Fast Track Strategy Research Articles

Fast-Track Anesthesia for Cito Craniotomy Evacuation Hematoma Due to Temporoparietal Subdural Hemorrhagic Hematoma in a Pediatric Patient: A Case Report

Introduction: Subdural hematoma (SDH) in early childhood is a serious condition that requires immediate surgical intervention. Fast-track anesthesia is an approach that aims to speed up the patient's recovery after surgery. This case report presents the experience of fast-track anesthesia in a 4-month-old pediatric patient with SDH who underwent a cito craniotomy. Case presentation: A 4-month-old child with a history of head trauma due to shaking experienced recurrent seizures. CT scan examination showed left temporoparietal SDH with intraparenchymal hemorrhage. The patient was classified as ASA IIIE and underwent a cito craniotomy. A fast-track anesthesia strategy was implemented using rapid induction, multimodal analgesia, and strict fluid management. Conclusion: Fast-track anesthesia was successfully applied to pediatric patients with SDH undergoing cito craniotomy. This approach allows for a quicker recovery, reduces postoperative complications, and shortens the length of hospital stay.

Can India achieve UNAIDS’ target by 2030?

The world is embarking on a fast-track strategy to end the AIDS epidemic by 2030. UNAIDS is targeted towards achieving the 95-95-95 strategy by 2025. Scaling up prevention, testing and treatment services towards HIV/AIDS is paramount in achieving these targets. To understand the status of India in achieving these targets, review of trials registered in the CTRI registry was done and found that among the 155 included trials, most (n=45, 29%) of the trials were drug trails, few were vaccine trials (n=6, 3.8%). Out of 155 studies, forty-one (20%) were in line to reach UNAIDS’ targets. The primary focus of those studies was improving CD4 counts and suppression of viral load (third target of UNAIDS’) (n=12, 7.7%), and the minimal focus was on promoting treatment adherence (second target of UNAIDS’) (n=11, 7%) and promotion of HIV testing (first target of UNAIDS’) (n=4, 2.5%). As prevention is always better than care, research should be encouraged towards prevention of HIV, which in turn facilitates achieving UNAIDS’ 2025 and 2030 targets.

Quantitative Risk Assessment Model and Optimization in Infrastructure Fast-Track Construction Projects

The construction industry has extensively applied the fast-tracking approach to the demanding need for the fast delivery of infrastructure projects. However, the fast-track strategy might be threatened by distinctive risks or changes in risk characteristics that emerge when activities are overlapped (overlapping risks). This article proposes a risk assessment simulation model to quantify the economic impact of overlapping risks on fast-track infrastructure projects. The model uses Monte Carlo simulation and a proprietary engine solution for the optimization procedure. It quantifies the overlapping risk impacts in the project duration and cost that could originate in three different overlapping degrees and evaluates the optimal overlapping degree to reduce the impact of the overlapping risks. The model demonstration used a commercial renovation project. The results suggest that overlapping risks have a high potential impact on the total cost, although with a high probability of attaining the target duration. Eight top risks affected the total duration, cost, or both. The optimum overlapping to reduce the economic impact and achieve the target project duration combines different overlapping degrees. This study contribution is a model for fast-track projects considering overlapping risks, their impact characteristic as a distribution, and the potential relationship between these risks.

Scale-Up of HIV Antiretroviral Therapy and Estimation of Averted Infections and HIV-Related Deaths - Uganda, 2004-2022.

On January 28, 2003, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to address a single disease in history, was announced.* In April 2004, the first person in the world to receive PEPFAR-supported antiretroviral therapy (ART) was a man aged 34 years in Uganda. Effective ART reduces morbidity and mortality among persons with HIV infection (1) and prevents both mother-to-child transmission (MTCT) (2) and sexual transmission once viral load is suppressed to undetectable levels (<200 viral copies/mL) (3). By September 2022, more than 1.3 million persons with HIV infection in Uganda were receiving PEPFAR-supported ART, an increase of approximately 5,000% from September 2004. As indicators of the ART program's effectiveness, a proxy MTCT rate decreased 77%, from 6.4% in 2010 to 1.5% in 2022, and the viral load suppression rate (<1,000 viral copies/mL) increased 3%, from 91% in 2016 to 94% in September 2022. During 2004-2022, ART scale-up helped avert nearly 500,000 HIV infections, including more than 230,000 infections among HIV-exposed infants, and approximately 600,000 HIV-related deaths. Going forward, efforts will focus on identifying all persons with HIV infection and rapidly linking them to effective ART. PEPFAR remains committed to continued strong partnership with the Government of Uganda, civil society, and other development partners toward sustainable solutions aligned with the Joint United Nations Programme on HIV/AIDS (UNAIDS) fast-track strategy to ending the global AIDS epidemic by 2030† and safeguarding impact achieved in the long term.

Review of antiretroviral therapy coverage in 10 highest burden HIV countries in Africa: 2015-2020.

Africa is responsible for two-thirds of the global total of new HIV infections. South Africa, Nigeria, Mozambique, Uganda, Tanzania, Zambia, Zimbabwe, Kenya, Malawi, and Ethiopia were responsible for 80% of HIV cases in Africa in 2014 according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). This study assesses antiretroviral coverage strategies implemented by these countries after the initiation of the "Fast-Track strategy to end the AIDS epidemic by 2030." Data reported in this review were obtained from different e-bibliographic including PubMed, Google Scholar, and Research Gate. Key terms were "Antiretroviral therapy,""Antiretroviral treatment,""HIV treatment," "HIV medication,""HIV/AIDS therapy,""HIV/AIDS treatment" + each of the countries listed earlier. We also extracted data on antiretroviral therapy(ART) coverage from the UNAIDS database. About 50 papers published from 2015 to 2021 met the inclusion criteria. All 10 countries have experienced an increase in ART coverage from 2015 to 2020 with an average of 47.6% increment. Nigeria recorded the highest increase in the rate of ART coverage (72% increase) while Ethiopia had the least (30%). New strategies adopted to increase ART coverage and retention in most countries were community-based models and the use of mobile health technology rather than clinic-based. These strategies focus on promoting task shifting, door-to-door access to HIV services, and a long-term supply of antiretroviral medications. Most of these strategies are still in the piloting stage. However, some new strategies and frameworks have been adopted nationwide in countries like Mozambique, Tanzania, Zambia, Zimbabwe, Kenya, and Malawi. Identified challenges include lack of funding, inadequate testing and surveillance services, poor digital penetration, and cultural/religious beliefs. The adoptionof community-based and digital health strategies could have contributed to increased ART coverage and retention. African countries should facilitate nationwide scaling of ART coverage strategies to attain the 95-95-95 goal by 2030.

Implementasi Kebijakan Tatalaksana HIV di Puskesmas Kabupaten Sleman

Background: HIV AIDS is still a global and national challenge. The government is trying to control it by expanding access to HIV treatment at the Puskesmas, including 4 Puskesmas in Sleman Regency. However, efforts to expand access to treatment have not yet reached the target of 95% of people living with HIV who are receiving ART and 95% of people living with HIV who are viral loadsuppressed. WHO in 2017 recommended the immediate initiation of diagnosed HIV-positive people regardless of CD4 cell count and followed by changes in the national HIV management policy through a fast-track strategy in 2018 to provideimmediate initiation of ARVs, provision of Tuberculosis Preventive Therapy, and viral load monitoring. The rapid change in HIV management strategies raises the question of whether the Puskesmas in Sleman Regency can carry out HIVmanagement according to the latest policy recommendations in achieving the target of 90% of people living with HIV who are suppressed by viral load. Objectives: Measuring the suitability of the implementation of HIV management at the Puskesmas based on regulations and finding the supporting factors and obstacles in the implementation of HIV management at the Puskesmas.Methods: This is mixed-method research with a sequential explanatory approach. The location of research was carried out in four health centres in Sleman Regency, which had organized the HIV Treatment Support Care Service Program. Data was collected in May-June 2022. Quantitative data was secondary data on cases of people with HIV who accessed PDP services registered at the Puskesmas from 2019 until July 2021. Qualitative data were taken from 9 informants, selected by the purposive sampling method, through in-depth interviews. The quantitative sampling method uses a non-probability sampling method. Results: There is a discrepancy in the suitability of treatment at the Puskesmas with management standards according to regulations, as well as the low number of people living with HIV who are monitored for viral load suppression. The inhibiting factor for implementing HIV management in Puskesmas is the attitude of health workers to delay treatment related to perceptions of HIV prevention policies that have not been well socialized. Not all service providers are trained,lack of viral load testing facilities in hospitals, inefficient HIV management records systems, and stigma are obstacles to implementing HIV management. The supporting factors for the implementation of PDP HIV are the attitude of the willingness of health workers to provide treatment related to the perception of peer support and the presence of trained officers in counseling and logisticalsupport for adequate drugs. Conclusion: Not all people living with HIV treated at the Puskesmas have received treatment according to regulations until viral load suppression is monitored. For this reason, it is necessary to increase the capacity of HIV counselingand management for all health workers involved in providing PDP services, adding viral load testing facilities at regional hospitals, and providing HIV stigma prevention programs for people living with HIV, families, communities and health services.

A training ground Lay out improves rehabilitation after trauma surgery: A Fast Track Policy

Abstract Fracture patients are frail and have high mortality. We investigated whether introducing a fast-track strategy during post-surgery care and including early rehabilitation protocols may shorten the length of hospital stay (LOS) while improving the overall clinical effectiveness. A training ground was built inside the inpatient area dedicated to trauma settings. Usual postoperative care consists of immobilization during the first day, but patients may start rehabilitation earlier, 24 hours after the surgical procedure, with a fast-track strategy. In general, gait speed, step length, and self-assessment in terms of mobility improve significantly in the first six postoperative weeks in fracture patients. As delayed postoperative mobility during hospitalization was observed, the established training ground may help with this concern. The expert physiotherapist may contribute to ameliorating the indicators showing great potential in postoperative rehabilitation regardless of fracture pattern. The primary outcome was postoperative physical functioning. Secondary outcomes included the patient’s assessment of therapeutic effect (overall improvement), perceived pain intensity, health services utilization, treatment side effects, and adverse events. Data were analyzed by univariate analysis and binary logistic regression showing a reduction of LOS of almost three days. Further, the optimized hip fracture program reduced the rate of in-hospital postoperative complications and mortality. Adding to the schedule, some PROMPTS (Patient-reported outcome measures) could further integrate the patient empowerment perspective into the quality set of values. For this reason, ‘fast track’ may define a crucial policy able to guarantee rapid rehabilitation, becoming a key factor to achieving a good clinical effect. Fast-track rehabilitation facilitates a shortened hospital stay and cost-saving and can be used to optimize the patient’s condition before admission to a rehabilitation facility Key messages • Early rehabilitation protocols may shorten the length of hospital stay (LOS) while improving the overall clinical effectiveness. • Human factors and patients empowerments may help.

Investigating racial disparities within an emergency department rapid-triage system

ObjectivesRacial disparities in emergency medical care are abundant, and processes aimed to increase throughput, such as a rapid triage fast-track (FT) systems, may exacerbate these inequities. A FT strategy may be more susceptible to implicit bias as subjective information is obtained quickly. We aim to determine whether a FT model was associated with greater disparities between Black and White emergency department (ED) patients. MethodsTriage-related outcomes were compared across race using a cohort selected from encounters in an ED that uses a FT model. White and Black patient encounters were exact-matched on potential confounders including sex; presence of abnormal vital signs; ED arrival time; insurance type; age category; and chief complaint. The primary triage-related outcome was use of the FT area (versus the main ED), and the secondary outcomes were wait time and assigned encounter acuity. ResultsEncounters for 5151 Black patients were exact-matched with 7179 encounters for White patients. Weights were applied to address differential numbers of encounters from each group. Within this matched cohort, Black patients were more likely to be triaged to FT than White patients (odds ratio = 1.28, 95% CI: 1.12; 1.46) and less likely to be given a high acuity score (odds ratio = 0.73, 95% CI: 0.66, 0.81). Among the high-acuity patients, Black patients were 40% more likely to be triaged to the FT area. ConclusionsThese results suggest that, after controlling for potential confounders, racial disparities may have been exacerbated in a FT ED triage process. In a FT model utilizing physicians and midlevel providers, this may create tiered levels of care between Black and White patients – an unacceptable side-effect of an effort to increase ED throughput.

Relevance of Fast-Track to Manage Overcrowding in Emergency Departments

This work aims to evidence the operability and effectiveness of using Fast-Track strategy to manage overcrowding in Emergency Departments. This study presents the results of a literature review on Fast-Track using database of the implementation of a Restructuring Project for the Implementation of Humanization in the Flow of Patients at Emergency Care Units (UPA-24h), developed by the Fluminense Federal University in partnership with the Brazilian Ministry of Health. Its results mainly reveal that overcrowding is a common phenomenon in hospitals, and that a Fast-Track approach has been widely used by hospital system managers to mitigate overcrowding impacts.

Ultrasound-Guided Core Biopsy for Tissue Diagnosis in Pediatric Oncology: 16-Year Experience With 597 Biopsies.

OBJECTIVE. Percutaneous imaging-guided core needle biopsies (CNBs) for cancer diagnosis in pediatric patients are gaining interest because of their availability, lower rate of complications, and high diagnostic power compared with traditional surgical biopsies. Nevertheless, their precise role in the diagnostic algorithm of pediatric oncology is still unknown. The purpose of this study was to report our accumulated 16-year experience with CNB; discuss the availability, safety, and diagnostic accuracy of the procedure and the adequacy of ancillary testing; and compare our findings with the available literature. MATERIALS AND METHODS. Pediatric ultrasound-guided CNBs performed in our hospital between November 2003 and December 2019 were retrospectively studied. Data collection included demographics, clinical and procedural parameters, complications, and final diagnosis. RESULTS. A total of 597 biopsies were performed in 531 patients (132 performed in known oncologic patients and 465 performed to establish diagnosis). The median time between the biopsy request and the procedure was 1 day. Of 432 biopsies performed in patients with malignancies, 12 (2.8%) had false-negative results. In 165 cases of benign pathologic findings, all had true-negative results. Ancillary testing was adequate in all malignant cases. Overall sensitivity, specificity, and accuracy rates were 97.2%, 100%, and 98.0%, respectively. Five biopsies (0.8%) resulted in complications, including one major bleed and one track seeding. CONCLUSION. Our experience shows that ultrasound-guided CNB for suspected malignancy in pediatric patients has a high safety profile, availability, and accuracy rate compared with surgical biopsy. Our fast-track strategy enables early initiation of designated therapy and has the potential to become the procedure of choice.

Structural insights of key enzymes into therapeutic intervention against SARS-CoV-2

COVID-19 pandemic, caused by SARS-CoV-2, has drastically affected human health all over the world. After the emergence of the pandemic the major focus of efforts to attenuate the infection has been on repurposing the already approved drugs to treat COVID-19 adopting a fast-track strategy. However, to date a specific regimen to treat COVID-19 is not available. Over the last few months a substantial amount of data about the structures of various key proteins and their recognition partners involved in the SARS-CoV-2 pathogenesis has emerged. These studies have not only provided the molecular level descriptions ofthe viral pathogenesis but also laid the foundation for rational drug design and discovery. In this review, we have recapitulated the structural details of four key viral enzymes, RNA-dependent RNA polymerase, 3-chymotrypsin like protease, papain-like protease and helicase, and two host factors including angiotensin-converting enzyme 2 and transmembrane serine protease involved in the SARS-CoV-2 pathogenesis, and described the potential hotspots present on these structures which could be explored for therapeutic intervention. We have also discussed the significance of endoplasmic reticulum α-glucosidases as potential targets for anti-SARS-CoV-2 drug discovery.

Increased HIV in Greater Kinshasa Urban Health Zones: Democratic Republic of Congo (2017\u20132018)

BackgroundDiagnosis of people living with HIV (PLHIV) is the first step toward achieving the new Fast Track Strategy to end AIDS by 2030: 95-95-95. However, reaching PLHIV is especially difficult in resource-limited settings such as the Democratic Republic of Congo (DRC), where reliable prevalence data is lacking. This study evaluated the prevalence of HIV in patients in the urban Kinshasa area.MethodsIndividuals seeking healthcare were tested for HIV between February 2017 and July 2018 at existing Kinshasa urban clinics. The study was conducted in two phases. Case finding was optimized in a pilot study phase using a modified cell phone-based Open\\Data Kit (ODK) collection system. HIV prevalence was then determined from data obtained between March–July of 2018 from 8320 individuals over the age of 18 years receiving care at one of 47 clinics in Kinshasa.ResultsThe prevalence of HIV in our study was 11.0% (95% CI 10.3–11.6%) overall and 8.14% in the subset of N = 1240 participants who were healthy mothers seeking prenatal care. These results are in sharp contrast to President's Emergency Plan for AIDS Relief (PEPFAR) estimates of 2.86%, but are consistent with data from surrounding countries.ConclusionWhile this data is sub-national and reflects an urban healthcare setting, given the large population of Kinshasa and rapidly changing age demographics, the results suggest that HIV prevalence in the DRC is substantially higher than previously reported.

Novel health system strategies for tuberculin skin test-guided Isoniazid preventive therapy

Abstract Background Global TB elimination demands a scale-up of Isoniazid preventive therapy (IPT) but tuberculin skin test (TST)-guided IPT poses great logistical and human resource challenges. Objectives Performance of TST self-reading by patients and fast-track TST reading by trained low cadre health care workers (task-shifting) was compared to formal TST reading by high cadre staff in a cohort of 278 South African adults living with HIV. Health economic impact of these novel strategies was assessed from a provider and societal perspective and simulations were performed for 5 other countries (USA, Germany, Brazil, India, Russia) to evaluate generalizability. In addition, accuracy of TST at antiretroviral treatment (ART) initiation was assessed by a repeat TST 6 and 12 month later. Results TST self-reading was highly accurate, with 89% sensitivity (95% CI 80, 95) and 100% specificity (95% CI 97,100) for detecting presence/absence of any induration. Agreement in TST reading between low and high cadre health care workers was very high (kappa 0.97). Compared to standard of care, a combined fast-track, task-shifting and self-reading strategy reduced TST reading costs in South Africa from a patient perspective by 81% and from a provider perspective by 92%. In all 5 countries simulated, TST reading cost was reduced by ≥ 78 % from a provider perspective. Repeat testing at 6 and 12 months showed high (31%, 95% CI 23, 40) TST conversion during the first 12 months of ART. Conclusions Empiric IPT for all people living with HIV followed by TST assessment after 6 or 12 months to identify those in need for lifelong IPT could increase the effectiveness of IPT programs. TST self-reading to reduce the number of patients that need to return for TST reading (to only those patients with self-determined presence of any induration) together with fast-tracking and task-shifting of TST reading could increase cost-effectiveness and reduce patient costs associated with IPT programs. Key messages Novel strategies are essential to control TB. Task-shifting, fast-tracking and patient TST self-reading empower patients and HCWs; optimal TST timing can increase cost-effectiveness of IPT programs.

Bahamas National Implementation Project: Proposal for Sustainability of an Evidence-based HIV Prevention Intervention in a School Setting.

BackgroundSustained implementation of school-based prevention programs is low. Effective strategies are needed to enhance both high-level implementation fidelity and sustainability of prevention programs.ObjectiveThis proposed study aims to determine if the provision of either biweekly monitoring and feedback and site-based assistance and mentorship or both to at-risk and moderate-performing teachers with monitoring through an enhanced decision-making platform by the Ministry of Education (MOE) and Ministry of Health (MOH) based on the real-time implementation data will increase national implementation fidelity and result in sustained implementation over time.MethodsThis study will target government schools including 200 grade 6 teachers in 80 primary schools and 100 junior/middle high school teachers (and their classes) on 12 Bahamian islands. Teacher and school coordinator training will be conducted by the MOE in year 1, followed by an optimization trial among teachers in the capital island. Informed by these results, an implementation intervention will be conducted to train using different levels of educational intensity all at-risk and moderate-performing teachers. Subsequently selected training and implementation strategies will be evaluated for the national implementation of Focus on Youth in the Caribbean and Caribbean Informed Parents and Children Together in years 2 to 5.ResultsIt is hypothesized that a more intensive training and supervision program for at-risk and moderate-performing teachers will enhance their implementation fidelity to the average level of the high-performing group (85%), an HIV prevention program delivered at the national level can be implemented with fidelity in grade 6 and sustained over time (monitored annually), and student outcomes will continue to be highly correlated with implementation fidelity and be sustained over time (assessed annually through grade 9). The proposed study is funded by the National Institute of Child Health and Human Development from August 1, 2018, through May 31, 2023.ConclusionsThe study will explore several theory-driven implementation strategies to increase sustained teacher implementation fidelity and thereby increase the general public health impact of evidence-based interventions. The proposed project has potential to make significant contributions to advancing school-based HIV prevention research and implementation science and serve as a global model for the Fast Track strategy.International Registered Report Identifier (IRRID)PRR1-10.2196/14816

Autonomy in HIV testing: a call for a rethink of personal autonomy in the HIV response in sub-Saharan Africa.

The author reviews various conceptions of autonomy to show that humans are actually not autonomous, strictly speaking. He argues for a need to rethink the personal autonomy approaches to HIV testing in sub-Saharan Africa (SSA) countries. HIV/AIDS has remained a leading cause of disease burden in SSA. It is important to bring this disease burden under control, especially given the availability of current effective antiretroviral regimens in low- and middle-income countries. In most SSA countries the ethic or value of personal autonomy or self-determination is promoted as primary in HIV testing decision-making. SSA policymakers have an ontological and moral duty to adopt HIV testing policies that reflect human and medical realities, relationships, local contexts, and respect human rights for both individuals and others who are affected by HIV in society. Without rethinking the value of autonomy in HIV testing decision-making, the article cautions that attainment of the Sustainable Development Goal (SDG) 3 and the UNAIDS fast-track strategy that explicitly call to end the epidemic by 2030 will not be feasible for SSA.

IMPLEMENTATION OF FAST-TRACK PROGRAM FOR STOMA REVERSAL PROCEDURES

AIM: evaluation of the effectiveness of the enhanced recovery protocol for stoma reversal procedures.PATIENTS AND METHODS: a single-center retrospective analysis of stoma reversal surgery in 130 ostomy patients in 2012-18 was performed. From 2012 to 2015, 56 (43.1%) patients were treated before the implementation of the Enhanced Recovery After Surgery (ERAS) protocol in clinical practice, 74(56.9%) patients were treated in accordance with the principles of fast-track.RESULTS: the introduction into clinical practice of the ERAS protocol reduced postoperative complications from 8.5% to 5.4% (p=0.002) and the hospital stay from 16,3±9,4 to 11,4±4,2 days (p=0.003).CONCLUSION: the fast-track strategy is an effective way to improve the results of stoma reversal procedures.

Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study

Background and objectivesAlthough high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact...

Applying user preferences to optimize the contribution of HIV self-testing to reaching the "first 90" target of UNAIDS Fast-track strategy: results from discrete choice experiments in Zimbabwe.

IntroductionNew HIV testing strategies are needed to reach the United Nations’ 90‐90‐90 target. HIV self‐testing (HIVST) can increase uptake, but users’ perspectives on optimal models of distribution and post‐test services are uncertain. We used discrete choice experiments (DCEs) to explore the impact of service characteristics on uptake along the testing cascade.Methods DCEs are a quantitative survey method that present respondents with repeated choices between packages of service characteristics, and estimate relative strengths of preferences for service characteristics. From June to October 2016, we embedded DCEs within a population‐based survey following door‐to‐door HIVST distribution by community volunteers in two rural Zimbabwean districts: one DCE addressed HIVST distribution preferences; and the other preferences for linkage to confirmatory testing (LCT) following self‐testing. Using preference coefficients/utilities, we identified key drivers of uptake for each service and simulated the effect of changes of outreach and static/public clinics’ characteristics on LCT.ResultsDistribution and LCT DCEs surveyed 296/329 (90.0%) and 496/594 (83.5%) participants; 81.8% and 84.9% had ever‐tested, respectively. The strongest distribution preferences were for: (1) free kits – a $1 increase in the kit price was associated with a disutility (U) of −2.017; (2) door‐to‐door kit delivery (U = +1.029) relative to collection from public/outreach clinic; (3) telephone helpline for pretest support relative to in‐person or no support (U = +0.415); (4) distributors from own/local village (U = +0.145) versus those from external communities. Participants who had never HIV tested valued phone helplines more than those previously tested. The strongest LCT preferences were: (1) immediate antiretroviral therapy (ART) availability: U = +0.614 and U = +1.052 for public and outreach clinics, respectively; (2) free services: a $1 user fee increase decreased utility at public (U = −0.381) and outreach clinics (U = −0.761); (3) proximity of clinic (U = −0.38 per hour walking). Participants reported willingness to link to either location; but never‐testers were more averse to LCT. Simulations showed the importance of availability of ART: ART unavailability at public clinics would reduce LCT by 24%.ConclusionsFree HIVST distribution by local volunteers and immediately available ART were the strongest relative preferences identified. Accommodating LCT preferences, notably ensuring efficient provision of ART, could facilitate “resistant testers” to test while maximizing uptake of post‐test services.

TRADITIONAL FASTING CESAREAN SECTION: WHAT IS GOOD AND WHAT IS BAD?

Delivery by cesarean section can be considered as a risk factor for developing hypoglycemia in the early neonatal period, as it is preceded by a period of pre-operative fasting. One of the important components of the “fast track” concept, which is actively introduced into surgery, is “rapid metabolic optimization” aimed at reducing the period of pre-operative fasting and activating intracellular glucose transport by using combined carbohydrate-protein-glutamine drinks for the purpose of prevention of insulin resistance. The aim of the study was to determine the influence of the methods of the management in the perioperative period during abdominal delivery on the level of glucose in the blood of the puerpera and in the blood of full-term newborns Material and methods. The study was approved at the meeting of the ethical committee of the Dagestan State Medical University of the Ministry of Health of Russia on April 17, 2018. In total, in the study there were included 87 patients, whose delivery was performed in term in the Perinatal Center of the Dagestan Republican Hospital by abdominal mode and their newborns; of them, 39 patients with a common perioperative period management regimen made up a comparison group, and 48 - with abdominal delivery in the fast track strategy (with carbohydrate load) - the main group. In all puerperas the glucose level was determined in blood obtained from the vein, in the blood from the umbilical cord and in the blood taken from the newborns from the finger in the first 6 to 15 minutes of life, using the ROKI-6T biochemical analyzer. Results. The concentration of glucose in the blood of full-term newborns it was found to be significantly reduced during the management of the preoperative period without oral administration of carbohydrate mixtures. The best results were obtained in newborns whose mothers took a carbohydrate drink 2 hours prior to surgery during the perioperative period under the concept of fast track.

The economic returns of ending the AIDS epidemic as a public health threat

BackgroundIn 2016, countries agreed on a Fast-Track strategy to “end the AIDS epidemic by 2030”. The treatment and prevention components of the Fast-Track strategy aim to markedly reduce new HIV infections, AIDS-related deaths and HIV-related discrimination. This study assesses the economic returns of this ambitious strategy. MethodsWe estimated the incremental costs, benefits and economic returns of the Fast-Track scenario in low- and middle-income countries, compared to a counterfactual defined as maintaining coverage of HIV-related services at 2015 levels. The benefits are calculated using the full-income approach, which values both the changes in income and in mortality, and the productivity approach. FindingsThe incremental costs of the Fast-Track scenario over the constant scenario for 2017–2030 represent US$86 billion or US$13.69 per capita. The full-income valuation of the incremental benefits of the decrease in mortality amounts to US$88.14 per capita, representing 6.44 times the resources invested for all countries. These returns on investment vary by region, with the largest return in the Asia-Pacific region, followed by Eastern and Southern Africa. Returns using the productivity approach are smaller but ranked similarly across regions. InterpretationIn all regions, the economic and social value of the additional life-years saved by the Fast-Track approach exceeds its incremental costs, implying that this strategy for ending the AIDS epidemic is a sound economic investment.