The effect of universal testing and treatment for HIV on health-related quality of life - An analysis of data from the HPTN 071 (PopART) cluster randomised trial

Background

HIV treatment has clear Health-Related Quality-of-Life (HRQoL) benefits. However, little is known about how Universal Testing and Treatment (UTT) for HIV affects HRQoL. This study aimed to examine the effect of a combination prevention intervention, including UTT, on HRQoL among People Living with HIV (PLHIV).

Methods

Data were from HPTN 071 (PopART), a three-arm cluster randomised controlled trial in 21 communities in Zambia and South Africa (2013-2018). Arm A received the full UTT intervention of door-to-door HIV testing plus access to antiretroviral therapy (ART) regardless of CD4 count, Arm B received the intervention but followed national treatment guidelines (universal ART from 2016), and Arm C received standard care. The intervention effect was measured in a cohort of randomly selected adults, over 36 months. HRQoL scores, and the prevalence of problems in five HRQoL dimensions (mobility, self-care, performing daily activities, pain/discomfort, anxiety/depression) were assessed among all participants using the EuroQol-5-dimensions-5-levels questionnaire (EQ-5D-5L). We compared HRQoL among PLHIV with laboratory confirmed HIV status between arms, using adjusted two-stage cluster-level analyses.

Results

At baseline, 7,856 PLHIV provided HRQoL data. At 36 months, the mean HRQoL score was 0.892 (95% confidence interval: 0.887-0.898) in Arm A, 0.886 (0.877-0.894) in Arm B and 0.888 (0.884-0.892) in Arm C. There was no evidence of a difference in HRQoL scores between arms (A vs C, adjusted mean difference: 0.003, -0.001-0.006; B vs C: -0.004, -0.014-0.005). The prevalence of problems with pain/discomfort was lower in Arm A than C (adjusted prevalence ratio: 0.37, 0.14-0.97). There was no evidence of differences for other HRQoL dimensions.

Conclusions

The intervention did not change overall HRQoL, suggesting that raising HRQoL among PLHIV might require more than improved testing and treatment. However, PLHIV had fewer problems with pain/discomfort under the full intervention; this benefit of UTT should be maximised during roll-out.

An agent-based model of binge drinking, inequitable gender norms and their contribution to HIV transmission, with application to South Africa

BACKGROUND

Binge drinking, inequitable gender norms and sexual risk behaviour are closely interlinked. This study aims to model the potential effect of alcohol counselling interventions (in men and women) and gender-transformative interventions (in men) as strategies to reduce HIV transmission.

METHODS

We developed an agent-based model of HIV and other sexually transmitted infections, allowing for effects of binge drinking on sexual risk behaviour, and effects of inequitable gender norms (in men) on sexual risk behaviour and binge drinking. The model was applied to South Africa and was calibrated using data from randomized controlled trials of alcohol counselling interventions (n = 9) and gender-transformative interventions (n = 4) in sub-Saharan Africa. The model was also calibrated to South African data on alcohol consumption and acceptance of inequitable gender norms. Binge drinking was defined as five or more drinks on a single day, in the last month.

RESULTS

Binge drinking is estimated to be highly prevalent in South Africa (54% in men and 35% in women, in 2021), and over the 2000-2021 period 54% (95% CI: 34-74%) of new HIV infections occurred in binge drinkers. Binge drinking accounted for 6.8% of new HIV infections (0.0-32.1%) over the same period, which was mediated mainly by an effect of binge drinking in women on engaging in casual sex. Inequitable gender norms accounted for 17.5% of incident HIV infections (0.0-68.3%), which was mediated mainly by an effect of inequitable gender norms on male partner concurrency. A multi-session alcohol counselling intervention that reaches all binge drinkers would reduce HIV incidence by 1.2% (0.0-2.5%) over a 5-year period, while a community-based gender-transformative intervention would reduce incidence by 3.2% (0.8-7.2%) or by 7.3% (0.6-21.2%) if there was no waning of intervention impact.

CONCLUSIONS

Although binge drinking and inequitable gender norms contribute substantially to HIV transmission in South Africa, recently-trialled alcohol counselling and gender-transformative interventions are likely to have only modest effects on HIV incidence. Further innovation in developing locally-relevant interventions to address binge drinking and inequitable gender norms is needed.

The impact of performance-based financing within local health systems: Evidence from Mozambique

Most evidence on Performance Based Financing (PBF) in low-income settings has focused on services delivered by providers in targeted health administrations, with limited understanding of how effects on health and care vary within them. We evaluated the population effects of a program implemented in two provinces in Mozambique, focusing on child, maternal and HIV/AIDS care and knowledge. We used a difference-in-difference estimation strategy applied to data on mothers from the Demographic Health Surveys, linked to information on their closest health facility. The impact of PBF was limited. HIV testing during antenatal care increased, particularly for women who were wealthier, more educated, or residing in Gaza Province. Knowledge about transmission of HIV from mother-to-child, and its prevention, increased, particularly for women who were less wealthy, less educated, or residing in Nampula Province. Exploiting the roll-out by facility, we found that the effects were concentrated on less wealthy and less educated women, whose closest facility was in the referral network of a PBF facility. Results suggest that HIV testing and knowledge promotion increased in the whole district, as a strategy to boost referral for highly incentivized HIV services delivered in PBF facilities. However, demand-side constraints may prevent the use of those services.

Economic shocks, health, and social protection: The effect of COVID-19 income shocks on health and mitigation through cash transfers in South Africa

COVID-19 caused an unprecedented health and economic crisis. Nation-wide lockdowns triggered major economic disruptions across the world. We provide evidence of the impact of these extreme economic shocks on health outcomes across wealth levels. We further identify if cash transfers can mitigate the negative health effects for the most economically vulnerable. The study focuses on South Africa, an Upper Middle-Income Country with high levels of inequality, a large informal labor market and with low levels of social welfare. Using difference-in-difference estimation (DD) on a longitudinal sample of 6437 South Africans, we find that the lockdown income shock significantly reduces health by 0.2 standard deviations (SD). We find no difference of the effect across wealth quartiles. Exposure to a cash transfer program mitigates the negative health effects for recipients in the lowest wealth quartile to 0.25 SD compared to 0.4 SD for non-recipients. Full mitigation occurs for individuals exposed to an on average higher scale-up of the cash transfer program. Our analysis shows that a lockdown induced income shock caused adverse health outcomes; however, a pro-poor cash transfer program protected the most economically vulnerable from these negative health effects.

The impact of a COVID-19 lockdown on work productivity under good and poor compliance

BACKGROUND

In response to the COVID-19 pandemic, governments across the globe have imposed strict social distancing measures. Public compliance to such measures is essential for their success, yet the economic consequences of compliance are unknown. This is the first study to analyze the effects of good compliance compared with poor compliance to a COVID-19 suppression strategy (i.e. lockdown) on work productivity.

METHODS

We estimate the differences in work productivity comparing a scenario of good compliance with one of poor compliance to the UK government COVID-19 suppression strategy. We use projections of the impact of the UK suppression strategy on mortality and morbidity from an individual-based epidemiological model combined with an economic model representative of the labour force in Wales and England.

RESULTS

We find that productivity effects of good compliance significantly exceed those of poor compliance and increase with the duration of the lockdown. After 3 months of the lockdown, work productivity in good compliance is £398.58 million higher compared with that of poor compliance; 75% of the differences is explained by productivity effects due to morbidity and non-health reasons and 25% attributed to avoided losses due to pre-mature mortality.

CONCLUSION

Good compliance to social distancing measures exceeds positive economic effects, in addition to health benefits. This is an important finding for current economic and health policy. It highlights the importance to set clear guidelines for the public, to build trust and support for the rules and if necessary, to enforce good compliance to social distancing measures.

The worse the better? Quantile treatment effects of a conditional cash transfer programme on mental health

Poor mental health is a pressing global health problem, with high prevalence among poor populations from low-income countries. Existing studies of conditional cash transfer (CCT) effects on mental health have found positive effects. However, there is a gap in the literature on population-wide effects of cash transfers on mental health and if and how these vary by the severity of mental illness. We use the Malawian Longitudinal Study of Family and Health containing 790 adult participants in the Malawi Incentive Programme, a year-long randomized controlled trial. We estimate average and distributional quantile treatment effects and we examine how these effects vary by gender, HIV status and usage of the cash transfer. We find that the cash transfer improves mental health on average by 0.1 of a standard deviation. The effect varies strongly along the mental health distribution, with a positive effect for individuals with worst mental health of about four times the size of the average effect. These improvements in mental health are associated with increases in consumption expenditures and expenditures related to economic productivity. Our results show that CCTs can improve adult mental health for the poor living in low-income countries, particularly those with the worst mental health.

Post-discharge care following acute kidney injury: quality improvement in primary care

BACKGROUND

Over the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI.

DESIGN

We conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI.

RESULTS

AKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality.

CONCLUSION

The findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.

The effect of cash transfers on mental health: Opening the black box - A study from South Africa

There is a gap in the literature in understanding how cash transfer programmes affect mental health. We aim to fill this gap by conceptualising and estimating the mediation effects of an unconditional cash transfer programme on mental health. We use a sample of 4,535 adults living below the South African poverty line in four waves (2008-2014) of the South African National Income Dynamics Study. We use information on individual exposure to South Africa's largest unconditional cash transfer programme, the Child Support Grant. Mental health is measured by the 10-item version of the Centre for Epidemiological Depression Scale. We use the product of the coefficient method for the mediation analysis in combination with instrumental variable estimation. We find that physical health and lifestyle factors mediate the relationship of the unconditional cash transfer programme, each explaining about eight percent and 16% of the total positive effect. Our findings show that individuals living in poverty make investment decisions that are positive for their mental health, which has strong implications for policy makers.

Is the road to good health paved in gold? HIV and mining in Sub-Saharan Africa

Background

This paper measures the impact of HIV prevalence on gold production in Sub-Saharan Africa. Gold mining adds billions of gross value to the African economy, however remains a highly-prevalent industry for HIV. Some of the largest global gold producers in South Africa estimate 30% of their workforce to be HIV-positive. In comparison, the current prevalence rate in the country is 3.7% in working-aged males.

Methods

There is a reverse causality between HIV and mining. HIV exerts a direct causal influence on mining production. The mining industry creates working and living environments which accelerate the spread of HIV. Using 22 years of panel data and an external instrumental variable, overseas development assistance, supported by an Arellano-Bond estimator, we measure the causal impact of HIV on gold mining.

Results

We estimate a 1% increase in HIV leads to a decrease in gold production of 9.866 tonnes, valued at over $402 million, nearly 3% of total African gold production, significant at the 10% level. These results are robust to the findings of the Arellano-Bond estimator, which are significant at the 5% level.

Conclusions

International aid foundations and donors have made great strides in funding for HIV treatment, and it is critical for multinational corporations to take necessary action to protect the progress that has been made so far, promoting health and economic outcomes. Understanding macroeconomic impacts will raise the cost-effectiveness of public health interventions, and increase the associated economic benefits to many individual sectors, as well as overall local and country-wide economies.

Key messages

In addition to saving lives and extending the quality of HIV-positive lives, there are economic gains to be had in investing in the prevention of HIV, as demonstrated in the gold mining industry. HIV-related productivity losses readily extend to a variety of industries across Africa and abroad. Policies that minimise these losses, and maximise health gains, can only be mutually beneficial.

The effect of cash transfers on mental health - new evidence from South Africa

BACKGROUND

Mental health and poverty are strongly interlinked. There is a gap in the literature on the effects of poverty alleviation programmes on mental health. We aim to fill this gap by studying the effect of an exogenous income shock generated by the Child Support Grant, South Africa's largest Unconditional Cash Transfer (UCT) programme, on mental health.

METHODS

We use biennial data on 10,925 individuals from the National Income Dynamics Study between 2008 and 2014. We exploit the programme's eligibility criteria to estimate instrumental variable Fixed Effects models.

RESULTS

We find that receiving the Child Support Grant improves adult mental health by 0.822 points (on a 0-30 scale), 4.1% of the sample mean.

CONCLUSION

Our findings show that UCT programmes have strong mental health benefits for the poor adult population.

Validation of the SF12 mental and physical health measure for the population from a low-income country in sub-Saharan Africa

Introduction

The Short Form Survey 12-item (SF12) mental and physical health version has been applied in several studies on populations from Sub-Saharan Africa. However, the SF12 has not been computed and validated for these populations. We address in this paper these gaps in the literature and use a health intervention example in Malawi to show the importance of our analysis for health policy.

Methods

We firstly compute the weights of the SF12 physical and mental health measure for the Malawian population using principal component analysis on a sample of 2838 adults from wave four (2006) of Malawian Longitudinal Study of Aging (MLSFH). We secondly test the construct validity of our computed and the US-population weighted SF12 measures using regression analysis and Fixed Effect estimation on waves four, seven (2012) and eight (2013) of the MLSFH. Finally, we use a Malawian cash transfer programme to exemplify the implications of using US- and Malawi-weighted SF12 mental health measures in policy evaluation.

Results

We find that the Malawian SF12 health measure weighted by our computed Malawian population weights is strongly associated with other mental health measures (Depression:-0.501, p = < 0.001; Anxiety:-1.755; p = < 0.001) and shows better construct validity in comparison to the US-weighted SF12 mental health component (rs = 0.675 versus rs = 0.495). None of the SF12 measures shows strong associations with other measures of physical health. The estimated average effect of the cash transfer is significant when using the Malawi-weighted SF12 mental health measure (treatment effect: 1.124; p = < 0.1), but not when using the US-weighted counterpart (treatment effect: 1.129; p > 0.1). The weightings affect the size of the impacts across mental health quantiles suggesting that the weighting scheme matters for empirical health policy analysis.

Conclusion

Mental health shows more pronounced associations with the physical health dimension in a Low-Income Country like Malawi compared to the US. This is important for the construct validity of the SF12 health measures and has strong implications in health policy analysis. Further analysis is required for the physical health dimension of the SF12.

The relationship between physical and mental health: A mediation analysis

There is a strong link between mental health and physical health, but little is known about the pathways from one to the other. We analyse the direct and indirect effects of past mental health on present physical health and past physical health on present mental health using lifestyle choices and social capital in a mediation framework. We use data on 10,693 individuals aged 50 years and over from six waves (2002-2012) of the English Longitudinal Study of Ageing. Mental health is measured by the Centre for Epidemiological Studies Depression Scale (CES) and physical health by the Activities of Daily Living (ADL). We find significant direct and indirect effects for both forms of health, with indirect effects explaining 10% of the effect of past mental health on physical health and 8% of the effect of past physical health on mental health. Physical activity is the largest contributor to the indirect effects. There are stronger indirect effects for males in mental health (9.9%) and for older age groups in mental health (13.6%) and in physical health (12.6%). Health policies aiming at changing physical and mental health need to consider not only the direct cross-effects but also the indirect cross-effects between mental health and physical health.

The dynamics of physical and mental health in the older population

Mental and physical aspects are both integral to health but little is known about the dynamic relationship between them. We consider the dynamic relationship between mental and physical health using a sample of 11,203 individuals in six waves (2002-2013) of the English Longitudinal Study of Ageing (ELSA). We estimate conditional linear and non-linear random-effects regression models to identify the effects of past physical health, measured by Activities of Daily Living (ADL), and past mental health, measured by the Centre for Epidemiological Studies Depression (CES-D) scale, on both present physical and mental health. We find that both mental and physical health are moderately state-dependent. Better past mental health increases present physical health significantly. Better past physical health has a larger effect on present mental health. Past mental health has stronger effects on present physical health than physical activity or education. It explains 2.0% of the unobserved heterogeneity in physical health. Past physical health has stronger effects on present mental health than health investments, income or education. It explains 0.4% of the unobserved heterogeneity in mental health. These cross-effects suggest that health policies aimed at specific aspects of health should consider potential spill-over effects.

External validation of a tumor-derived 5-gene prognostic signature for recurrence (R) of stages I/II colon and stage I rectal cancer following potentially curative resection

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Background: Optimizing post-operative clinical management for early-stage (I/II) colorectal cancer (CRC) patients (pts) is a significant unmet medical need. We hypothesized that a molecular prognostic test using primary CRC tissue would better predict the chances of tumor R within 36 months (mo) than current NCCN Clinical Practice Guidelines (NCCN).

Methods: Pts had tumor R by 36 mo (n=46) or confirmed non-recurrence (NR) for ≥36 mo (n=69) after surgery; none had received neoadjuvant or adjuvant therapy. Archival formalin-fixed paraffin-embedded primary adenocarcinoma tissues (median storage 7 years; range 4-15) obtained at initial surgical resection with curative intent were retrieved for 86 stage I/II (pT1-4 pN0 M0) colon cancer and 29 stage I (pT1-2, pN0 M0) rectal cancer pts from 2 US and 2 European sites that were different from those previously used to generate the molecular test. Tumor gene expression was assessed by qRT-PCR with custom 384- well TaqMan Low Density Arrays (Applied Biosystems) using RNA that had satisfied a set of rigorous quality control parameters.

Results: For stages I/II CRC (n=115), the dichotomous rule correctly classified 32/46 R and 38/69 NR pts: sensitivity (S) 0.70, specificity (SP) 0.55. High-risk pts had a significantly higher probability of R by 36 mo than low-risk pts: PPV 0.51, NPV 0.73; hazard ratio (HR) 2.06 (95% CI: 1.10 to 3.86; p=0.020). NCCN (V.1.2011) was not able to differentiate 36-mo R vs NR in this population: S 0.72, SP 0.42, PPV 0.45, NPV 0.69; HR 1.38 (95% CI: 0.73 to 2.63; p=0.315). The SP of the molecular test was significantly greater than that for NCCN (p=0.05). For stage I pts (n=29; 13R, 16NR), the prognostic accuracy of the test (0.79; 23/29) surpassed that for NCCN (0.55; 16/29).

Conclusions: External validation of a 5-gene prognostic rule confirmed its ability to differentiate early stage CRC pts at high risk vs low risk for R within 36 mo after surgery better than current NCCN Guidelines, especially for stage I. The improved specificity and high sensitivity of the molecular test confirm its potential utility for optimizing post-op clinical management of early stage CRC.

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Alternative methods of preparing whole-cell DNA from fungi for dot-blot, restriction analysis, and colony filter hybridization

There is a large and increasing number of methods for preparing whole-cell DNA from fungi. Modifications have evolved for two reasons. This first is to simplify the protocol as much as possible to allow processing of large sample numbers, in some cases for very specific uses, e.g., dot-blots. The second is to increase the quality of the DNA. Most preparations are contaminated with varying amounts of polysaccharides and unknown wall contaminants that can inhibit subsequent restriction or ligation. The extent of contamination varies with the species, the individual isolate, and at least in Neurospora, with the method or extent of growth. This paper offers three new methods. The first is a simplified procedure for isolating denatured DNAs from filamentous fungi for dot-blot analysis. The second is a rapid method for isolating DNAs from large numbers of small- to medium-scale cultures of filamentous fungi. These preparations are sufficiently pure for a variety of enzymatic reactions. The third is a nonenzymatic method for yeast colony filter hybridization that is simple, inexpensive, and efficient and results in uniform signals for a variety of species.

Suppressor mutants of Neurospora crassa that tolerate allelic differences at single or at multiple heterokaryon incompatibility loci

Allelic differences at any one of at least 11 heterokaryon incompatibility (het) loci in Neurospora crassa trigger an incompatibility response: localized cell death at sites of hyphal anastomosis. We have isolated spontaneous and insertional suppressor mutants that are heterokaryon-compatible in spite of allelic differences at one or at several het loci. Some intra- and extragenic mutants tolerated allelic differences only at single het loci. Multi-tolerant spontaneous mutants were isolated by selecting simultaneously for tolerance of differences at het-c, -d and -e, or at each of these plus mating-type. Some suppressor mutants were specific for only one allele at the affected het locus; others suppressed both alleles. Insertional mutations were isolated from banks of transformants, each having a plasmid integrated into a random position in the chromosome. One mutant tolerated allelic differences at het-d. A homologous cosmid from a Neurospora genomic bank complemented the mutant phenotype. A second insertional inactivation mutant was tolerant of het-c differences. Inactivation of the wild-type locus corresponding to the integration site was accomplished by repeat-induced point mutation (RIP). The RIP progeny, like the original mutant, were tolerant of differences at het-c. It may be possible to use such suppressor mutants as universal donors of hypovirulence in pathogenic fungi.