Our study suggests that federal estimates of deaths caused by smoking are not substantially altered by adjustment for behavioral and demographic factors associated with smoking beyond the current adjustment for age and sex. JAMA. 2000;284:706-712

We conducted an implementation science study of a community-based ART distribution program for HIV-positive female sex workers (FSW) whereby clients received ART services through community-based mobile and home-based platforms. We compared 6-month treatment-related outcomes in the community-based ART arm (N = 256) to the standard facility-based ART delivery arm (N = 253). Those in the intervention arm were more likely to have initiated ART (100.0% vs. 71.5%; p = 0.04), be currently taking ART at the 6-month visit (100.0% vs. 95.0%; p < 0.01), and less likely to have stopped taking ART for more than 30 days continuously (0.9% vs. 5.7%; p = 0.008) or feel high levels of internalized stigma (26.6% vs. 39.9%; p = 0.001). In the adjusted regression model, internalized stigma (adjusted OR [aOR]: 0.5; 95% CI 0.28-0.83) and receiving community-based ART (aOR: 208.6; 95% CI 12.5-3479.0) were significantly associated with ART initiation. Community-based ART distribution model can improve linkage to and adherence to ART over standard facility-based ART programs for FSWs.

BackgroundOral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers’ (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs’ knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.MethodsA self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.ResultsFew HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP.Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.ConclusionsPreparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs’ biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

This article reviews the epidemiologic studies of the association of ischemic heart disease risk and environmental tobacco smoke (ETS) exposure from a spouse who smokes. Seventeen studies (nine cohort, eight case-control) comprising more than 485,000 lifelong nonsmokers and 7,345 coronary heart disease (CHD) events were included in a meta-analysis. Together, these studies include 36% more CHD events and 58% more study subjects than were available for review by the U.S. Occupational Safety and Health Administration (OSHA) in 1994. The relative risk (RR) for fatal or nonfatal coronary events among never smokers married to smokers, compared to those whose spouses did not smoke, was RR = 1.25 (95% confidence interval [95% Cl], 1.17-1.33) across the combined studies. This association was statistically similar in men (RR = 1.24; 95% Cl, 1.15-1.32) and women (RR = 1.23; 95% Cl, 1.15-1.32); in studies of cohort (RR = 1.23; 95% Cl, 1.15-1.31) and case-control (RR = 1.47; 95% Cl, 1.19-1.81) design; in the United States (RR =1.22; 95% Cl, 1.13-1.30) and other countries (RR = 1.41; 95% Cl, 1.21-1.65); and in studies of fatal (RR = 1.22; 95% Cl, 1.14-1.30) and nonfatal (RR = 1.32; 95% Cl, 1.04-1.67) heart disease. In three studies that presented data separately for nonsmokers married to current or former smokers, the association was stronger when the spouses continued to smoke (RR = 1.16, 1.06-1.28) than with former smokers (RR = 0.98; 95% Cl, 0.89-1.08). The aggregate data are unlikely to be attributable to chance, publication bias, confounding, or misclassification of exposure. The evidence linking heart disease and ETS exposure from a spouse has become substantially stronger since OSHA first proposed including heart disease in its risk assessment of ETS in 1994. Key words: environmental tobacco smoke, heart disease. -Environ Health Perspect 107(suppl 6):841-846 (1999). http.//ehpnetl.niehs.nih.gov/docs/1999/suppl6/84 1-846thun/abstract. html

Children and youth affected by AIDS typically face a wide range of stressful events and circumstances, including poverty, the loss of caregivers and loved ones, having to drop out of school, the burden of adultlike responsibilities, and social isolation. Increasingly programs for orphans and vulnerable children are addressing not only their material and educational needs, but their psychosocial needs as well. Yet there has been little research on how to evaluate psychosocial support (PSS) programs and the impact of these programs on vulnerable youth's psychosocial well-being. This report presents findings from an exploratory study by the Regional Psychosocial Support Initiative (REPSSI) and Catholic Relief Services' Support to Replicable, Innovative Village/Community-level Efforts (STRIVE) Program of vulnerable youth living in and around Bulawayo, Zimbabwe. It describes their demographic characteristics, exposure to stress and trauma, and psychosocial well-being. The report also highlights the relationships between psychosocial well-being outcomes and exposure to stress and trauma, and the differences in psychosocial well-being between males and females, orphaned and nonorphaned youth, and younger and older adolescents. In addition, the report explores the relationships between exposure to different psychosocial support programs and measures of psychosocial well-being and distress. The report concludes with program and research implications. Methods First, formative qualitative research was conducted with youth and adults working with youth to determine local concepts, manifestations, and domains of well-being among youth. These findings, together with input from local youth and international research experts and psychologists, were used to draft a quantitative survey. After pre-testing and finalizing the survey, the researchers administered it to a cross-sectional sample of 1,258 orphans and vulnerable youth, ages 14 to 20. All of the youth fell into one of three intervention groups, or into a fourth comparison group. The intervention groups included (1) youth exposed to community PSS, (2) youth exposed to the Salvation Army Masiye Camp, a residential PSS program, and (3) youth who attended Masiye Camp and went on to become youth peer leaders. Youth in the comparison group had not been exposed to any known PSS program. Data analysis was conducted in three stages to: (1) produce a profile of the sample, (2) determine relationships between psychosocial measures and demographic characteristics of the sample, and (3) explore associations between participation by youth in PSS interventions and psychosocial outcomes. The cross-sectional design of the study does not allow for establishing a causal relationship between program exposure and psychosocial well-being measures. But, using multiple regression analysis, the researchers were able to explore differences in select psychosocial well-being variables (e.g., self-Despite widespread trauma, daily stress, and psychosocial distress, many youth maintained selfconfidence,...