Community and activists demand for tenofovir/emtricitabine or lamivudine/dolutegravir and routine viral load testing.

PURPOSE OF REVIEW: Since the beginning of the HIV epidemic, informed communities have demanded and fought for access to life-saving treatment. The last several years have seen interesting developments in this area - particularly with respect to the switch to dolutegravir (DTG)-based regimens and scale-up of routine viral load testing (RVLT), and how these directly and indirectly impact issues of treatment optimization, HIV drug resistance, and sexual and reproductive health. In this review, we present recent advances in antiretroviral treatment and monitoring in the context of how treatment education and community demand for them. RECENT FINDINGS: The latest developments with DTG and RVLT highlight underlying issues for global health systems that need to be addressed - including drug surveillance, supply chain management, and comprehensive care linkages - and the importance of community engagement in such issues. SUMMARY: Decisions about treatment must be grounded in informed community demand, and should exist in the context of optimal care and treatment across the entire HIV cascade. Informed advocacy is essential for people living with HIV and their communities, so that they benefit from existing and future therapeutic advances. Research is needed on the importance of community demand across the HIV treatment cascade.

Community-driven demand creation for the use of routine viral load testing: a model to scale up routine viral load testing.

INTRODUCTION: HIV treatment outcomes are dependent on the use of viral load measurement. Despite global and national guidelines recommending the use of routine viral load testing, these policies alone have not translated into widespread implementation or sufficiently increased access for people living with HIV (PLHIV). Civil society and communities of PLHIV recognize the need to close this gap and to enable the scale up of routine viral load testing. METHODS: The International Treatment Preparedness Coalition (ITPC) developed an approach to community-led demand creation for the use of routine viral load testing. Using this Community Demand Creation Model, implementers follow a step-wise process to capacitate and empower communities to address their most pressing needs. This includes utlizing a specific toolkit that includes conducting a baseline assessment, developing a treatment education toolkit, organizing mobilization workshops for knowledge building, provision of small grants to support advocacy work and conducting benchmark evaluations. RESULTS AND DISCUSSION: The Community Demand Creation Model to increase demand for routine viral load testing services by PLHIV has been delivered in diverse contexts including in the sub-Saharan African, Asian, Latin American and the Caribbean regions. Between December 2015 and December 2016, ITPC trained more than 240 PLHIV activists, and disbursed US$90,000 to network partners in support of their national advocacy work. The latter efforts informed a regional, community-driven campaign calling for domestic investment in the expeditious implementation of national viral load testing guidelines. CONCLUSIONS: HIV treatment education and community mobilization are critical components of demand creation for access to optimal HIV treatment, especially for the use of routine viral load testing. ITPC's Community Demand Creation Model offers a novel approach to achieving this goal.

Barriers to Reconstructive Surgery in Low- and Middle-Income Countries: A Cross-Sectional Study of 453 Cleft Lip and Cleft Palate Patients in Vietnam.

BACKGROUND: Despite health system advances, residents of low- and middle-income countries continue to experience substantial barriers in accessing health care, particularly for specialized care such as plastic and reconstructive surgery. METHODS: A cross-sectional household survey of patients seeking surgical care for cleft lip and/or cleft palate was completed at five Operation Smile International mission sites throughout Vietnam (Hanoi, Nghe An, Hue, Ho Chi Minh City, An Giang, and Bac Lieu) in November of 2014. RESULTS: Four hundred fifty-three households were surveyed. Cost, mistrust of medical providers, and lack of supplies and trained physicians were cited as the most significant barriers to obtaining surgery from local hospitals. There was no significant difference in household income or hospital access between those who had and had not obtained cleft surgery in the past. Fewer households that had obtained cleft surgery in the past were enrolled in health insurance (p < 0.001). Of those households/patients who had surgery previously, 83 percent had their surgery performed by a charity. Forty-three percent of participants did not have access to any other surgical cleft care and 41 percent did not have any other access to nonsurgical cleft care. CONCLUSIONS: The authors highlight barriers specific to surgery in low- and middle-income countries that have not been previously addressed. Patients rely on charitable care outside the centralized health care system; as a result, surgical treatment of cleft lip and palate is delayed beyond the standard optimal window compared with more developed countries. Using these data, the authors developed a more evidence-based framework designed to understand health behaviors and perceptions regarding reconstructive surgical care.

The Medical Mission and Modern Core Competency Training: A 10-Year Follow-Up of Resident Experiences in Global Plastic Surgery.

BACKGROUND: The emphasis on cultural competency for physicians and surgeons is increasingly important, as communication with both patients and other providers significantly affects individual and system-wide outcomes. International surgical training has been shown to improve leadership skills, cultural competency, and technical proficiency of participants in short-term follow-up. This study explores the long-term impact of international surgical mission experiences on developing participants' core competencies, professional outcomes, and commitment to global health. METHODS: All 208 plastic and reconstructive surgeons who completed the Operation Smile Regan/Stryker fellowship programs between 2006 and 2015 were surveyed electronically. RESULTS: One hundred sixty-five surveys were returned, for an overall response rate of 79.3 percent. The majority of participants reported that the fellowship positively impacted all six Accreditation Council for Graduate Medical Education core competencies. Most participants who were attending physicians at the time of the survey were practicing general plastic surgery, with 42 percent in an academic/teaching environment, 32 percent in assistant/associate professor positions, and 6 percent in either a program director or department chairman position. The majority currently volunteer on local or international missions, and all respondents would consider volunteering again. CONCLUSIONS: Carefully structured and rigorously proctored programs such as the Regan/Stryker Fellowship offer plastic surgery residents the opportunity to gain valuable professional and personal experiences that benefit them long after their service experience. Programs of this nature can not only effectively improve cultural competency of physicians, but also positively influence their attitudes toward leadership and direct that potential to meet the growing need for surgical care in low- and middle-income countries.

The Tsao Fellowship in Global Health: A Model for International Fellowships in a Surgery Residency.

OBJECTIVE: To present a model for integrated global health fellowships in plastic surgical residency training. BACKGROUND: National surveys have found that North American surgical residents have significant interest in international training. While global health training opportunities exist, less than a third of these are housed within surgical residency programs; even fewer are designed specifically for plastic surgery residents. METHODS: The Tsao Fellowship was created through a partnership between Operation Smile, Children's Hospital Los Angeles, Shriners Hospital for Children, and the University of Southern California. Designed for Accreditation Council for Graduate Medical Education accredited plastic surgery residents between their third and fourth years of residency, the fellowship curriculum is completed over 24 months and divided into 3 areas: clinical research, international reconstructive surgery fieldwork, and the completion of a Master of Science in Clinical and Biomedical Investigations. RESULTS: The Tsao Fellowship has matriculated 4 fellows: 3 have graduated from the program and 1 is in the current cycle. Fellows completed 4 to 7 international missions each cycle and have performed an aggregate total of 684 surgical procedures. Each fellow also conducted 2 to 6 research projects and authored several publications. All fellows continue to assume leadership roles within the field of global reconstructive surgery. CONCLUSIONS: Comprehensive global health fellowships provide invaluable opportunities beyond surgical residency. The Tsao Fellowship is a model for integrating international surgical training with global health research in plastic surgical residency that can be applied to other residency programs and different surgical specialties.

Perceptions of foreign health aid in East Africa: an exploratory baseline study.

BACKGROUND: There is insufficient literature on the perceptions of aid recipients with respect to foreign health aid administration and impact. This study sought to identify perceptions of foreign health aid among individuals, health care workers (HCWs), and policymakers in three East African countries: Kenya, Uganda, and Ethiopia. Each country receives substantial foreign aid and shares regional proximity. METHODS: A qualitative exploratory study design was adopted and 81 questionnaires were administered to individuals, HCWs and policymakers. Questionnaires ascertained perceptions of foreign aid, health aid and the USA. Responses were compared between groups and across countries. RESULTS: Perceptions of how much foreign aid a community receives varied between individuals ('a little'), HCWs ('some') and policymakers ('a lot'). Respondents were positive towards the USA irrespective of the level of aid they perceived came from the USA. Opinions regarding the impact of aid varied by country and by profession. Aid priorities were similar among all countries and participants, with health care, education and economic development among the primary sectors reported. CONCLUSIONS: More research is needed on perceptions of aid recipients. The findings of this pilot study highlight the need for inclusion of these stakeholders in order to better inform decisions regarding foreign aid.