To estimate per-person and aggregate direct medical costs of overweight and obesity and to examine the effect of study design factors. PubMed (1968-2009), EconLit (1969-2009) and Business Source ...Premier (1995-2009) were searched for original studies. Results were standardized to compute the incremental cost per overweight person and per obese person, and to compute the national aggregate cost. A total of 33 US studies met review criteria. Among the four highest-quality studies, the 2008 per-person direct medical cost of overweight was $266 and of obesity was $1723. The aggregate national cost of overweight and obesity combined was $113.9 billion. Study design factors that affected cost estimates included use of national samples vs. more selected populations, age groups examined, inclusion of all medical costs vs. obesity-related costs only, and body mass index cut-offs for defining overweight and obesity. Depending on the source of total national healthcare expenditures used, the direct medical cost of overweight and obesity combined is approximately 5.0% to 10% of US healthcare spending. Future studies should include nationally representative samples, evaluate adults of all ages, report all medical costs and use standard body mass index cut-offs.
HIV prevalence among cisgender female sex workers (FSW) and/or women who use drugs (WWUD) is substantially higher compared to similarly aged women. Consistent with PRISMA guidelines, we conducted the ...first systematic review on the pre-exposure prophylaxis (PrEP) continuum among FSW and/or WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting a PrEP related result among FSW and/or WWUD aged 18 + ; peer-reviewed; and published in English between 2012 and 2018. Our search identified 1365 studies; 26 met eligibility requirements, across the following groups: FSW (n = 14), WWUD (n = 9) and FSW-WWUD (n = 3). Studies report on at least one PrEP outcome: awareness (n = 12), acceptability (n = 16), uptake (n = 4), and adherence (n = 8). Specific barriers span individual and structural levels and include challenges to daily adherence, cost, and stigma. Combining health services and long-acting PrEP formulas may facilitate better PrEP uptake and adherence. The limited number of studies indicates a need for more research.
Transgender women who sell sex (TWSS) experience high rates of HIV acquisition. Antiretrovirals for pre-exposure prophylaxis (PrEP) represent an efficacious HIV prevention strategy. The social and ...structural factors affecting PrEP delivery amongst TWSS are underexplored in the literature. We conducted ethnographic research to examine how multilevel social and structural factors manifest in TWSS's lived experiences and affect PrEP delivery and use. Twenty-four transgender women were recruited from the SAPPHIRE cohort and completed interviews focused on barriers and facilitators to PrEP engagement in the context of street-based sex work. Stakeholder interviews (N = 7) were also conducted. Our findings suggest there are unique features of the risk environment that can collectively impede PrEP use among TWSS.
The TOwards a Revolution in COPD Health (TORCH) study was a 3-yr multicentre trial of 6,112 patients randomised to salmeterol (Salm), fluticasone propionate (FP), a Salm/FP combination (SFC) or ...placebo (P). Here the cost-effectiveness of treatments evaluated in the TORCH study is assessed. For four regions, 3-yr all-cause hospitalisation, medication and outpatient care costs were calculated. The sample was restricted to the 21 countries (n = 4,237) in which European quality of life five-dimension (EQ-5D) data were collected in order to estimate the number of quality-adjusted life years (QALYs). Regression models were fitted to survival, study medication cost, other medication cost and EQ-5D data in order to estimate total cost, number of QALYs and cost per QALY, adjusted for missing data and region. SFC had a trial-wide estimate of cost per QALY of 43,600 US dollars (USD) compared with P (95% confidence interval 21,400-123,500 USD). Estimates for Salm versus P (197,000 USD) and FP versus P (78,000 USD) were less favourable. The US estimates were greater than those from other regions; for SFC versus P, the cost per QALY was 77,100 (46,200-241,700) USD compared to 24,200 (15,200-56,100) USD in Western Europe. Compared with P, SFC has a lower incremental cost-effectiveness ratio than either FP or Salm used alone, and is, therefore, preferred to these monotherapies on the grounds of cost-effectiveness.
•Studies report ART uptake (30–76 %) and adherence (27–95 %) ranges among WWUD globally.•Adherence measurement and uptake definition are not consistent across literature.•Substance use, psychiatric ...disorders, and side effects were primary ART barriers, few facilitators were identified.•Many ART barriers/facilitators were identified at the intrapersonal level.•More research is needed on ART barriers/facilitators at additional SEM levels.
To assess the state of peer-reviewed literature surrounding uptake and adherence of antiretroviral therapy (ART) among HIV-positive women who use drugs (WWUD).
Consistent with PRISMA-ScR guidelines, we conducted a scoping literature review on ART uptake and adherence among WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting at least one ART uptake or adherence related result among WWUD aged 18 or older; peer-reviewed; published in English between 1996–2018.
Our search identified 6735 studies; 86 met eligibility requirements. ART uptake ranged from 30 % to 76 % and adherence ranged from 27 % to 95 %. Substance use, co-morbid psychiatric disorders, and side effects emerged as the primary ART uptake and adherence barriers among this population. Few facilitators were identified.
This study is the first scoping review to look at ART uptake and adherence among WWUD globally. The wide range in uptake and adherence outcomes indicates the need for gold standard assessments, which may differ between high and low resource settings. This study offers rich insight into uptake and adherence barriers and facilitators, primarily at the intrapersonal level. More research is needed to examine interventions that focus on additional levels of the SEM (e.g., community and policy levels). These review findings can inform ART interventions, future research, and offer guidance to other support services with WWUD, such as PrEP interventions.
Despite growing availability, HIV pre-exposure prophylaxis (PrEP) uptake and adherence remains suboptimal among female sex workers (FSW) in the United States. Using cross-sectional data from a survey ...of 236 street-based cisgender FSW in Baltimore, Maryland, we examined interest in event-driven and long-acting PrEP formulations. Latent class analysis identified discrete patterns of interest in five novel PrEP agents. Multinomial latent class regression then examined factors associated with probabilistic class membership. A three-class solution emerged as the best-fit latent class model:
Injectable Acceptors
(~ 24% of sample),
Universal Acceptors
(~ 18%), and
Non-Acceptors
(~ 58%). Compared to
Non-Acceptors
,
Universal Acceptors
had significantly (
p
< 0.05) higher odds of reporting condomless vaginal sex with clients, client condom coercion, and client-perpetrated physical violence. Relative to
Non-Acceptors
,
Injectable Acceptors
were distinguished by significantly higher rates of condomless vaginal sex with clients and injection drug use. Expanding PrEP options for FSW could help overcome barriers to PrEP initiation and persistence.
Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive. The cost-effectiveness of treatment in primary care settings is particularly relevant.
We conducted a ...within-trial cost-effectiveness analysis of a primary care-based obesity intervention. Study participants were randomized to: Usual Care (UC; quarterly visits with their primary care provider); Brief Lifestyle Counseling (BLC; quarterly provider visits plus monthly weight loss counseling visits) or Enhanced Brief Lifestyle Counseling (EBLC; all above interventions, plus choice of meal replacements or weight loss medication). A health-care payer perspective was used. Intervention costs were estimated from tracking data obtained prospectively. Quality-adjusted life years (QALYs) were estimated with the EuroQol-5D. We estimated cost per kilogram-year of weight loss and cost per QALY.
Weight losses after 2 years were 1.7, 2.9 and 4.6 kg for UC, BLC and EBLC, respectively (P=0.003 for comparison of EBLC vs UC). The incremental cost per kilogram-year lost was $292 for EBLC compared with UC (95% confidence interval (CI): $219-$437). The short-term incremental cost per QALY was $115,397, but the 95% CI were undefined. Comparison of short-term cost per kg with published estimates of longer-term cost per QALY suggested that the intervention could be cost-effective over the long term (≥ 10 years).
A primary care intervention that includes monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term. However, additional studies are needed on the cost-effectiveness of behavioral treatment of obesity.
Background
The optimal BMI threshold above which gastric bypass surgery should be offered to obese patients is controversial. The objective of this study was to compare the impact of Roux-en-Y ...gastric bypass (RYGB) vs. diet and exercise (D&E) on life expectancy to find the BMI at which patients experience an improvement in their life expectancy by undergoing surgery.
Methods
A Markov state transition model was designed to implement a decision tree that simulated the lives of obese patients. Life expectancies following RYGB and 2 years of D&E were estimated and compared. Ten thousand patients’ lives were simulated in each weight-loss intervention group in the model. In addition to base case analysis (45 kg/m
2
BMI pre-intervention), sensitivity analysis of initial BMI at the start of the study was completed. Markov model parameters were extracted from the literature.
Results
The impact of RYGB on survival relative to D&E depended on the patient’s initial BMI. Compared to patients who underwent 2 years of “optimal” diet and exercise (7 % total body weight loss/year), RYGB improved long-term survival for patients above a BMI of 31.3 kg/m
2
.
Conclusions
Roux-en-Y gastric bypass can improve long-term survival for patients with class I obesity. This study suggests that RYGB should not be reserved solely for patients with class II or III obesity.
Pre-exposure prophylaxis (PrEP) has the potential to be an empowering HIV prevention tool among female sex workers (FSW), yet little is known about PrEP awareness and interest in this population. Sex ...workers and Police Promoting Health in Risky Environments (SAPPHIRE) is a prospective cohort study of street-based FSW in Baltimore, MD. A cross-sectional analysis explored awareness and interest in PrEP among HIV-negative FSW. Multivariable Poisson regressions modeled associations between individual, interpersonal, and structural variables and PrEP awareness and interest. Of n = 232 FSW, 66% were white, half were less than 35 years old, 59% injected drugs daily, and 66% sold sex daily. Only 21% of FSW were aware of PrEP, though 74% were interested. PrEP awareness was associated with experiencing client condom coercion adjusted incidence rate ratio (aIRR) = 0.50, 95% CI: 0.28-0.90 and condomless sex with an intimate partner (aIRR = 0.54, 95% CI: 0.30-0.98). PrEP interest was associated with perceiving PrEP as "very easy" to take (aIRR = 1.91, 95% CI: 1.49-2.45) and moving to an unfamiliar geographic area to sell sex (aIRR = 1.20, 95% CI: 1.04-1.39). Women who had a current gonorrhea or chlamydia infection were less likely to be interested in PrEP (aIRR = 0.75, 95% CI: 0.59-0.95). Though PrEP awareness among FSW is low, there are FSW who are significantly more likely to express interest in PrEP and outreach efforts should target these women. Results suggest that women-controlled HIV prevention methods may be important for reducing incidence among FSW.
We assessed acceptability of nonoral HIV pre-exposure prophylaxis (PrEP) formulations among transgender women (TW) engaged in street-based sex work in Baltimore, Maryland. In a
K
-means cluster ...analysis, TW (
N
=36) were partitioned into groups characterized by high interest in long-acting injectable PrEP only (
Injectable Enthusiasts
, 36%), high interest in injectables and subdermal implants (
Long-Acting Acceptors
, 36%), and low interest across PrEP formulations (
Non-Acceptors
, 28%). TW's interest in novel PrEP agents varied widely across formulations (range: 22–66%) and clustered around numerous relational, occupational, and structural factors, highlighting the importance of availing multiple PrEP formulations for this impacted population.
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