High Levels Of Marginalization Research Articles

The Cervical Cancer Treatment Gap in Mexico Under Seguro Popular, 2006-2016

ABSTRACT From 2005 to 2019, the Mexican government financed cervical cancer treatment for individuals without social security insurance through Seguro Popular’s Fund for Protection against Catastrophic Health Expenses. To better understand the impact of this program on access to treatment, we estimated the cervical cancer treatment gap (the proportion of patients with cervical cancer in this population who did not receive treatment). To calculate the expected number of incident cervical cancer cases we used national surveys with information on insurance affiliation and incidence estimates from the Global Burden of Disease study. We used a national claims database to determine the number of cases whose treatment was financed by Seguro Popular. From 2006 to 2016, the national cervical cancer treatment gap changed from 0.61 (95% CI 0.59 to 0.62) to 0.45 (95% CI 0.43 to 0.48), with an average yearly reduction of −0.012 (95% CI −0.024 to −0.001). The gap was greater in states with higher levels of marginalization and in the youngest and oldest age groups. Although the cervical cancer treatment gap among individuals eligible for Seguro Popular decreased after the introduction of public financing for treatment, it remained high. Seguro Popular was eliminated in 2019; however, individuals without social security have continued to receive cancer care financed by the government in the same healthcare facilities. These results suggest that barriers to care persisted after the introduction of public financing for treatment. These barriers must be reduced to improve cervical cancer care in Mexico, particularly in states with high levels of marginalization.

Abstract 260: Sociodemographic Analysis of Paediatric Out-of-Hospital Cardiac Arrest in Ontario, Canada: A Province-Wide Case-Control Study

Background: Paediatric out-of-hospital cardiac arrest (POHCA) is associated with significant mortality and severe neurological sequelae. Previous literature indicates that there are sociodemographic disparities in POHCA survival and in the provision of upstream interventions. However, it’s unclear if the populations impacted by these disparities also have an elevated risk of experiencing POHCA. We sought to describe the relationship between sociodemographic factors and POHCA risk in Ontario, Canada. Methods: We conducted a province-wide case-control study using health administrative data at ICES. The case group included children (1 day to 17 years of age) who experienced an OHCA between 2004 and 2020. Controls were matched up to 1:4 on age, sex, index date, and key comorbidities. We used conditional logistic regression to measure the association between POHCA and neighbourhood-level marginalization indicators, geographical context, and immigration status. Results: The case and control groups included 1,826 and 7,254 children, respectively. Children living in areas with the highest levels of material deprivation (adjusted odds ratio, aOR: 2.35, 95% CI: 1.94, 2.85) and dependency (aOR: 1.23, 95% CI: 1.02, 1.49) had a higher odds of POHCA, relative to children living in regions with the lowest levels of material deprivation and dependency, respectively. Children living in neighbourhoods with the lowest levels of ethnic diversity had a higher odds of POHCA (aOR: 1.34, 95% CI: 1.08, 1.67), as compared to children living in neighbourhoods with the highest levels of ethnic diversity. Northern urban (aOR: 1.42, 95% CI: 1.11, 1.82) and southern rural residence (aOR: 1.27, 95% CI: 1.04, 1.55) were associated with a higher odds of POHCA, relative to southern urban residence. The odds of POHCA were lower in child immigrants (aOR: 0.60, 95% CI: 0.42, 0.85) and maternal immigrants (aOR: 0.70, 95% CI: 0.61, 0.81), relative to the general population. The impact of residential instability was not significant in adjusted analyses. Conclusion: Children living in neighbourhoods with high levels of marginalization are likely at an elevated risk of experiencing POHCA. These communities should be prioritized in POHCA prevention and intervention efforts.

Sociodemographic Factors and the Risk of Pediatric Out-of-Hospital Cardiac Arrest in Ontario, Canada: A Province-Wide Case-Control Study.

Pediatric out-of-hospital cardiac arrest (POHCA) is associated with significant mortality and poor neurological outcomes. We aimed to describe the association between sociodemographic factors and POHCA risk in Ontario, Canada. We conducted a province-wide case-control study at ICES, where patient records are linked across administrative databases. The case group included children (aged 1 day to 17 years) who experienced an out-of-hospital cardiac arrest between 2004 and 2020. Controls were matched up to 1:4 on age, sex, index date, and key comorbidities. We used conditional logistic regression to measure the association between sociodemographic indicators and POHCA risk. The case and control groups included 1826 and 7254 children, respectively. Children living in areas with the highest levels of material deprivation (adjusted odds ratio [aOR], 2.35 [95% CI, 1.94-2.85]) and dependency (aOR, 1.22 [95% CI, 1.01-1.48]) had a higher odds of POHCA, relative to children living in regions with the lowest levels of material deprivation and dependency, respectively. Children living in neighborhoods with the lowest levels of ethnic diversity had a higher odds of POHCA (aOR, 1.62 [95% CI, 1.30-2.01]), relative to children living in neighborhoods with the highest levels of ethnic diversity. The odds of POHCA were lower in immigrants (aOR, 0.67 [95% CI, 0.47-0.95]), relative to the general population. Northern urban residence was associated with a higher odds of POHCA (aOR, 1.45 [95% CI, 1.13-1.87]), relative to southern urban residence. Children living in neighborhoods with high levels of marginalization may have an elevated risk of experiencing POHCA. These findings highlight the importance of addressing disparities through targeted prevention and intervention efforts.

The effect of non-medical cannabis retailer proximity on use of mental health services for psychotic disorders in Ontario, Canada.

Cannabis is associated with the onset and persistence of psychotic disorders. Evidence suggests that accessibility of substances is associated with an increased risk of use-related harms. We sought to examine the effect of residing in proximity to non-medical cannabis retailers on the prevalence of health service use for psychosis. We conducted a cross-sectional study using linked health administrative data, and used geospatial analyses to determine whether people in Ontario, Canada (aged 14-60 years) resided within walking (1.6 km) or driving (5.0 km) distance of non-medical cannabis retailers (open as of February-2020). We identified outpatient visits, emergency department (ED) visits, and hospitalizations for psychotic disorders between 01-April-2019 and 17-March-2020. We used zero-inflated Poisson regression models and gamma generalized linear models to estimate the association between cannabis retailer proximity and indicators of health service use. Non-medical cannabis retailers were differentially located in areas with high levels of marginalization and pre-existing health service use for psychosis. People residing within walking or driving distance of a cannabis retailer had a higher rate of psychosis-related outpatient visits, ED visits, and hospitalizations, compared to people living outside these areas. This effect was stronger among those with no prior service use for psychosis. Proximity to a non-medical cannabis retailer was associated with higher health service use for psychosis, even after adjustment for prior health service use. These findings suggest that opening of non-medical cannabis retailers could worsen the burden of psychosis on mental health services in areas with high-risk populations.

Social Mobility and Vocational Outcomes: A Psychology of Working Perspective

The current study was aimed at understanding how social mobility relates to vocational outcomes. Drawing from Psychology of Working Theory (PWT), social mobility was operationalized as changes in experiences of economic constraints and marginalization between childhood and adulthood. We used latent profile analysis to create profiles among a sample of employed adults ( N = 533) and compared profile membership to PWT informed outcomes: work volition, career adaptability, and decent work. The five profiles of social mobility that emerged were as follows: sustained privilege (low levels of marginalization and economic constraints during childhood and adulthood), downward mobility (low levels of marginalization and economic constraints in childhood, high levels in adulthood), upward mobility (high levels of marginalization and economic constraints in childhood, low levels in adulthood), highly marginalized (high levels of marginalization at both points), and sustained barriers (high levels of marginalization and economic constraints in childhood and adulthood). Participants who belonged to the sustained privilege and upward mobility groups experienced greater work volition and decent work compared to those in groups who experienced higher levels of economic constraints and marginalization throughout their lives. Implications for research and practice are discussed.

From prison to work? Job-crime patterns for women in a precarious labor market

Finding and retaining a job is one of the most challenging problems women confront after being released from prison. Given the dynamic and fluid interactions between legal and illegal work, we argue that to better identify and describe job trajectories after release, we must simultaneously consider disparities in work types and offending behavior. We leverage a unique dataset – the Reintegration, Desistance and Recidivism Among Female Inmates in Chile study– to describe patterns of employment within a cohort of 207 women during the first year after being released from prison. By considering different types of work (i.e., self-employed/employed, legitimate/under-the- table) and including offending as another type of income-generating activity, we adequately account for the intersection between work and crime in a particularly understudied population and context. Our results reveal stable heterogeneity in employment trajectories by job type across respondents but limited overlap between crime and work despite the high levels of marginalization in the job market. We discuss the role of barriers to and preferences for certain types of jobs as possible explanations for our findings.

Regional Wealth with Biodiversity and Socioeconomic Marginality

Purpose. Mexico is a country with a richness in biodiversity and a high level of Natural Capital throughout the territory; however, the highest concentration is distributed in regions where a population with high levels of marginalization and socioeconomic poverty lives.
 Methodhology. The characteristics of genetic resources and their sustainable use in conservation require the establishment of cross-cutting strategies in the design and implementation of comprehensive public policies focused on society and the diversity of territories and social needs.
 Findings and originality. This reality highlights the relevance of identifying the main elements that characterize the Natural Capital in the environments, mainly in the South Pacific region due to its social and cultural importance. The originality of this document is the analysis of the socioeconomic and marginalization conditions of the population with the most incredible wealth in biodiversity and establish strategies that facilitate the conservation of genetic resources in tune with sustainable social and economic growth in the medium and long term.

Regional Wealth with Biodiversity and Socioeconomic Marginality


 
 
 Purpose. Mexico is a country with a richness in biodiversity and a high level of Natural Capital throughout the territory; however, the highest concentration is distributed in regions where a population with high levels of marginalization and socioeconomic poverty lives.
 Methodology. The characteristics of genetic resources and their sustainable use in conservation require the establishment of cross-cutting strategies in the design and implementation of comprehensive public policies focused on society and the diversity of territories and social needs.
 Findings and originality. This reality highlights the relevance of identifying the main elements that characterize the Natural Capital in the environments, mainly in the South Pacific region due to its social and cultural importance. The originality of this document is the analysis of the socioeconomic and marginalization conditions of the population with the most incredible wealth in biodiversity and establish strategies that facilitate the conservation of genetic resources in tune with sustainable social and economic growth in the medium and long term.
 
 

Social determinants for overweight and obesity in a highly marginalized population from Comitán, Chiapas, Mexico.

We assessed the prevalence of overweight and obesity and its association with some social determinants in a highly marginalized population in Mexico. Cross-sectional study conducted in Comitán, Chiapas, from 2010 to 2012, comprising 1 858 subjects aged ≥20 years. We evaluated proximal, intermediate, and structuralsocial determinants. The prevalence of overweight and obesity was 37.9 and 16.5%, respectively. The probability of overweight and obesity was higher in participants with ≥primary school, self-reported non-indigenous origin, and medium level of marginalization compared with those with <primary school, self-reported indigenous origin, and high/very high level of marginalization. The pro-bability of overweight and obesity was higher in population with more favorable social conditions, which may be partially explained by changes in the traditional lifestyle with greater access to high energy foods and physical inactivity.

Marginalization and fluorosis its relationship with dental caries in rural children in Mexico: A cross-sectional study.

Examine the association between marginalization and fluorosis with caries experience in Mexican rural children aged 8-12, in Oaxaca, Mexico. Cross-sectional study of 283 rural schoolchildren selected from two locations with high and medium levels of marginalization where the water fluoride concentration ranged from 2.0 to 2.5 ppm/F. Caries was evaluated using the DMFT index and dental fluorosis with the Thylstrup-Fejerskov Index (TFI). Socioeconomic data were collected from participants' parents, with data on the children's characteristics collected from them via a questionnaire. The prevalence of caries was 72.4% (DMFT ≥1) in the permanent dentition. The prevalence of fluorosis was 98.0% (TFI ≥4=71.4%). 54.8% of the children brushed their teeth two or more times daily. In logistic regression children living in high levels of marginalization were more likely to present caries (OR=2.11, 95% CI 1.13 - 3.93) than children living in medium levels. Children with severe fluorosis (TFI ≥4) (OR=1.93, 95% CI 1.06 - 3.53) were more likely have caries than those with TFI ⟨3. Rural children with a high level of marginalization and fluorosis (TFI ≥4) were more likely to present caries. Poor oral hygiene and low dental service levels were found in both marginalized areas. Populations with medium/high marginalization are more susceptible to caries.

Vulnerability in health and social capital: a qualitative analysis by levels of marginalization in Mexico

BackgroundSocial capital is employed as an asset when there is a lack of an efficient health-care system. However, this relationship is not homogeneous and can differ according to the characteristics of individuals and their context. In this paper, we aim to analyze the role of social capital in the solution of healthcare problems among individuals with different levels of marginalization and unequal access to health services.MethodsThis qualitative study examines the role of social capital in the demand for healthcare among Mexican individuals with different levels of marginalization. The research draws data from semi-structured interviews (N = 247) that were collected in four Mexican states with different social welfare benefits: Mexico City, Tamaulipas, the State of Mexico, and Oaxaca. The interviewees were selected using the snowball method and other eligibility criteria such as education, age, and gender.ResultsFindings suggest that social capital is a relevant factor in solving healthcare problems, depending on the level of marginalization. The role of social capital can be explained by the precariousness of medical service delivery, the poor health infrastructure, and the difficult access to health care in Mexico. Networks are the main resource to deal with health related issues, food, medicine, and out-of-the-pocket medical expenses in contexts of high levels of marginalization. In the middle level of marginalization, networks also help in raising funds for more-specialized medical services and higher quality hospitals. In the least-marginalized levels, social capital is used as companionship for sick individuals, while support networks act as emotional relief. At this level, most individuals have private health insurance, and many of them have major medical healthcare coverage.ConclusionsParticipants reported low levels of trust in the health care system because of the poor infrastructure and quality of medical service delivery. Although the main criticism is focused on public healthcare institutions, there is a lack of trust in private medical services as well. These facts are related to the access and quality of medical service delivery and turn social capital into a significant asset. Despite that social bonds or links are valuable resources that individuals can use to solve healthcare related issues, the use of social capital is not homogenous. Indeed, it can be influenced by several factors that were represented in this study through the municipal marginalization index.

El desarrollo sostenible a través de empresas sociales en comunidades indígenas de América Latina

Objetivo: explorar y describir el rol de las empresas sociales para impulsar el desarrollo sostenible de comunidades indígenas. Metodología: a través de un método cualitativo basado en una estrategia de investigación de estudio de caso, se analizaron dos empresas sociales indígenas ubicadas en Perú y México. El método principal de recolección de información fue la entrevista, y de forma secundaria la observación y el análisis de documentos. Resultados: el liderazgo local de ambas organizaciones busca involucrar y empoderar a la comunidad a través de distintas estrategias como empleo digno, creación de nuevas empresas, sensibilización ambiental, construcción de infraestructura, y nuevos mercados para productos locales. Además, la cosmovisión de cada grupo indígena permitió crear organizaciones alineadas a los valores y cultura de cada comunidad, potenciando las sinergias con los principales grupos de interés. El desarrollo de un ecosistema de emprendimiento ha permitido la creación de nuevas empresas que generan empleo digno, y han convertido a ambas comunidades en polos de desarrollo regional. Finalmente, la innovación social dirigida a la reducción del impacto ambiental negativo ha permitido legitimar las operaciones de las empresas, diversificar, y obtener certificaciones relacionadas con desarrollo sostenible. Limitaciones: la cosmovisión de cada comunidad indígena limita la utilidad de los resultados derivados de esta investigación en otros contextos culturales. La fase exploratoria del fenómeno invita a ser cautos al formular relaciones causales. Conclusiones: las lecciones derivadas de estas empresas sociales indígenas contribuyen a replantear lógicas largamente establecidas en el ámbito del desarrollo regional y la administración de empresas. Este trabajo contribuye a la literatura al analizar el papel de las empresas sociales en el desarrollo regional de comunidades indígenas, en cuya conversación existe poca evidencia empírica de América Latina, y más aún en un contexto con altos niveles de marginación y exclusión.

Climate change and flood risk: vulnerability assessment in an urban poor community in Mexico:

The impacts of climate change tend to be unevenly distributed, affecting mostly urban poor communities. This research analyses the case of El Colli, a community with high levels of marginalization ...

Climate change and flood risk: vulnerability assessment in an urban poor community in Mexico

The impacts of climate change tend to be unevenly distributed, affecting mostly urban poor communities. This research analyses the case of El Colli, a community with high levels of marginalization and urban poverty in an area characterized by informal settlements in the Metropolitan Area of Guadalajara (state of Jalisco, Mexico). The main objective was to analyse the vulnerability to climate change in El Colli, focusing on the flood risk it is exposed to and using a mixed-methods design with various research tools. The findings show the specific aspects of vulnerability in a context of urban poverty, in which basic municipal services are scarce, government action is inadequate and residents show a high acceptance of risk. Based on the data, we state the need to incorporate local urban challenges into the debate on climate change, particularly those affecting informal settlements.

English

The discovery and exploration of oil in Nigeria seems to have come with good tidings and hope for a better development but today the reverse is the case. Oil has brought agony and insecurity in the country, particularly the oil communities of the Niger Delta region. The high level of marginalization and negligence on the part of the government, the elite and the MNOCs has resulted in militancy, which has consequently inflicted the economic growth of Nigeria. Resource curse is used to examine how the perceive petro dollar turns out to bring curse on the country. Despite different response by the government to address the unrest in the oil rich Niger Delta,yet the insurgency persist. This has been attributed to a commandist and lack of proper consultation with people of the region. This paper therefore, calls for a meaningfulcorroboration between the major actors in the exploration of oil and the people in order to have lasting solution to the prevailing problem and as a consequence a meaningful ataraxia. Keywords : MNOCs, militancy, politics, Niger Delta, Nigeria.

Las mujeres y la salud sexual y reproductiva

Human reproduction has been a controversial and highly political issue from the historical point of view, which has gone from being a matter of public interest to a topic that has been addressed in international meetings, in which strategies to reduce fertility rates of the population through family planning methods have been discussed. In the state of Oaxaca, The situation of women's sexual and reproductive health, as well as the high levels of marginalization, has become aspects that make it difficult for the population to have access to the social benefits of health. In addition, the non-acceptance and use of contraceptives place the state with the highest maternal death rate in the country, a situation that is aggravated inequalities and the fact of being poor and indigenous.

Centroamericanos en el Sur-Sureste de México. La Construcción de una Región Migratoria

El presente estudio es un esbozo de la migración centroamericana en Oaxaca-México, considerando el periodo 2009- 2014 para el nivel nacional y el periodo 2012-2015 para el nivel local, se hizo uso de datos producidos principalmente por la Red de Documentación de las Organizaciones Defensoras de Migrantes (REDODEM), y por la Encuesta sobre Migración en la Frontera Sur de México, los cuales muestran el comportamiento de este fenómeno en la entidad sureña de México, las circunstancias que enfrentan y cómo las afrontan, convirtiéndose ésta en un lugar de tránsito pero también de residencia temporal y, en algunos casos, definitiva bajo la modalidad de migración indocumentada. Oaxaca tiene una característica principal, pues a la vez que es un estado expulsor de migrantes, es una zona receptora de migración centroamericana. Sus condiciones socioeconómicas y políticas lo ubican como un lugar de marginación y pobreza, con regiones donde el índice de violencia es alto y donde muchas veces, los migrantes de Centroamérica tienen que transitar o vivir, constituyendo su región migratoria.Revista Población y Desarrollo: Argonautas y Caminantes Vol.12, 2016: 107-114

Cincuenta años de Radio Comunitaria en Colombia. Análisis sociohistórico (1945-1995)

Bajo el nombre de Radio Comunitaria se agrupan experiencias de diversa índole que se insertan en contextos urbanos y rurales de Colombia, caracterizados por altos niveles de marginación y exclusión de las dinámicas sociales, económicas, políticas y culturales del país. Se trata de cientos de experiencias que son mucho más que un simple correlato de la situación de violencia, desigualdad y crisis generalizada que hoy protagoniza este país. Pensar la Radio Comunitaria como proceso histórico y social fue el primer paso de una investigación que se propuso contestar el interrogante de ¿Cómo se ha transformado la definición y el sentido de lo comunitario en la Radio Comunitaria en Colombia, desde sus antecedentes hasta su actual resurgimiento? En el presente artículo presentamos los resultados del análisis sociohistórico realizado en el marco de un trabajo más amplio. La periodización propuesta obedece a las dinámicas que marcaron las rupturas y continuidades en las concepciones prevalecientes desde la década del cincuenta, en la que surge Radio Sutatenza como primer referente histórico de la Radio Comunitaria en Colombia, hasta su “resurgimiento” en la primera mitad de la década de los noventa.

Navigating Risk: Understanding the Impact of the Conflict on Children and Young People in Northern Ireland

Twenty years on from the 1994 cease-fires, Northern Ireland is a markedly safer place for children and young people to grow up. However, for a significant number, growing up in post-conflict Northern Ireland has brought with it continued risks and high levels of marginalization. Many young people growing up on the sharp edge of the transition have continued to experience troubling levels of poverty, lower educational attainment, poor standards of childhood health, and sustained exposure to risk-laden environments. Reflecting on interdisciplinary research carried out since the start of the “transition” to peace, this article emphasizes the impact that embedded structural inequalities continue to have on the social, physical, mental, and emotional well-being of many children and young people. In shining a light on the enduring legacy of the conflict, this article moves to argue that greater attention needs to be given to the ongoing socioeconomic factors that result in limited lifetime opportunities, marginalization, and sustained poverty for many young people growing up in “peacetime” Northern Ireland.

Mapping community viral load and social boundaries

Recently, Castel et al.[1] sought to measure and map community viral load (CVL) in Washington, DC. The authors included the most recent viral load data in the city and two indicators of socioeconomic status, namely poverty rates and the percentage of high school diplomas, as part of their analysis [1]. Findings were distributed by geopolitical regions and were presented on various maps of the city. They show an overrepresentation of racialized and poor neighbourhoods as where individuals are most likely to have a detectable viral load and suffer from HIV-related disparities. In many ways, the findings presented by Castel et al.[1] are not new or surprising. We have known for decades that the HIV epidemic concentrates in geographical areas where individuals are most vulnerable to HIV infection, areas marked by high levels of marginalization, poverty, oppression, and social exclusion. This is clearly evident in the District of Columbia where the HIV epidemic is generalized in geographical areas where target populations are most likely to present with high viral loads and live in socioeconomic conditions that make them disproportionally affected by HIV. What is innovative is the ways that CVL allows for a new form of surveillance that can then be used to draw boundaries geographically and identify specific areas for the deployment of high impact interventions, areas that are then identified as ‘risky’ and in need of attention. Despite its sophistication, CVL draws a rather partial and incomplete portrait of the HIV epidemic. We would go as far as to say that it decontextualizes HIV transmission [2]. CVL fails to consider the personal circumstances of people who are rendered visible by mapping exercises and the implications for people living with HIV who reside in areas that are being targeted by public health authorities. Not surprisingly, CVL has led to the intensification of prevention efforts and the deployment of more aggressive interventions to drive down CVL, with little further consideration of the realities of people living with HIV on the ground. The techniques of CVL allow us to measure and map concentrations of the virus, as if they might occur at random. This belies the reality that target populations we are most interested in are often forced into particular geographic areas, economic and ethnic ‘ghettos’. We are concerned that CVL and its ‘geographic’ distribution have become a proxy for naming target populations, but with new levels of sophistication. In particular, we are concerned with the potential to increase stigma directed at populations who occupy what we term ‘viral spaces’. This phenomenon has important implications for the health and safety of people living with HIV [3], and may have broader implications for everyone living in these spaces. This is especially true of geographical areas where higher CVL overlap with concentrations of racialized people as reported by Castel et al.[1]. This could result in the combining of HIV-related stigma with racism, classism and other discriminatory practices. What will it mean to know that a particular neighbourhood is where people have HIV and where people get HIV? What are the implications for those living there and for those living outside the well defined boundaries of this particular neighbourhood? We noticed Castel et al.[1] reporting measurements of CVL alongside ‘ward of residence’ and insurance status. The study is able to represent pockets of higher CVL in neighbourhoods that we imagine might be recognizable to those living in the District of Columbia, and surely recognizable to those for whom mapping risk is their trade. We appreciate the ways CVL is useful for epidemiological surveillance, but are concerned over the implications for actuarial surveillance and the possibility of decreased insurance options for individuals because of where they live. Additionally, we call for more discussions on the use of surveillance data and the ethics of CVL as a mapping exercise. Do the individuals whose viral load is calculated know that these data will be used to draw boundaries between ‘sick’ and ‘healthy’? Are they given an option over how their medical data will be used, including when used in aggregate, for such purposes? These issues have yet to be addressed in the literature on CVL. In our view, it is imperative that researchers engage in discussions and debates around the use of this new biomarker because it may very well contribute to the production of new spaces of exclusion for people living with HIV and others living in areas where the highest viral loads are found. For this reason, we argue that CVL merit closer examination. Acknowledgements Conflicts of interest There are no conflicts of interest.