Cortisol awakening response over the course of humanitarian aid deployment: a prospective cohort study.

Background: Internationally deployed humanitarian aid (HA) workers are routinely confronted with potentially traumatic stressors. However, it remains unknown whether HA deployment and related traumatic stress are associated with long-term changes in hypothalamic-pituitary-adrenal (HPA) axis function. Therefore, we investigated whether cortisol awakening response (CAR) decreased upon deployment and whether this was moderated by previous and recent trauma exposure and parallel changes in symptom severity and perceived social support. Methods: In this prospective study, n = 86 HA workers (68% females) completed questionnaires regarding trauma exposure, posttraumatic stress disorder (PTSD), anxiety and depressive symptoms and perceived social support, as well as salivary cortisol assessments at awakening and 30 minutes post-awakening at before, early and 3-6 months post-deployment. Results: Linear mixed models showed significantly decreased CAR (b(SE) = -.036(.011), p = .002) and awakening cortisol over time (b(SE) = -.007(.003), p = .014). The extent of awakening cortisol change was significantly moderated by interactions between previous and recent trauma exposure. Also, a steeper awakening cortisol decrease was significantly associated with higher mean anxiety and PTSD symptoms across assessments. No significant effects were found for social support. Conclusions: We observed attenuated CAR and awakening cortisol upon HA deployment, with a dose-response effect between trauma exposure before and during the recent deployment on awakening cortisol. Awakening cortisol change was associated with PTSD and anxiety symptom levels across assessments. Our findings support the need for organizational awareness that work-related exposures may have long-lasting biological effects. Further research assessing symptoms and biological measures in parallel is needed to translate current findings into guidelines on the individual level.

Antecedentes: Los trabajadores de la ayuda humanitaria desplegados internacionalmente (HA) se enfrentan rutinariamente a estresores potencialmente traumáticos. Sin embargo, aún se desconoce si el despliegue de la HA y el estrés traumático relacionado están asociados con cambios a largo plazo en la función del eje hipotalámico-pituitaria-suprarrenal (HPA). Por lo tanto, investigamos si la respuesta del cortisol al despertar (CAR, en sus siglas en inglés) disminuyó en el momento del despliegue y si esto fue moderado por una anterior o reciente exposición a un trauma y los cambios paralelos en la gravedad de los síntomas y el apoyo social percibido.Métodos: En este estudio prospectivo, x = 86 trabajadores de la HA (68% mujeres) completaron cuestionarios sobre la exposición al trauma, el trastorno de estrés postraumático (TEPT), la ansiedad y los síntomas depresivos y el apoyo social percibido, así como evaluaciones del cortisol salival al despertar y 30 minutos después del despertar, antes, durante y 3-6 meses después del despliegue.Resultados: Los modelos lineales mixtos mostraron una disminución significativa de la CAR (b(SE) = −.036(.011), p = .002) y del cortisol al despertar, en el transcurso del tiempo (b(SE) = −.007(.003), p = .014). El grado de cambio en el cortisol al despertar fue significativamente moderado por las interacciones entre la exposición anterior y reciente al trauma. Además, una disminución más pronunciada del cortisol al despertar se asoció significativamente con una mayor media de ansiedad y síntomas de TEPT en todas las evaluaciones. No se encontraron efectos significativos en cuanto al apoyo social.Conclusiones: Observamos CAR atenuado y cortisol al despertar en el despliegue de HA, con un efecto dosis-respuesta en el cortisol al despertar, entre la exposición al trauma antes y durante el reciente despliegue. El cambio de cortisol al despertar se asoció con el TEPT y los niveles de síntomas de ansiedad en todas las evaluaciones. Nuestros hallazgos apoyan la necesidad de la conciencia organizacional de que las exposiciones relacionadas con el trabajo pueden tener efectos biológicos duraderos. Se necesitan más investigaciones que evalúen los síntomas y las medidas biológicas en paralelo para traducir los hallazgos actuales en directrices a nivel individual.

Global Trends of Monitoring and Data Collection on the HIV Response among Key Populations Since the 2001 UN Declaration of Commitment on HIV/AIDS.

Monitoring and evaluation indicators for HIV programs' response to the epidemic among key populations (sex workers, people who inject drugs, men who have sex with men, transgender people) are critical for reviewing the global response. From the beginning of global reporting, insufficiency of data has been a challenge for monitoring the epidemic response among key populations. However, key populations were only indirectly referenced in the 2001 Declaration of Commitment. By the 2006 Political Declaration on HIV/AIDS, data from key populations were still not required from every country, and were sparsely reported compared to other indicators. The 2011 Political Declaration on HIV/AIDS referenced key populations by name for the first time. In 2006, fewer than twenty countries (10%) reported HIV prevalence among key populations, whereas in 2012 the number of countries surpassed sixty (30%).

The importance of assessing self-reported HIV status in bio-behavioural surveys.

In bio-behavioural surveys measuring prevalence of infection with human immunodeficiency virus (HIV), respondents should be asked the results of their last HIV test. However, many government authorities, nongovernmental organizations, researchers and other civil society stakeholders have stated that respondents involved in such surveys should not be asked to self-report their HIV status. The reasons offered for not asking respondents to report their status are that responses may be inaccurate and that asking about HIV status may violate the respondents' human rights and exacerbate stigma and discrimination. Nevertheless, we contend that, in the antiretroviral therapy era, asking respondents in bio-behavioural surveys to self-report their HIV status is essential for measuring and improving access to - and coverage of - services for the care, treatment and prevention of HIV infection. It is also important for estimating the true size of the unmet needs in addressing the HIV epidemic and for interpreting the behaviours associated with the acquisition and transmission of HIV infection correctly. The data available indicate that most participants in health-related surveys are willing to respond to a question about HIV status - as one of possibly several sensitive questions about sexual and drug use behaviours. Ultimately, normalizing the self-reporting of HIV status could help the global community move from an era of so-called exceptionalism to one of destigmatization - and so improve the epidemic response worldwide.

Dans les enquêtes bio-comportementales évaluant la prévalence de l'infection par le virus de l'immunodéficience humaine (VIH), il conviendrait de demander aux répondants le résultat de leur dernier test de dépistage du VIH. Mais nombre d'autorités gouvernementales, d'organisations non gouvernementales, de chercheurs et d'acteurs de la société civile sont défavorables à ce que l'on demande aux répondants de déclarer leur statut VIH dans ce type d'enquêtes. Parmi les raisons invoquées pour ne pas demander le statut VIH figure le fait que les réponses peuvent être inexactes et qu'une telle demande pourrait transgresser les droits humains des répondants et accentuer les problèmes de stigmatisation et de discrimination. Néanmoins, nous soutenons qu'aujourd'hui, à l'ère de la thérapie antirétrovirale, le fait de demander leur statut VIH aux répondants des enquêtes bio-comportementales est essentiel à des fins d'évaluation des services de soins, traitement et prévention de l'infection à VIH et pour en optimiser l'accès et la couverture. Cela est également fondamental pour évaluer la véritable ampleur des besoins non satisfaits dans la gestion de l'épidémie de VIH et pour correctement interpréter les comportements associés à l'acquisition et à la transmission du VIH. Les données disponibles indiquent que la plupart des participants aux enquêtes liées à la santé acceptent de répondre à une question sur leur statut VIH, parmi d'autres questions sensibles concernant les comportements sexuels et l'usage de drogues. Enfin, une normalisation de l'auto-déclaration du statut VIH pourrait aider la communauté mondiale à dépasser ce que l'on appelle « l'exceptionnalisme ¼ pour ouvrir une ère de déstigmatisation, ce qui permettrait d'améliorer la réponse face à l'épidémie dans le monde entier.

Durante la realización de encuestas bioconductuales que miden la prevalencia del contagio del virus de la inmunodeficiencia humana (VIH), los encuestados deberían entregar los resultados de la última prueba de VIH a la que se hayan sometido. No obstante, muchas autoridades gubernamentales, organizaciones no gubernamentales, investigadores y otras partes interesadas de la sociedad civil han declarado que las personas encuestadas implicadas en dichas encuestas no deberían tener que realizar una autodeclaración de su estado con relación al VIH. Las razones expuestas para no pedir a los encuestados que informen de su condición son que las respuestas pueden ser inexactas y que preguntarles por su estado en relación al VIH puede violar sus derechos humanos y exacerbar la estigmatización y la discriminación. Sin embargo, se sostiene que, en la era de terapias antirretrovirales, solicitar a los encuestados en encuestas bioconductuales que declaren su estado en relación al VIH es fundamental para medir y mejorar el acceso a, y la cobertura de, servicios para la atención, el tratamiento y la prevención del contagio del VIH. También es importante para estimar el verdadero alcance de las necesidades insatisfechas a la hora de abordar la epidemia de VIH, así como para interpretar las conductas asociadas a la adquisición y transmisión del virus de forma adecuada. Los datos disponibles indican que la mayor parte de los participantes en encuestas relacionadas con la salud están dispuestos a responder una pregunta sobre su estado en relación al VIH como una de las muchas posibles preguntas delicadas sobre comportamientos sexuales y de consumo de drogas. Por último, normalizar las declaraciones sobre el estado en relación al VIH podría ayudar a la comunidad mundial a pasar de una época caracterizada por el "excepcionalismo" a una caracterizada por la "desestigmatización", y, de este modo, mejorar la respuesta frente a las epidemias a nivel mundial.

Risk factors and outcomes for late presentation for HIV-positive persons in Europe: results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE).

BACKGROUND: Few studies have monitored late presentation (LP) of HIV infection over the European continent, including Eastern Europe. Study objectives were to explore the impact of LP on AIDS and mortality. METHODS AND FINDINGS: LP was defined in Collaboration of Observational HIV Epidemiological Research Europe (COHERE) as HIV diagnosis with a CD4 count <350/mm(3) or an AIDS diagnosis within 6 months of HIV diagnosis among persons presenting for care between 1 January 2000 and 30 June 2011. Logistic regression was used to identify factors associated with LP and Poisson regression to explore the impact on AIDS/death. 84,524 individuals from 23 cohorts in 35 countries contributed data; 45,488 were LP (53.8%). LP was highest in heterosexual males (66.1%), Southern European countries (57.0%), and persons originating from Africa (65.1%). LP decreased from 57.3% in 2000 to 51.7% in 2010/2011 (adjusted odds ratio [aOR] 0.96; 95% CI 0.95-0.97). LP decreased over time in both Central and Northern Europe among homosexual men, and male and female heterosexuals, but increased over time for female heterosexuals and male intravenous drug users (IDUs) from Southern Europe and in male and female IDUs from Eastern Europe. 8,187 AIDS/deaths occurred during 327,003 person-years of follow-up. In the first year after HIV diagnosis, LP was associated with over a 13-fold increased incidence of AIDS/death in Southern Europe (adjusted incidence rate ratio [aIRR] 13.02; 95% CI 8.19-20.70) and over a 6-fold increased rate in Eastern Europe (aIRR 6.64; 95% CI 3.55-12.43). CONCLUSIONS: LP has decreased over time across Europe, but remains a significant issue in the region in all HIV exposure groups. LP increased in male IDUs and female heterosexuals from Southern Europe and IDUs in Eastern Europe. LP was associated with an increased rate of AIDS/deaths, particularly in the first year after HIV diagnosis, with significant variation across Europe. Earlier and more widespread testing, timely referrals after testing positive, and improved retention in care strategies are required to further reduce the incidence of LP.

Population size estimation of men who have sex with men through the network scale-up method in Japan.

BACKGROUND: Men who have sex with men (MSM) are one of the groups most at risk for HIV infection in Japan. However, size estimates of MSM populations have not been conducted with sufficient frequency and rigor because of the difficulty, high cost and stigma associated with reaching such populations. This study examined an innovative and simple method for estimating the size of the MSM population in Japan. We combined an internet survey with the network scale-up method, a social network method for estimating the size of hard-to-reach populations, for the first time in Japan. METHODS AND FINDINGS: An internet survey was conducted among 1,500 internet users who registered with a nationwide internet-research agency. The survey participants were asked how many members of particular groups with known population sizes (firepersons, police officers, and military personnel) they knew as acquaintances. The participants were also asked to identify the number of their acquaintances whom they understood to be MSM. Using these survey results with the network scale-up method, the personal network size and MSM population size were estimated. The personal network size was estimated to be 363.5 regardless of the sex of the acquaintances and 174.0 for only male acquaintances. The estimated MSM prevalence among the total male population in Japan was 0.0402% without adjustment, and 2.87% after adjusting for the transmission error of MSM. CONCLUSIONS: The estimated personal network size and MSM prevalence seen in this study were comparable to those from previous survey results based on the direct-estimation method. Estimating population sizes through combining an internet survey with the network scale-up method appeared to be an effective method from the perspectives of rapidity, simplicity, and low cost as compared with more-conventional methods.

Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011-2050.

BACKGROUND: Antiretroviral Treatment (ART) significantly reduces HIV transmission. We conducted a cost-effectiveness analysis of the impact of expanded ART in South Africa. METHODS: We model a best case scenario of 90% annual HIV testing coverage in adults 15-49 years old and four ART eligibility scenarios: CD4 count <200 cells/mm(3) (current practice), CD4 count <350, CD4 count <500, all CD4 levels. 2011-2050 outcomes include deaths, disability adjusted life years (DALYs), HIV infections, cost, and cost per DALY averted. Service and ART costs reflect South African data and international generic prices. ART reduces transmission by 92%. We conducted sensitivity analyses. RESULTS: Expanding ART to CD4 count <350 cells/mm(3) prevents an estimated 265,000 (17%) and 1.3 million (15%) new HIV infections over 5 and 40 years, respectively. Cumulative deaths decline 15%, from 12.5 to 10.6 million; DALYs by 14% from 109 to 93 million over 40 years. Costs drop $504 million over 5 years and $3.9 billion over 40 years with breakeven by 2013. Compared with the current scenario, expanding to <500 prevents an additional 585,000 and 3 million new HIV infections over 5 and 40 years, respectively. Expanding to all CD4 levels decreases HIV infections by 3.3 million (45%) and costs by $10 billion over 40 years, with breakeven by 2023. By 2050, using higher ART and monitoring costs, all CD4 levels saves $0.6 billion versus current; other ART scenarios cost $9-194 per DALY averted. If ART reduces transmission by 99%, savings from all CD4 levels reach $17.5 billion. Sensitivity analyses suggest that poor retention and predominant acute phase transmission reduce DALYs averted by 26% and savings by 7%. CONCLUSION: Increasing the provision of ART to <350 cells/mm3 may significantly reduce costs while reducing the HIV burden. Feasibility including HIV testing and ART uptake, retention, and adherence should be evaluated.

Costing human rights and community support interventions as a part of universal access to HIV treatment and care in a Southern African setting.

Expanding access to antiretroviral therapy (ART) has both individual health benefits and potential to decrease HIV incidence. Ensuring access to HIV services is a significant human rights issue and successful programmes require adequate human rights protections and community support. However, the cost of specific human rights and community support interventions for equitable, sustainable and non-discriminatory access to ART are not well described. Human rights and community support interventions were identified using the literature and through consultations with experts. Specific costs were then determined for these health sector interventions. Population and epidemic data were provided through the Statistics South Africa 2009 national mid-year estimates. Costs of scale up of HIV prevention and treatment were taken from recently published estimates. Interventions addressed access to services, minimising stigma and discrimination against people living with HIV, confidentiality, informed consent and counselling quality. Integrated HIV programme interventions included training for counsellors, 'Know Your Rights' information desks, outreach campaigns for most at risk populations, and adherence support. Complementary measures included post-service interviews, human rights abuse monitoring, transportation costs, legal assistance, and funding for human rights and community support organisations. Other essential non-health sector interventions were identified but not included in the costing framework. The annual costs for the human rights and community support interventions are United States (US) $63.8 million (US $1.22 per capita), representing 1.5% of total health sector HIV programme costs. Respect for human rights and community engagement can be understood both as an obligation of expanded ART programmes and as a critically important factor in their success. Basic rights-based and community support interventions constitute only a small percentage of overall programmes costs. ART programs should consider measuring the cost and impact of human rights and community support interventions as key aspects of successful programme expansion.