Chemokine receptors on T cells are frequently categorized as functioning either in immune system homeostasis within lymphoid organs, or in peripheral inflammation. CXCR3 is in the latter category and is reported to be expressed selectively on Th1 cells. We found that CXCR3 was expressed in vivo on newly activated tonsillar CD4+ T cells. Using CD4+ T cells from cord blood, we found that CXCR3 was induced by cellular activation in vitro independently of the cytokine milieu, although on resting cells, expression was maintained preferentially on those that had been activated in type 1 conditions. In inflamed tonsils, CXCR3+CD4+ T cells were localized around and within germinal centers. The inference that CXCR3 has a role in germinal center reactions was supported by the finding that the CXCR3 ligand CXC chemokine ligand 9 was expressed in a pattern demarcating a subset of germinal centers both in tonsil and in lymph nodes from an HIV-infected individual. We next investigated the role of CXCR3 on peripheral effector/memory CD4+ T cells by comparing its pattern of expression with that of CCR5, another Th1-cell associated chemokine receptor. Analysis of cells directly from peripheral blood and after activation in vitro suggested that CXCR3 expression preceded that of CCR5, supporting a model of sequential induction of chemokine receptors during CD4+ T cell differentiation. Taken together, our data show that CXCR3 can be expressed at all stages of CD4+ T cell activation and differentiation, bridging central function in lymphoid organs and effector function in peripheral tissues.

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Pay-for-performance (P4P) programmes have been introduced in numerous developing countries with the goal of increasing the provision and quality of health services through financial incentives. Despite the popularity of P4P, there is limited evidence on how providers achieve performance gains and how P4P affects health system quality by changing structural inputs. We explore these two questions in the context of Rwanda's 2006 national P4P programme by examining the programme's impact on structural quality measures drawn from international and national guidelines. Given the programme's previously documented success at increasing institutional delivery rates, we focus on a set of delivery-specific and more general structural inputs. Using the programme's quasi-randomized roll-out, we apply multivariate regression analysis to short-run facility data from the 2007 Service Provision Assessment. We find positive programme effects on the presence of maternity-related staff, the presence of covered waiting areas and a management indicator and a negative programme effect on delivery statistics monitoring. We find no effects on a set of other delivery-specific physical resources, delivery-specific human resources, delivery-specific operations, general physical resources and general human resources. Using mediation analysis, we find that the positive input differences explain a small and insignificant fraction of P4P's impact on institutional delivery rates. The results suggest that P4P increases provider availability and facility operations but is only weakly linked with short-run structural health system improvements overall.

IMPORTANCE Based on mortality estimates for 32 causes of death that are amenable to health care, the US health care system did not perform as well as other high-income countries, scoring 88.7 out of 100 on the 2016 age-standardized Healthcare Access and Quality (HAQ) index.OBJECTIVE To compare US age-specific HAQ scores with those of high-income countries with universal health insurance coverage and compare scores among US states with varying insurance coverage. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study used 2016 Global Burden of Diseases, Injuries, and Risk Factor study results for cause-specific mortality with adjustments for behavioral and environmental risks to estimate the age-specific HAQ indices. The US national age-specific HAQ scores were compared with high-income peers (Canada, western Europe, high-