. RESULTS: Most facilities offered one (Kampala) or two (Soroti) facility-based models and one community-based model. Among 1864 TB clients enrolled between April 2021 and March 2022, 1822 (97.7%) used ≥ 1 DSD models; 210/1822 (11.5%) ever switched models. Overall, 70.5% (1284/1822) of clients enrolled in ≥ 1 facility-based model and 40.5% (737/1822) in ≥ 1 community-based model. The use of community-based models increased during the continuation phase. Facility-Based Individual Management and Home Delivery were the most-used models. In the intensive phase, the longest medication dispensation interval was biweekly for 50.0% of patients, monthly for 41.3% and MMD for 8.8%. During the continuation phase, the longest interval was biweekly for 0.6%, monthly for 71.7% and MMD for 27.6%. Overall, 1582/1864 (84.9%) clients were successfully treated, compared to 858/1177 (72.9%) in 2018-2019 (p < 0.001). Seven (0.4%) patients failed treatment, 32 (1.7%) were lost to follow-up, 101 (5.4%) died and 142 (7.6%) were not evaluated. CONCLUSIONS: TB DSD models were successfully implemented. TB treatment outcomes under DSD compared favourably to historical outcomes. Investigating factors affecting MMD use and model choice could further inform programme design.

This paper explores population segments that differentiate people based on attitudes and perceptions about surveys and how those segments differ in survey participation intention. Our analysis finds 5 population segments across which general affinity toward surveys differs significantly. Survey Enthusiasts have high affinity toward surveys and underlying sense of civic responsibility to participate. Obligated Responders recognize the importance of participating, yet view surveys as an imposition. Reluctant Responders recognize survey participation as important but are moderately concerned about data misuse. The remaining 2 segments, the Disengaged and Shy Responders, have low affinities for survey participation. These findings suggest that effective survey designs should tailor different appeals and protocols to the motivations of a heterogeneous population. A multidimensional approach would parallel those approaches used in marketing where product differentiation and market segmentation help to successfully reach the consumer market. © 2025 The Author(s). Published by Oxford University Press on behalf of The World Association for Public Opinion Research. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site - for further information please contact journals.permissions@oup.com.

Objective: To compare clinical and socioeconomic characteristics of U.S. Medicare beneficiaries overall and with diagnosed diabetes by age group (18–64 years and ≥65 years) and insurance type (traditional fee-for-service [FFS] vs Medicare Advantage [MA]) and to compare the prevalence of diabetes among beneficiaries by age group and type of insurance. Methods: In this retrospective, cross-sectional study from the U.S. Medicare Current Beneficiary Survey (MCBS), we combined data from 2017 to 2022 and conducted an unadjusted, pooled analysis of administrative and survey data, weighted to represent U.S. Medicare beneficiaries. We used logistic regression to assess difference by insurance type in care satisfaction. Results: Beneficiaries more likely to enroll in MA than FFS were the same groups at high risk of diabetes, including non-Hispanic Black (18–64: 21.2 % vs 15.9 %; ≥65: 11.4 % vs 6.5 %) and Hispanic (18–64: 14.4 % vs 8.9 %; ≥65: 11.0 % vs 5.4 %) populations, those with less than a high school education (≥65: 16.4 % vs 9.2 %) or annual income <$25,000 (18–64: 69.0 % vs 64.0 %; ≥65: 34.5 % vs 21.6 %), and full dual-eligible beneficiaries (≥65: 10.5 % vs 6.1 %). Beneficiaries with diabetes enrolled in MA did not differ from those enrolled in FFS in diabetes self-management or satisfaction with healthcare. Conclusions: Subgroups of people at highest risk of diabetes were more likely to enroll in MA. Our findings support studies reporting that people with diabetes self-select into MA, and their lack of difference in satisfaction between FFS and MA may support studies that report MA is no less effective than FFS in diabetes care. © 2025 The Authors

INTRODUCTION: Sexual violence (SV) affects millions globally and has a well-documented bidirectional association with HIV. Post-exposure prophylaxis (PEP) is a critical, yet often underutilized, HIV prevention tool in post-SV care. Despite its potential impact to reduce HIV transmission, SV care remains an overlooked service delivery point for HIV prevention. The U.S. Centers for Disease Control and Prevention (CDC), as part of the President's Emergency Plan for AIDS Relief (PEPFAR), supports PEP provision within broader post-violence care (PVC) services. Understanding PEP utilization is crucial for optimizing service delivery and HIV prevention efforts. METHODS: Using Monitoring Evaluation and Reporting data from fiscal years 2018-2023, we conducted a descriptive analysis of clients who received PVC and SV services through CDC-supported programming in 14 sub-Saharan African countries. RESULTS: From 2018 to 2023, the annual number of clients receiving any PVC, and specifically SV, services increased by 233% (in 2018, n = 206,764; in 2023, n = 689,349) and 163% (in 2018, n = 42,848; in 2023, n = 112,838), respectively. Fewer than half of SV clients completed PEP (38% in 2018, n = 16,103; 31% in 2023, n = 35,118). Across all years combined, most SV clients (female: 185,414; male: 59,618) were aged 15-19 years. The age band and sex with the lowest proportion of clients completing PEP were males aged 15-19 (4%, n = 2296). CONCLUSIONS: The findings underscore a critical gap between the scaling of SV services and the completion of PEP within violence response programmes. Innovative implementation science approaches may help to identify and address barriers inhibiting effective PEP delivery and uptake within PVC service delivery programmes. Enhancing PEP uptake and completion can support mitigating the bidirectional relationship between violence and HIV acquisition, particularly among vulnerable populations like adolescents and young adults. Low PEP coverage also reflects missed opportunities, particularly among adolescent girls and young women, who experience disproportionate rates of HIV acquisition.

Mozambique's National Blood Transfusion Services (NBTS) is tasked with providing safe and available blood but also conducting systematic screening of at-risk potential donors, notifying seropositive blood donors, and linking them to HIV care and treatment services. Potential blood donors who were deferred from donating following a behavioral risk screening and all blood donors who screened seropositive for HIV were notified and offered linkage to HIV testing, care, and treatment services by community-based organizations. A prospective study among HIV-positive blood donors and deferred donors was conducted from May 2019 to July 2020 at Maputo Central Hospital Blood Bank and the National Reference Blood Center. The associations between testing, initiating care and treatment services among HIV-positive blood donors and prospective deferred donors were estimated using fully Bayesian multivariable logistic models and odds ratios. Among 885 prospective blood donors enrolled, 173 (20%) were deferred due to self-reported high-risk behaviors identified through a screening questionnaire, and 712 (80%) passed the behavioral-risk screening tool, donated, and the blood donation tested positive for HIV. There were more than 2.5 times as many male donors as female donors with a positive HIV test, and among the deferred donors, more than 84% were males. 36% (256/712) of seropositive donors and 35% (61/173) of deferred donors were referred to HIV testing services. 62% (158/256) of seropositive donors and 4.9% (3/61) of deferred donors who were successfully referred were linked to care and treatment services, and 96% (152/158) of these seropositive donors and 100% (3/3) of deferred as high-risk donors initiated antiretroviral therapy (ART). Of the three service organizations used, one outperformed the other two in linking seropositive donors to ART treatment. The NBTS can serve as a critical entry point for identifying HIV-positive persons. Improved implementation of risk behavior screening tools is needed and could contribute to early identification and initiation of ART for potential donors. Innovative strategies and solutions by community-based organizations can be used to improve blood donor notification and linkage to HIV testing and treatment services.

INTRODUCTION: In Eswatini, HIV incidence among adolescent girls and young women (AGYW), aged 15-24 years, is 10 times that of their male peers. Despite the World Health Organization's 2014 recommendation for post-exposure prophylaxis (PEP) to be available for all HIV exposures, it has been underutilized among youth. PEP is an effective prevention method, and a better understanding of the characteristics, risk factors and behaviours that are associated with PEP awareness, as a precursor to effective use, is needed. METHODS: Using data from the 2022 Eswatini Violence Against Children and Youth Survey, we used logistic regression models to explore the relationships between PEP awareness and a set of hypothesized explanatory variables among AGYW aged 13-24 years who had ever had sex (N = 2648). Explanatory variables included socio-demographic characteristics, sexual risk factors and sexual health behaviours. RESULTS: A slight majority (57.3%) of AGYW who had ever had sex were aware of PEP as an HIV prevention method. PEP awareness increased with age (aOR 1.1, 95% CI 1.0, 1.1) and was higher among AGYW who had a sexual partner whose age was 5 or more years older in the past 12 months (aOR 1.4, 95% CI 1.1, 1.9), those who had ever taken part in an HIV prevention programme (aOR 1.6, 95% CI 1.2, 2.3) and those who had ever heard of pre-exposure prophylaxis (aOR 8.1, 95% CI 6.4, 10.2). Participants who were ever married or partnered (aOR 0.7, 95% CI 0.5, 1.0) and those who engaged in inconsistent condom use with non-spouse/main partner or multiple partners in the past 12 months (aOR 0.8, 95% CI 0.6, 1.00) had lower odds of knowing about PEP in the adjusted model. CONCLUSIONS: We identified sub-optimal PEP awareness among Swazi AGYW who had ever had sex. Our findings suggest that engagement in HIV prevention programmes increased PEP awareness and that knowing about pre-exposure prophylaxis (PrEP) was associated with PEP awareness. Future efforts could include tailored PEP awareness activities and campaigns to resonate with AGYW at elevated risk of HIV and integration of PEP education into routine sexual and reproductive service delivery and school-based HIV curriculum.

The first COVID-19 case in a healthcare worker in Kenya was reported on March 30, 2020, in Nairobi, leading to a 41-day closure of the health facility where he had worked. We assessed infection prevention and control (IPC) activities and implemented recommendations to re-open and operate the facility. We conducted a risk assessment of the facility in April 2020 using a modified World Health Organization, six-element IPC facility risk assessment tool. IPC recommendations were made, and a follow-up assessment of their implementation was conducted in July 2020. Breaches in IPC measures included poor ventilation in most service delivery areas; lack of physical distancing between patients; inadequate COVID-19 information, education, and communication materials; lack of standard operating procedures on cleaning and disinfecting high-touch areas; insufficient IPC training; inadequate hand hygiene facilities; insufficient personal protective equipment supplies; and an inactive IPC committee. Strengthening IPC measures is critical to prevent healthcare facility closures.

INTRODUCTION: Data on sexual violence (SV) prevalence in Nigeria is limited; however, 2014 data indicate that 24.8% of females aged 18-24 years experienced SV in childhood and only 3.5% received any form of services. Initiation of post-exposure prophylaxis (PEP) to prevent HIV acquisition following SV is most effective when started immediately and is not recommended after 72 hours. Police stations are often entry points for survivors; however, lengthy processes may result in delays and missed PEP opportunities. Using an ongoing phased approach, we introduced PEP into selected police stations in Nigeria's Federal Capital Territory in order to explore expanding access to time-sensitive HIV prevention within non-health services. METHODS: Our intervention phase consisted of the provision of training of police officers and the provision of PEP starter packs coupled with linkage to referral facilities. During two time periods (pre-intervention: January-March 2023) and (during intervention: July-September 2023), we evaluated routinely reported programme data from 27 U.S. Centers for Disease Control and Prevention-supported health facilities for changes in the provision of SV services and PEP initiation. We used geospatial mapping to assess the proximity of participating health facilities to police stations and to see changes in both SV and PEP service provision. The statistical significance of the difference in PEP uptake proportion during the two periods was determined using the Wilcoxon signed rank test at a 0.05 level of significance. RESULTS: Of the total 27 health facilities, 24 were within a 5-km radius of a participating police station. Total SV service provision increased from 114 cases to 218 cases, representing a 91.2% increase and with most of this increase seen among females. PEP initiation increased by 289.3% at the two time points, with 56 initiations pre-intervention to 218 PEP initiations during the intervention. CONCLUSIONS: Our findings showed promise in increasing immediate access to PEP in non-health services and highlighted the feasibility of police stations and health facilities collaboration to address urgent health needs. There was an overall increase in PEP initiations by referral and non-referral facilities which could be the result of demand creation and increased access at police stations.

BACKGROUND: In 2023, an estimated 36 million pregnancies occurred in malaria endemic sub-Saharan Africa, but only 44% received the WHO recommended ≥ 3 doses of intermittent preventive treatment (IPTp3). Group Antenatal Care (G-ANC) is a service delivery model associated with higher quality of and greater retention in ANC, in which pregnant women are enrolled into groups at their first ANC visit and subsequent care is provided in groups. A cluster-randomized controlled trial was conducted in Atlantique Department, Benin, to assess whether G-ANC improved ANC retention and IPTp3 uptake at community level. METHODS: Forty purposively selected health facilities (HF) were randomized 1:1 to control (individual ANC) or G-ANC. Cross-sectional household surveys to measure uptake of ANC and IPTp were conducted in each HF catchment area before and after implementation among randomly selected women who had given birth in the previous 12 months. Changes in coverage were assessed using a difference-in-difference approach, adjusting for HF clustering. RESULTS: At baseline (N = 1259), coverage of at least 4 ANC visits (ANC4) and IPTp3 was 52.8% and 48.0%, respectively, in the intervention catchment, and 44.9% and 49.4% in the control catchment. Coverage of ANC4 improved in both arms by endline (N = 1280), to 56.7% in the intervention and 46.1% in the control, but the difference in the increase was not significant between arms (p = 0.51). Coverage of IPTp3 increased non-significantly (p = 0.26), to 53.2% (intervention) and 49.7% (control). Overall, only 140 (10.6%) surveyed women reported participating in G-ANC. Participation improved coverage of both ANC4 (65.0% vs 50.5%, p = 0.002; odds ratio (OR) 1.9, 95% CI 1.4-2.5) and IPTp3 (64.0 vs 50.6%, p = 0.004; OR = 1.8, 95% CI 1.2-2.6). CONCLUSIONS: G-ANC increased ANC attendance and IPTp3 uptake among women who participated, but participation was limited. Understanding and addressing the barriers to participation is critical if G-ANC is to be used more widely to increase IPTp coverage. TRIAL REGISTRATION: PACTR202405487752509.

The Centers for Disease Control and Prevention (CDC) funds tuberculosis (TB) Centers of Excellence (COEs) that support TB control and prevention efforts in the United States. In 2018, the TB COEs conducted a multiphased assessment among U.S. staff involved in TB service delivery to identify needs related to TB training, resources, and medical consultation. Representatives from each TB COE and CDC's Division of TB Elimination formed a workgroup to guide the design of the needs assessment. The group used an online survey for data collection. Participants were staff working in some capacity on TB within the United States, Puerto Rico, and the U.S. Virgin Islands. Staff could be in non-public health (e.g., community health center, hospital, laboratory, private practice) or public health (state or local health department staff responsible for TB) settings and did not have to be a clinical health care provider (N = 1,482). We identified four priority areas for future TB training and education efforts. These areas include (1) focus on key topics; (2) tailor training and products to different professions, settings, and skill levels; (3) keep learners updated on the latest resources and best practices; and (4) use a mix of training methods and formats. The findings highlighted future priorities for TB training and education and were shared with health department TB programs throughout the United States.

BACKGROUND: On January 30, 2020, the World Health Organization declared COVID-19 a Public Health Emergency of International Concern (PHIEC). On March 11, 2020, it was characterized as a pandemic, prompting the Government of Sierra Leone to implement response plans. The first case in the country was reported on March 31, 2020. To build resilient public health systems after the Ebola crisis, the Sierra Leone Field Epidemiology Training Program (SLFETP) was launched in 2016 with funding from the U.S. CDC in collaboration with the Ministry of Health and the African Field Epidemiology Network (AFENET). The program started at the FETP Frontline level, a 3-month in-service training program, followed by the FETP Intermediate, a 9-month in-service training program launched in 2017. Both levels adopted the CDC curriculum to the local context. The curriculum consists of classroom modules focusing on surveillance, outbreak investigation, and field projects. The SLFETP graduates and trainees were deployed to assist in COVID-19 response efforts. While reports indicate the SLFETP's contributions to COVID-19 preparedness and response, the specific roles of its graduates and trainees remain undocumented. This paper outlines their crucial involvement during the pandemic in Sierra Leone. METHODS: We reviewed 12 documents from the SLFETP, including work plans, outbreak investigation reports, and success stories, to assess the FETP's contributions during the COVID-19 pandemic. We interviewed graduates and trainees about their roles and conducted discussions with stakeholders and FETP staff to explore the FETP's role during the pandemic's preparedness and response phases. A thematic analysis was performed. RESULTS: The SLFETP played a critical role during the preparedness and response phase of the COVID-19 pandemic. The trainees and graduates enhanced the surveillance system and led key response pillars, such as coordination, surveillance, and quarantine. SLFETP supported districts by building their capacity, especially in the district surveillance pillar, to conduct case investigations, contact tracing, quarantine monitoring, and data management. CONCLUSIONS: The graduates and trainees reportedly played critical roles in key response pillars across the country in the preparedness and response phase of the COVID-19 pandemic. These gains should be maintained and scaled up to build a strong and resilient public health workforce in Sierra Leone, which is crucial for preparedness and response to future outbreaks.

INTRODUCTION: Municipalities can improve access to food through transit planning. The primary objective of this study was to describe the prevalence of public transit supports for food access among a sample of US municipalities and their association with the municipalities' sociodemographic characteristics. METHODS: This study used a nationally representative sample (N = 1,956) of US municipalities with a population of at least 1,000 that responded to the 2021 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living. We assessed 4 outcomes: public transit availability and planning, presence of demand responsive transportation (DRT), DRT services to food retail destinations (farmers markets and supermarkets), and consideration of these locations in transit planning. We used χ(2) tests to compare the prevalence of outcomes by municipal characteristics and multivariable logistic regression to calculate odds ratios to assess the relationship between municipal characteristics and having DRT. RESULTS: Approximately half (weighted 53.2%) of municipalities reported having or planning for public transit, of which 27.1% and 52.6% reported considering service to farmers markets or supermarkets, respectively. Approximately one-third (35.5%) of municipalities reported having DRT, of which 52.0% and 84.4% reported services to farmers markets or supermarkets, respectively. All outcomes significantly differed by municipal characteristics. We found higher odds of having DRT in municipalities with 2,500 to 50,000 people or more (vs <2,500 people); those with 50% or less of the population being non-Hispanic White (vs >50% non-Hispanic White); and municipalities containing low-income/low-access tracts. The odds of having DRT were lower in rural (vs urban) municipalities and in those in Northeast and South (vs the Midwest). CONCLUSION: Results suggest opportunities for municipalities to use transit planning to improve food access, especially in northeastern, southern, smaller, or rural communities.

OBJECTIVE: Overall, police officers have higher rates of several adverse health conditions (e.g., cardiovascular health profiles and post-traumatic stress disorder (PTSD)) compared to persons in many other occupations. Our objective was to conduct a comparative study of occupational exposures and health outcomes among police officers across: (a) a 7-year period, from the baseline examination (2004-2009) to the 1st follow-up examination (2011-2015) and (b) a 12-year period, from baseline to the 2nd follow-up examination (2015-2019). METHODS: Participants were from the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) Study. Variables were assessed through self-report, standardized validated questionnaires, or standardized medical procedures. We computed the 7- and 12-year changes in mean values (for continuous/numeric variables) or prevalence (for categorical variables) and the corresponding 95% confidence intervals (CIs) using MIXED and GENMOD procedures in SAS. RESULTS: Occupational stress significantly increased over 12 years [3.4; (95% CI 1.2, 5.6)]. The percentage of officers who reported excellent/very good health significantly decreased across both time periods: [- 11.8%; (- 17.8, - 5.9)] across seven years and [- 17.3%; (- 24.2, - 10.4)] across 12 years. The prevalence of metabolic syndrome increased over seven years [10.7%; (5.3-16.0)] and over 12 years [7.4%; (0.1-14.0)]. Abdominal obesity and glucose intolerance significantly increased over both time periods while hypertension and elevated triglyceride levels increased slightly but not significantly over both time periods. CONCLUSION: Occupational stressors and some health outcomes of officers worsened over time indicating the need for self-health monitoring and wellness programs for police.

Detecting and responding to clusters of rapid HIV transmission is a core HIV prevention strategy in the United States, guiding public health interventions and identifying gaps in prevention and care services. In 2016, the Centers for Disease Control and Prevention (CDC) initiated molecular cluster detection using data from 27 jurisdictions. During 2016-2023, CDC expanded sequence reporting nationwide and deployed Secure HIV-TRACE, an application supporting health department (HD) molecular cluster detection. CDC conducts molecular cluster detection quarterly; state and local HDs analyze local data monthly. HDs began routinely reporting clusters to CDC by using cluster report forms in 2020. During 2018-2023, CDC identified 404 molecular clusters of rapid HIV transmission; 325 (80%) involved multiple jurisdictions. During 2020-2023, HDs reported 298 molecular clusters to CDC; 249 were first detected by HDs. Expanding molecular cluster detection has provided a foundation for improving service delivery to networks experiencing rapid HIV transmission.

BACKGROUND: We assessed annual out-of-pocket (OOP) costs for HIV preexposure prophylaxis (PrEP)-related services among commercially insured individuals in the U.S. before and after the Affordable Care Act (ACA) mandated no cost-sharing in 2021. METHODS: Using data from a large commercial database, we identified persons aged ≥18 years who were prescribed PrEP from 2017-2022. Medical claims for PrEP-related services submitted within one week before each PrEP prescription were extracted using CPT codes. For each service, we calculated the annual proportion of persons incurring OOP costs and associated annual amounts, adjusted to 2022 U.S. dollars. We assessed trends in the proportion of persons with OOP costs for each service from 2019-2022. We also examined the association between OOP cost occurrence and patient demographic characteristics. RESULTS: Among 141,300 PrEP users, we observed decreasing trends in the proportion incurring OOP costs for PrEP ancillary services over the study period. In 2022, OOP costs were incurred by 65.6% for provider visits, 14.3% for HIV testing, and 32.5% for creatinine testing, with mean OOP costs of $54.18, $26.06, and $6.07, respectively. Rural users were more likely to incur costs than urban users. CONCLUSIONS: Despite ACA mandates, many persons received cost-sharing bills for PrEP services. Standardized billing and coding, along with enhanced monitoring and enforcement, could help protect access to evidence-based preventive care.

BACKGROUND: During the COVID-19 pandemic, the US President's Emergency Plan for AIDS Relief supported oral caregiver-assisted HIV self-testing (CG-HIVST) to address the gap in HIV diagnosis of children. We aimed to investigate caregiver uptake, results return, acceptability, and potential social harms of CG-HIVST. METHODS: This prospective, interventional, study was done at 32 health facilities in Uganda and 15 health facilities in Zambia. Caregivers aged 18 years and older (plus emancipated minors aged 15-17 years in Uganda) living with HIV who were currently accessing HIV care and considered index cases, with no positive responses to an intimate partner violence screen, and with one or more children aged 18 months to 14 years with unknown HIV status were eligible to participate. Eligible caregivers were offered oral HIVST kits to screen their children and primary outcomes were described by caregiver and child characteristics. Following HIVST kit administration, caregivers were surveyed using a standardised questionnaire to document their perceptions, adverse events, and social harm. Primary outcomes were the uptake of HIVST and the number and proportion of returned screening test results, reactive results, reactive screens with confirmatory HIV testing, confirmatory testing with a positive result, and children who were confirmed HIV-positive who were linked to treatment. This study was registered with ClinicalTrials.gov, NCT04774666 and NCT04754386, and is completed. FINDINGS: From Feb 1 to Oct 31, 2021, 12 998 interested caregivers were screened for eligibility, 4023 of whom were eligible. 3903 (97·0%) accepted HIVST kits to screen their child for HIV (1609 [41·2%] in Zambia and 2294 [58·8%] in Uganda). Among caregivers, 3094 (79·3%) of 3903 were female, and 809 (20·7%) were male. 7601 children were enrolled (3779 [49·7%] were female and 3822 [50·3%] were male). 4766 (97·9%) of 4866 test results were returned in Uganda and 2647 (96·8%) of 2735 in Zambia. 119 (1·6%) of 7413 children had reactive HIVST results, requiring confirmatory testing. Of 116 children with confirmatory testing, 43 were confirmed HIV-positive (HIV prevalence 0·7% [n=32] in Uganda and 0·4% [n=11] in Zambia) and 100% were linked to antiretroviral therapy. Adverse events were rare (11 [0·4%] of 2720) and minor, and there were no reports of social harm or violence. Caregivers surveyed reported the HIVST kit was easy to use (2637 [97·0%] of 2718), they would use it again (2650 [99·1%] of 2674), and they would recommend it to other parents (2615 [97·8%] of 2674). INTERPRETATION: Our findings suggest that oral CG-HIVST is acceptable, feasible, and safe, with no reports of social harm, and has the potential to expand access to HIV testing for children while reducing the service delivery burden on health facilities. FUNDING: US President's Emergency Plan for AIDS Relief and Wellcome Trust.

IMPORTANCE: Less than half of the US population with any mental health condition receives services. Cost is the most commonly cited barrier to treatment. OBJECTIVE: To examine whether service use and out-of-pocket expenditures among Medicare beneficiaries with depression changed after Medicare implemented equal cost-sharing for outpatient mental health and medical services (Medicare parity). DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a single-group, interrupted time series design and examined data from the Medical Expenditure Panel Survey Household Component from 2008 to 2019. The sample included Medicare beneficiaries aged 65 years or older with depression. Data were analyzed from June 2, 2023, to June 17, 2024. EXPOSURE: Under the Medicare Improvements for Patients and Providers Act of 2008, beneficiary cost-sharing for outpatient mental health services decreased from 50% prior to 2010 to 20% in 2014, creating parity with equivalent medical care. MAIN OUTCOMES AND MEASURES: The primary outcomes were outpatient mental health service use, as assessed by mean use, proportion of beneficiaries with any use, and intensity of use (ie, mean use among users), and out-of-pocket expenditures. RESULTS: The analysis included 5831 Medicare beneficiaries. Using the Medical Expenditure Panel Survey person-level survey weights, this number corresponded to a nationally representative sample of 72 436 656 beneficiaries (median [IQR] age, 72 [68-79] years; 64.2%-72.2% female per study year). After Medicare parity, mean use of outpatient mental health services among beneficiaries with depression increased by 0.54 visits per year (95% CI, 0.31-0.76 visits per year), and proportion of use increased by 6.61% per year (95% CI, 2.23%-10.99% per year). Intensity of use decreased at parity by a factor of 0.90 (95% CI, 0.82-1.00) and increased after parity by a multiple of 1.07 per year (95% CI, 1.04-1.10 per year). Mean out-of-pocket expenditures for these services increased after parity by $12.25 per year (95% CI, $2.42-$22.08 per year). Sensitivity analysis using the 2016 US Preventive Services Task Force recommendation for routine adult depression screening indicated that the proportion of use increased 28.26% (95% CI, 24.33%-32.19%) once the recommendation was issued. CONCLUSIONS AND RELEVANCE: In this economic evaluation of Medicare parity, implementation of Medicare parity coupled with routine adult depression screening was associated with significant increases in outpatient mental health service use among Medicare beneficiaries with depression. These findings suggest that parity policies alone may not be sufficient to effectively address multiple barriers to mental health care but in tandem with physician screening, diagnosis, and referral practices, may increase the accessibility of mental health services.

Racial misclassification on death certificates leads to inaccurate mortality data for American Indian and Alaska Native (AI/AN) populations. We describe methods for correcting for racial misclassification among non-Hispanic AI/AN (NH-AI/AN) populations using data from the year 2020. We linked National Death Index (NDI) records with the Indian Health Service (IHS) patient registration database to identify AI/AN decedents. Matches were then linked to the National Vital Statistics System (NVSS) mortality data to identify AI/AN individuals that had been misclassified as another race on their death certificates. Analyses were limited to NH-AI/AN and purchased/referred care delivery areas (PRCDA) or urban areas. We compared death rates and counts pre- and post- linkage and calculated sensitivity and classification ratios by region, sex, age, cause of death (COD) and urban area. Racial misclassification on death certificates among NH-AI/AN varied by geographic region. Some of the highest racial misclassification occurred in the Southern Plains and Pacific Coast. Death rates for NH-AI/AN people and differences between NH-AI/AN and Non-Hispanic White (NHW) people were larger using the linked data. Improving AI/AN mortality data using linkages between vital statistics data and IHS strengthens data quality and can help address health disparities through public health planning efforts.

Starting in the 1970s with robots that were physically isolated from contact with their human co-workers, robots now collaborate with human workers towards a common task goal in a shared workspace. This type of robotic device represents a new era of workplace automation. Industrial robotics is rapidly evolving due to advances in sensor technology, artificial intelligence (AI), wireless communications, mechanical engineering, and materials science. While these new robotic devices are used mainly in manufacturing and warehousing, human-robot collaboration is now seen across multiple goods-producing and service-delivery industry sectors. Assessing and controlling the risks of human-robot collaboration is a critical challenge for occupational safety and health research and practice as industrial robotics becomes a pervasive feature of the future of work. Understanding the physical, psychosocial, work organization, and cybersecurity risks associated with the increasing use of robotic technologies is critical to ensuring the safe development and implementation of industrial robotics. This commentary provides a brief review of the uses of robotic technologies across selected industry sectors; the risks of current and future industrial robotic applications for worker and employer alike; strategies for integrating human-robot collaboration into a health and safety management system; and the role of robotic safety standards in the future of work.

Antiretroviral therapy (ART) has been adopted as a form of HIV treatment and prevention. This study assesses rapid ART initiation using clinical outcomes such as viral load (VL) and CD4+ T lymphocytes count. Over the course of one year, the progress of newly diagnosed people living with HIV who started ART early in a hospital in Panama City was followed. The evaluation of early initiation of ART in achieving viral suppression (VL <200 copies/ml) was analyzed using descriptive statistics. Additionally, the cost difference between early (first 7 days) and late initiation of ART was evaluated from the perspective of the service provider. In total, 209 people were followed up during the study; 85% were male, 70% started ART on same day from hospital arrival, 80% had suppressed viral load at 6 months, and the median count of CD4 increased from 285 (IQR: 166-429) to 509 (IQR: 373-696) over 12 months. Starting ART early led to a 42% increase for the provider in terms of staffing costs; however, the clients had the opportunity to decrease absenteeism in daily activities. The results reveal that early initiation of ART generates clinical and economic benefits for the person in treatment.