Removing the societal and legal impediments to the HIV response: An evidence-based framework for 2025 and beyond.

Societal and legal impediments inhibit quality HIV prevention, care, treatment and support services and need to be removed. The political declaration adopted by UN member countries at the high-level meeting on HIV and AIDS in June 2021, included new societal enabler global targets for achievement by 2025 that will address this gap. Our paper describes how and why UNAIDS arrived at the societal enabler targets adopted. We conducted a scoping review and led a participatory process between January 2019 and June 2020 to develop an evidence-based framework for action, propose global societal enabler targets, and identify indicators for monitoring progress. A re-envisioned framework called the '3 S's of the HIV response: Society, Systems and Services' was defined. In the framework, societal enablers enhance the effectiveness of HIV programmes by removing impediments to service availability, access and uptake at the societal level, while service and system enablers improve efficiencies in and expand the reach of HIV services and systems. Investments in societal enabling approaches that remove legal barriers, shift harmful social and gender norms, reduce inequalities and improve institutional and community structures are needed to progressively realize four overarching societal enablers, the first three of which fall within the purview of the HIV sector: (i) societies with supportive legal environments and access to justice, (ii) gender equal societies, (iii) societies free from stigma and discrimination, and (iv) co-action across development sectors to reduce exclusion and poverty. Three top-line and 15 detailed targets were recommended for monitoring progress towards their achievement. The clear articulation of societal enablers in the re-envisioned framework should have a substantial impact on improving the effectiveness of core HIV programmes if implemented. Together with the new global targets, the framework will also galvanize advocacy to scale up societal enabling approaches with proven impact on HIV outcomes.

Mandatory vaccination for infants and children: the Italian experience.

Maintaining high vaccination coverage is important in order to protect the individual and the community. Mandatory vaccination is an option in case of declining coverage. Widely used in the USA, it is considered a rather controversial issue in Europe. In Italy, after a decrease of vaccination coverage for the hexavalent and the MPR vaccine under the optimal threshold, a new law, which extended the number of mandatory vaccines from 4 to 10 and reinforced coercive measures, was introduced in July 2017. After 2 years, vaccination coverage increased for all mandatory vaccines and for the other two recommended vaccines (anti-pneumococcal and anti-meningococcal C). Although it is not possible to disentangle the role of other factors contributing to the positive outcome, consistently with the results of studies conducted in the USA, vaccine mandates appeared to be successful in increasing vaccination coverage in Italy. The long-term sustainability of the effect of mandatory vaccination and the potential negative drawbacks of the coercive measures need to be evaluated to generate scientific evidence in public health.

Prevention is Better than Cure, But who Foots the Bill? R (National AIDS Trust) v NHS England.

This case note discusses R (on the Application of National Aids Trust) v The National Health Service Commissioning Board (NHS England), The Local Government Association, The Secretary of State For Health [2016] EWCA Civ 1100. The case is an appeal on an earlier finding by the High Court that the power to commission pre-exposure prophylaxis (PrEP) lies within National Health Service (NHS) England's competence, instead of being within the realm of local authorities' responsibilities. It now forms the sole piece of judicial guidance on NHS England's duties under the National Health Service Act 2006 and is significant for the process by which the Court of Appeal reached its decision. Rather than adhere to the literal meaning of relevant legislation, the judges engaged in a holistic examination of the issue to reach a functional and sensible decision. Examining this case under the lens of both legal theory and pragmatism, comment is made on the soundness of the judges' approach and it is argued that the decision reached was the correct one. This case now forms binding precedent on this issue and the clear process by which the judges reached their conclusion may form instructive guidance for similar such problems in the future.

Effects of the ACA on Preventive Care Disparities.

BACKGROUND: The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care. OBJECTIVES: We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears. METHODS: We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA. RESULTS: After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status. CONCLUSIONS: Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits.

Good practices and challenges in addressing poliomyelitis and measles in the European Union.

Background: All European Union (EU) and European Economic Area (EEA) Member States have pledged to ensure political commitment towards sustaining the region's poliomyelitis-free status and eliminating measles. However, there remain significant gaps between policy and practice in many countries. This article reports on an assessment conducted for the European Commission that aimed to support improvements in preparedness and response to poliomyelitis and measles in Europe. Methods: A documentary review was complemented by qualitative interviews with professionals working in International and EU agencies, and in at-risk or recently affected EU/EEA Member States (six each for poliomyelitis and measles). Twenty-six interviews were conducted on poliomyelitis and 24 on measles; the data were subjected to thematic analysis. Preliminary findings were then discussed at a Consensus Workshop with 22 of the interviewees and eight other experts. Results: Generic or disease-specific plans exist in the participating countries and cross-border communications during outbreaks were generally reported as satisfactory. However, surveillance systems are of uneven quality, and clinical expertise for the two diseases is limited by a lack of experience. Serious breaches of protocol have recently been reported from companies producing poliomyelitis vaccines, and vaccine coverage rates for both diseases were also sub-optimal. A set of suggested good practices to address these and other challenges is presented. Conclusions: Poliomyelitis and measles should be brought fully onto the policy agendas of all EU/EEA Member States, and adequate resources provided to address them. Each country must abide by the relevant commitments that they have already made.

The Development of Public Policies to Address Non-communicable Diseases in the Caribbean Country of Barbados: The Importance of Problem Framing and Policy Entrepreneurs.

BACKGROUND: Government policy measures have a key role to play in the prevention and control of non-communicable diseases (NCDs). The Caribbean, a middle-income region, has the highest per capita burden of NCDs in the Americas. Our aim was to examine policy development and implementation between the years 2000 and 2013 on NCD prevention and control in Barbados, and to investigate factors promoting, and hindering, success. METHODS: A qualitative case study design was used involving a structured policy document review and semi-structured interviews with key informants, identified through stakeholder analysis and 'cascading.' Documents were abstracted into a standard form. Interviews were recorded, transcribed verbatim and underwent framework analysis, guided by the multiple streams framework (MSF). There were 25 key informants, from the Ministry of Health (MoH), other government Ministries, civil society organisations, and the private sector. RESULTS: A significant policy window opened between 2005 and 2007 in which new posts to address NCDs were created in the MoH, and a government supported multi-sectoral national NCD commission was established. Factors contributing to this government commitment and funding included a high level of awareness, throughout society, of the NCD burden, including media coverage of local research findings; the availability of policy recommendations by international bodies that could be adopted locally, notably the framework convention on tobacco control (FCTC); and the activities of local highly respected policy entrepreneurs with access to senior politicians, who were able to bring together political concern for the problem with potential policy solutions. However, factors were also identified that hindered multi-sectoral policy development in several areas, including around nutrition, physical activity, and alcohol. These included a lack of consensus (valence) on the nature of the problem, often framed as being predominantly one of individuals needing to take responsibility for their health rather than requiring government-led environmental changes; lack of appropriate detailed policy guidance for local adaptation; conflicts with other political priorities, such as production and export of alcohol, and political reluctance to use legislative and fiscal measures. CONCLUSION: The study's findings indicate mechanisms to promote and support NCD policy development in the Caribbean and similar settings.

Parental Consent and Access to Oral Health Care for Adolescents.

While most states allow minors 12 years and older to consent to services for contraception, prenatal care, or sexually transmitted infections, the same adolescents are required to have parental consent for even preventive oral health care. Many adolescents are denied access to preventive oral health care because of the challenge of securing parental consent for care when parents are unwilling, unable, or unavailable to consent. Our purpose is to examine the barriers to preventive oral health care for U.S. adolescents related to parental consent laws, explore the issues surrounding these laws, and recommend policy changes. We explain the current range and status of consent laws across the country and arguments for parental consent law as it now stands. We discuss the difficulty of applying general medical consent law to preventive oral health care, neuroscience research on cognitive capacity among adolescents, and the distinction between parental consent and adolescent assent. We recommend replacing required "opt-in" consent with simpler "opt-out" consent; developing a tool for assessing adolescent decision-making capacity; advocating for consent laws that apply specifically to preventive oral health care; and empowering school nurses to lead local, state, and nationwide policy and legislation efforts.

[Does the Prevention Act Improve Prevention in Pediatric Outpatient Settings!?] / Mehr Prävention durch das Präventionsgesetz in der kinder- und jugendärztlichen Praxis!?

Aim of the study: The Prevention Act was adopted by the German Federal Parliament on 18.06.2015. The paediatric practice is an important place from which to reach out to children and teenagers and to positively influence them through targeted prevention services in their health-related behaviour. It is therefore an important setting for the implementation of the Prevention Act. Could the delegation of prevention services to qualified medical assistants promote the successful implementation of the Prevention Act? Since 2003, medical assistants have qualified as "Prevention Assistants" after completing training courses and offered support in preventive services to children and teenagers in the paediatrician's office. The aim of this study was to improve the effectiveness of the training to increase the competence of the participants, expansion of preventive services for children and teenagers in the paediatrician's office and reduction of physician workload. Methodology: Training was accompanied by ongoing evaluation; there were two extensive studies in 2009 and 2011, respectively. Between 2003 and 2006 (n=126, after 75% response rate) and in 2011 (n=119 after 24% response rate), participants were assessed with standardized questionnaires, and in the survey of 2011, their employers also were interviewed, (n=76, after 22% response rate). Results: The prevention assistants assess their learning successes as good and are able to take over delegated tasks in the paediatrician's office. The involvement of a trained prevention assistant contributed to the transformation and re-establishment of prevention offers in paediatrician's offices and reduced physician workload. 44% of physicians felt that the time saved by prevention assistant was very good or good, 80% of physicians surveyed also indicated that prevention assistants carried out preventive consultations in the doctor's office. Conclusion: In light of the paediatricians' workload and their own wishes and demands, and for a targeted implementation of the Prevention Act, it is necessary to delegate preventive services to trained personnel. It is also possible to accomplish this task. It is necessary to introduce billing numbers in the fee schedule for doctors similar to the billing numbers for dental health prophylaxis.

[The complaint of suspected occupational disease: news, critical issues and applicative suggestions]. / La denuncia di sospetta tecnopatia: novità e criticità normative, suggerimenti applicativi.

OBJECTIVES: The Legislative Decree n. 151 of 14 September 2015 lays down new provisions concerning the DPR 1124/65. The major developments occur with Article 53 of Presidential Decree 1124/65, which transfer the obligation to send the medical certificate, attached to the report of accident and occupational disease, from the employer to the physician - "every physician lends immediate assistance to an injured worker or to a worker that suffers from an occupational disease" - using telematic systems, either directly or through the health facilities. There are however residual critical issues not easily overcome by the general pratictioner or by the physician not specialist in occupational medicine, because of the impossibility of knowing the real occupational causative agents of disease and the production cycle. So, the general practitioner cannot properly study the link between damage to health and work. In addition, there are no indications for diseases not included by tables (DM 09.04.2008) and lists (DM 10.06.2014), which should be evaluated about the possible occupational origin. Moreover, there is no indication of reporting for the pathologies present in the tables of occupational diseases, but not included in the lists of the DM 10.06.2014, and for the diseases with nosological differences between the tables of occupational diseases and lists, as well as those that the doctor believed to be linked to exposure at work, although not included in the two documents (tables or lists). To date, there are other technical critical issues that the legislation seems to overlook. In any of the laws reported (and even in the recent legislation) is mentioned the key element essential to evaluate, according to technical and scientific criteria, the first occupational origin attribution of a suspected technopathy: the results of an appropriate and specific risk assessment of the recognized causative agent. METHODS: We propose an operational way to create a technical and sustainable system of reporting suspicious technopathies. RESULTS: This system should be based on the figure and the role of occupational physician, both as a "competent" physician, according to the Legislative Decree n. 81/08 (in Italy), both as a doctor inserted in the community and hospital health services (in Lombardy these services are organized in the Health Protection Agencies - ATS - and in the Operative Unit Hospital of Occupational Medicine (UOOML of socio-territorial health companies - ASST). CONCLUSIONS: Complementarily, an organized reporting system should be based on risk assessment (according to art. 17 of Legislative Decree n. 81/08). Other aims are to overcome outdated practices, create a constant channel of dialogue between the territorial and the hospital health centers, send and capture in a structured and efficient way reports of technopathy, track all occupational disease reports and create a dedicated archive.

The ACA's Zero Cost-Sharing Mandate and Trends in Out-of-Pocket Expenditures on Well-Child and Screening Mammography Visits.

BACKGROUND: Starting in September of 2010, the Patient Protection and Affordable Care Act required most health insurance policies to cover evidence-based preventive care with no cost-sharing (no copays, coinsurance, or deductibles). It is unknown, however, whether declines in out-of-pocket costs for preventive services are large enough to prompt increases in utilization, the ultimate goal of the policy. METHODS: In this study, we use a nationally representative sample of ambulatory care visits to estimate the impact of the zero cost-sharing mandate on out-of-pocket expenditures on well-child and screening mammography visits. Estimates are made using 2-part interrupted time-series models, with well-woman visits serving as the control group because they were not covered under the zero cost-sharing mandate until after our study period. RESULTS: Results indicate a substantial reduction in out-of-pocket costs attributable to the Affordable Care Act. Between January 2011 and September 2012, the zero cost-sharing mandate reduced per-visit out-of-pocket costs for well-child visits from $18.46 to $8.08 (56%) and out-of-pocket costs for screening mammography visits from $25.43 to $6.50 (74%). No reduction was apparent for well-woman visits. CONCLUSIONS: The Affordable Care Act's zero cost-sharing mandate for preventive care has had a large impact on out-of-pocket expenditures for well-child and mammography visits. To increase preventive service use, research is needed to better understand barriers to obtaining preventive care that are not directly related to cost.

[Impact of the Core Training Law on preventive medicine and public health training and other common medical specialties]. / Impacto del Real Decreto de la Troncalidad en la formación en medicina preventiva y salud pública y en otras especialidades del tronco común médico.

OBJECTIVE: The purpose of the Core Training Law (CTL) is to amend specialised medical training to include 24 months of common training. The aim of this study is to assess its potential impact on the Preventive Medicine and Public Health (PM&PH) training programme and other medical specialties. METHOD: The programmes of the 21 common medical specialties were analysed and the recommended training periods for each specialty collected, before the information was agreed upon by three observers. The training impact was calculated as the percentage of months that should be amended per specialty to adapt to the common training schedule. RESULTS: The Preventive Medicine and Public Health training programme is the specialty most affected by the Core Training Law (100%, 24 months). Intensive medicine (0%, 0 months) and medical oncology (17%, 4 months) is the least affected. CONCLUSIONS: The CTL affects the common medical specialties in different ways and requires a complete reorganisation of the activities and competencies of PM&PH professionals.

[The new German prevention act: an effective strategy?]. / Das neue Präventionsgesetz: ein Schritt in die richtige Richtung?

The new German prevention act attempts to deal with the influx of obesity and chronic diseases by educating and informing. It seeks to change individual behaviour and supress lifestyle-related risk factors. In the past, however this behavioural prevention strategy has proved ineffective. A structural prevention strategy, as requested by the WHO, should additionally be put into effect with measures that reach all walks of life, not just the health-conscious people in society. It proposes the following: · At least one hour of daily physical activity or sport at school and kindergarten. · A differential food tax that makes unhealthy foods more expensive and healthy foods cheaper (taxing sugary / fatty foods). · Mandatory quality standards for kindergarten and school meals. · Banning food advertising targeted at children.

[Conflicting Rules and Incentives for Health Promotion and Prevention in the German Statutory Health Insurance (GKV)]. / Normen- und Anreizkonflikte für die gesetzlichen Krankenkassen in Gesundheitsförderung und Prävention.

OBJECTIVES: This study examines what role the German statutory health insurance (GKV) has in health promotion and prevention, if regulations and incentives are consistent, and if the politically-intended strengthening of prevention has been achieved. METHODS: We compiled the regulations and incentives of the German Sozialgesetzbuch V as the legal basis for health promotion and prevention of the GKV and studied their effects and interactions. Using annual financial reports of GKV we determined how the spending in prevention overall and in specific fields of prevention has -developed. RESULTS: The responsibilities of the GKV in health promotion and prevention lack a clear scientific foundation. Regulations have been incrementally added following changing ideas in prevention and health promotion policies. Currently, different norms and a variety of incentives lead to inconsistent and conflicting aims. Only 2% of all expenditures of the GKV are for health promotion and prevention, mainly spent for medical measures like preventive medical check-ups or vaccination. While spending of the GKV in general is rising, expenditures for prevention have decreased since 2009. CONCLUSIONS: There is a need to harmonise the different regulations in health promotion and prevention and to correct currently inconsistent incentives in the GKV. Given the similar evidence base there seems to be no reason why responsibilities for health promotion and primary, secondary or tertiary prevention should be regulated by different normative constructs. Incentives should account for the different aims of health insurers and their members. Financial incentives to increase spending in prevention may be particularly effective when there is no short-term -financial interest for the health insurer.

Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans Pacific Partnership Agreement.

The Trans Pacific Partnership Agreement (TPPA) is one of a new generation of 'deep' preferential trade and investment agreements that will extend many of the provisions seen in previous agreements. This paper presents a prospective policy analysis of the likely text of the TPPA, with reference to nutrition policy space. Specifically, we analyse how the TPPA may constrain governments' policy space to implement the 'policy options for promoting a healthy diet' in the World Health Organization's Global Action Plan for Prevention and Control of Noncommunicable Diseases (NCDs) 2013-2020. This policy analysis suggests that if certain binding commitments are made under the TPPA, they could constrain the ability of governments to protect nutrition policy from the influence of vested interests, reduce the range of interventions available to actively discourage consumption of less healthy food (and to promote healthy food) and limit governments' capacity to implement these interventions, and reduce resources available for nutrition education initiatives. There is scope to protect policy space by including specific exclusions and/or exceptions during negotiation of trade and investment agreements like the TPPA, and by strengthening global health frameworks for nutrition to enable them to be used as reference during disputes in trade fora.

Arte, salud y prevención: primeras colaboraciones / Art, health and prevention: initial collaborations

Este artículo presenta un resumen de lo que han sido los 2 años de colaboración entre la Facultad de Bellas Artes de la Universidad Complutense de Madrid y el Organismo Autónomo Madrid Salud del Ayuntamiento de Madrid. Esta colaboración ha permitido el desarrollo de experiencias y proyectos conjuntos entre profesionales y perfiles muy diversos: profesionales de la salud (sexólogos, psiquiatras, enfermeras, etc.), profesores, investigadores, artistas y estudiantes de la Facultad de Bellas Artes. Resultado de ello han sido las siguientes experiencias que pueden considerarse como antecedentes de posibles futuras colaboraciones entre el arte, la salud y la prevención (AU)

This article presents a summary of the first 2 years of the collaboration between the Faculty of Fine Arts of the Universidad Complutense in Madrid and Madrid Health, an autonomous organism of Madrid Council. This collaboration has allowed the development of joint experiences and projects among distinct professionals with highly diverse profiles: health professionals (sexologists, psychiatrists, nurses, etc.), and teachers, researchers, artists and students in the Faculty of Fine Arts. As a result, these experiences could be the beginning of future collaborations between the arts, health and prevention (AU)