Effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections: observational study, systematic reviews and mathematical modelling

BACKGROUND Partner notification is essential to the comprehensive case management of sexually transmitted infections. Systematic reviews and mathematical modelling can be used to synthesise information about the effects of new interventions to enhance the outcomes of partner notification. OBJECTIVE To study the effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections (STIs). DESIGN Secondary data analysis of clinical audit data; systematic reviews of randomised controlled trials (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials) published from 1 January 1966 to 31 August 2012 and of studies of health-related quality of life (HRQL) [MEDLINE, EMBASE, ISI Web of Knowledge, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA)] published from 1 January 1980 to 31 December 2011; static models of clinical effectiveness and cost-effectiveness; and dynamic modelling studies to improve parameter estimation and examine effectiveness. SETTING General population and genitourinary medicine clinic attenders. PARTICIPANTS Heterosexual women and men. INTERVENTIONS Traditional partner notification by patient or provider referral, and new partner notification by expedited partner therapy (EPT) or its UK equivalent, accelerated partner therapy (APT). MAIN OUTCOME MEASURES Population prevalence; index case reinfection; and partners treated per index case. RESULTS Enhanced partner therapy reduced reinfection in index cases with curable STIs more than simple patient referral [risk ratio (RR) 0.71; 95% confidence interval (CI) 0.56 to 0.89]. There are no randomised trials of APT. The median number of partners treated for chlamydia per index case in UK clinics was 0.60. The number of partners needed to treat to interrupt transmission of chlamydia was lower for casual than for regular partners. In dynamic model simulations, > 10% of partners are chlamydia positive with look-back periods of up to 18 months. In the presence of a chlamydia screening programme that reduces population prevalence, treatment of current partners achieves most of the additional reduction in prevalence attributable to partner notification. Dynamic model simulations show that cotesting and treatment for chlamydia and gonorrhoea reduce the prevalence of both STIs. APT has a limited additional effect on prevalence but reduces the rate of index case reinfection. Published quality-adjusted life-year (QALY) weights were of insufficient quality to be used in a cost-effectiveness study of partner notification in this project. Using an intermediate outcome of cost per infection diagnosed, doubling the efficacy of partner notification from 0.4 to 0.8 partners treated per index case was more cost-effective than increasing chlamydia screening coverage. CONCLUSIONS There is evidence to support the improved clinical effectiveness of EPT in reducing index case reinfection. In a general heterosexual population, partner notification identifies new infected cases but the impact on chlamydia prevalence is limited. Partner notification to notify casual partners might have a greater impact than for regular partners in genitourinary clinic populations. Recommendations for future research are (1) to conduct randomised controlled trials using biological outcomes of the effectiveness of APT and of methods to increase testing for human immunodeficiency virus (HIV) and STIs after APT; (2) collection of HRQL data should be a priority to determine QALYs associated with the sequelae of curable STIs; and (3) standardised parameter sets for curable STIs should be developed for mathematical models of STI transmission that are used for policy-making. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Governança,alavancagem e ciclicidade: a eficiência do modelo brasileiro de private equity

Este trabalho objetiva analisar a eficiência dos comitês de investimento no modelo de investimento em private equity através de FIPs (Fundos de Investimento em Participações) que não utilizam alavancagens em suas aquisições. Tal análise é feita através de uma comparação com o modelo americano, no qual tipicamente o gestor do fundo tem o poder de decisão sobre os investimentos e as aquisições são realizadas utilizando financiamento de terceiros. A dissertação é iniciada com uma revisão bibliográfica não-exaustiva dos trabalhos da academia brasileira sobre o tema de private equity. Em seguida, levanta-se as particularidades do modelo dos FIPs, principalmente a decisão de investimento feita em conjunto pelo gestor e seus investidores através de comitês de investimento e a rara utilização de alavancagem nas aquisições, e demonstra-se como o impacto destas características altera o equilíbrio do modelo proposto por Axelson, Strömberg e Weisbach. Conclui-se que as particularidades do modelo dos FIPs que não utilizam alavancagens nas aquisições oferecem: (i) melhor proteção aos interesses dos investidores, e uma representativade similar aos conselhos de administração de companhias abertas, e (ii) permitem que o gestor aproveite os períodos nos quais as transações ocorrem a um múltiplo mais baixo, resultando num modelo mais eficiente de investimento e que evita a multiplicação dos ciclos econômicos. Tais conclusões, no entanto, estão sujeitas à observação das seguintes condições: (i) o comitê deve ter qualificação igual ou superior ao do gestor; (ii) o comitê deve ter disponibilidade de tempo e corpo suficientes para analisar os investimentos nas mesma profundidade que o gestor, (iii) a existência do comitê de investimento não deve acarretar numa desvantagem para o gestor em termos de agilidade de resposta nas negociações. Finalmente, são levantadas algumas situações de ponteciais conflitos de interesse nas quais os membros dos comitês de investimento podem se encontrar.

Repositioning a Multifamily Asset

Multifamily investments, particularly value-added strategies, have been of keen interest to real estate investors for years now. Successful execution of a multifamily investment offers excellent risk-adjusted returns when compared to other classes of real estate such as industrial, retail, and office. From a volatility standpoint, multifamily enjoys relatively stable long-term cash flows with less downside risk during periods of recession due to stable tenancy in most major markets. The stability during downturns is also supported by the fact that recessions tend to make renters out of owners, increasing demand for apartments.

Niagara-Welland Power Company Limited fonds, 1833, 1852, 1904-1906, 1909, n.d.

The Welland Power and Supply Canal Company Limited, established in 1893 and incorporated in 1894 with a capital stock of $500,000. The aim of the company was to harness the natural water supply of the Niagara and Welland Rivers. In 1898 the Canadian Electrical News published a report by Henry Symons, QC outlining the main project of the company. This project involves the construction of a canal from the Welland River to the brow of the mountain at Thorold, a distance of 8 miles; the construction at Thorold of a power house, and from Thorold to Lake Ontario, a raceway by which to carry water into the lake. The estimate for the machinery to generate 100,000 horse power is £125,000; for transmission line to Toronto at a voltage of 10,000….The total estimate therefore amounts to £2,452,162, or roughly speaking, $12,000,000. Source: Canadian Electrical News, August 1898, p. 172. In 1899 the company officers petitioned the federal government desiring a name change to the Niagara-Welland Power Company Limited. Officers of the company were Harry Symons, President; Charles A. Hesson, Vice-President; and M.R. O’Loughlin, James B. Sheehan, James S. Haydon, Frederick K. Foster, directors; John S. Campbell, secretary-treasurer. The company’s head offices were located in St. Catharines, with a New York (City) office on Broad Street. In 1905 and 1909 the company petitioned the federal government for additional time to construct its works, which was granted. The company had until May 16, 1915 to complete construction. John S. Campbell (1860-1950) was a graduate of the University of Toronto and Osgoode Hall. During his university years John began his military career first in "K" Company, Queens Own rifles and then later as Commanding Officer of the 19th Lincoln Regiment, from 1906 to 1910. Upon his return to St. Catharines John Campbell served as secretary in the St. Catharines Garrison Club, a social club for military men begun in 1899. After being called to the Bar, he became a partner in the firm of Campbell and McCarron and was appointed to the bench in 1916, serving until retirement in 1934. Judge Campbell served as an alderman for several terms and was the mayor of St. Catharines in 1908 and 1909. He also served as the first chairman of the St. Catharines Public Utilities in 1914. John S. Campbell was married to Elizabeth Oille, daughter of Jerome B. and Charlotte (St. John) Oille. The family home "Cruachan" was located at 32 Church St.

Impact of male partner responses on sexual function in women with vulvodynia and their partners: a dyadic daily experience study.

Note de l'éditeur : This article may not exactly replicate the final version published in the APA journal. It is not the copy of record. / Cet article ne constitue pas la version officielle, et peut différer de la version publiée dans la revue.

Investigating a robot as a therapy partner for children with autism

The aurora project is investigating the possibility of using a robotic platform as a therapy aid for--children with autism. Because of the nature of this disability, the robot could be beneficial in its ability--to present the children with a safe and comfortable environment and allow them to explore and learn--about the interaction space involved in social situations. The robotic platform is able to present--information along a limited number of channels and in a manner which the children are familiar with--from television and cartoons. Also, the robot is potentially able to adapt its behaviour and to allow the--children to develop at their own rates. Initial trial results are presented and discussed, along with the--rationale behind the project and its goals and motivations. The trial procedure and methodology are--explained and future work is highlighted.

Molecular species delimitation of a symbiotic fig-pollinating wasp species complex reveals extreme deviation from reciprocal partner specificity

Background: Symbiotic relationships have contributed to major evolutionary innovations, the maintenance of fundamental ecosystem functions, and the generation and maintenance of biodiversity. However, the exact nature of host/symbiont associations, which has important consequences for their dynamics, is often poorly known due to limited understanding of symbiont taxonomy and species diversity. Among classical symbioses, figs and their pollinating wasps constitute a highly diverse keystone resource in tropical forest and savannah environments. Historically, they were considered to exemplify extreme reciprocal partner specificity (one-to-one host-symbiont species relationships), but recent work has revealed several more complex cases. However, there is a striking lack of studies with the specific aims of assessing symbiont diversity and how this varies across the geographic range of the host. Results: Here, we use molecular methods to investigate cryptic diversity in the pollinating wasps of a widespread Australian fig species. Standard barcoding genes and methods were not conclusive, but incorporation of phylogenetic analyses and a recently developed nuclear barcoding gene (ITS2), gave strong support for five pollinator species. Each pollinator species was most common in a different geographic region, emphasising the importance of wide geographic sampling to uncover diversity, and the scope for divergence in coevolutionary trajectories across the host plant range. In addition, most regions had multiple coexisting pollinators, raising the question of how they coexist in apparently similar or identical resource niches. Conclusion: Our study offers a striking example of extreme deviation from reciprocal partner specificity over the full geographical range of a fig-wasp system. It also suggests that superficially identical species may be able to co-exist in a mutualistic setting albeit at different frequencies in relation to their fig host’s range. We show that comprehensive sampling and molecular taxonomic techniques may be required to uncover the true structure of cryptic biodiversity underpinning intimate ecological interactions.

Prioritising prevention strategies for patients in antiretroviral treatment programmes in resource-limited settings

Expanded access to antiretroviral therapy (ART) offers opportunities to strengthen HIV prevention in resource-limited settings. We invited 27 ART programmes from urban settings in Africa, Asia and South America to participate in a survey, with the aim to examine what preventive services had been integrated in ART programmes. Twenty-two programmes participated; eight (36%) from South Africa, two from Brazil, two from Zambia and one each from Argentina, India, Thailand, Botswana, Ivory Coast, Malawi, Morocco, Uganda and Zimbabwe and one occupational programme of a brewery company included five countries (Nigeria, Republic of Congo, Democratic Republic of Congo, Rwanda and Burundi). Twenty-one sites (96%) provided health education and social support, and 18 (82%) provided HIV testing and counselling. All sites encouraged disclosure of HIV infection to spouses and partners, but only 11 (50%) had a protocol for partner notification. Twenty-one sites (96%) supplied male condoms, seven (32%) female condoms and 20 (91%) provided prophylactic ART for the prevention of mother-to child transmission. Seven sites (33%) regularly screened for sexually transmitted infections (STI). Twelve sites (55%) were involved in activities aimed at women or adolescents, and 10 sites (46%) in activities aimed at serodiscordant couples. Stigma and discrimination, gender roles and funding constraints were perceived as the main obstacles to effective prevention in ART programmes. We conclude that preventive services in ART programmes in lower income countries focus on health education and the provision of social support and male condoms. Strategies that might be equally or more important in this setting, including partner notification, prompt diagnosis and treatment of STI and reduction of stigma in the community, have not been implemented widely.

Qualitative study: Understanding Mexican American women's experience in intimate partner violence

The purpose of this qualitative study was to gain an understanding of the experiences of Mexican American women living with intimate partner abuse relevant to the process of disclosure of abuse. Limited research exists on the experiences of women who are of Mexican descent living with intimate partner abuse and their disclosure of abuse. Factors that influence disclosure for other populations are well articulated in the literature however, these factors have not been adequately verified in persons of Mexican descent. Data are reported from in-depth interviews with 26 clients at a shelter and an outreach agency in a south Texas-Mexico border community. Semi-structured interview guide was used to elicit information over an 11 month period. A grounded theory ethnography approach was used to analyze data. Verification strategies and constant comparison techniques (e.g. investigator responsiveness, methodological coherence, sampling adequacy, an active analytic stance, and saturation) enhanced rigor of analysis. Nineteen Mexican immigrant women and seven Mexican American women participated in the study. Several themes were discerned related to women's experiences in abuse: painful living, questioning endurance, and confronting reality. In almost every participant's account there was a description of repeated victimization by her intimate partner or partners, and again, by others within and outside her network. The participants discussed several cultural factors (e.g. embarrassment, concerns for family, avoidance of causing pain to family, protection of partner, avoidance of being judged) that hindered their decisions whether or not to disclose. Participants noted that healthcare workers rarely asked probing questions regarding abuse. The timing and process of disclosure took many turns for women in this study. Some of the factors hindering women from disclosing were found to be influenced by cultural practices. The consequences of disclosure for many of the women led them to re-victimization. Implications for practice to avoid missed opportunities with women living in abuse are to: ask questions routinely to encourage disclosure of abuse and offer community resource information for women living in abuse or both.^

How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol

Background: Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues—such as IPV management—get integrated into health systems, and that focuses on healthcare teams’ learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services. Methods: This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management. Discussion: Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.

Mapping and exploring health systems' response to intimate partner violence in Spain

Background: For a comprehensive health sector response to intimate partner violence (IPV), interventions should target individual and health facility levels, along with the broader health systems level which includes issues of governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. This study aims to map and explore the integration of IPV response in the Spanish national health system. Methods: Information was collected on five key areas based on WHO recommendations: policy environment, protocols, training, monitoring and prevention. A systematic review of public documents was conducted to assess 39 indicators in each of Spain’s 17 regional health systems. In addition, we performed qualitative content analysis of 26 individual interviews with key informants responsible for coordinating the health sector response to IPV in Spain. Results: In 88% of the 17 autonomous regions, the laws concerning IPV included the health sector response, but the integration of IPV in regional health plans was just 41%. Despite the existence of a supportive national structure, responding to IPV still relies strongly on the will of health professionals. All seventeen regions had published comprehensive protocols to guide the health sector response to IPV, but participants recognized that responding to IPV was more complex than merely following the steps of a protocol. Published training plans existed in 43% of the regional health systems, but none had institutionalized IPV training in medical and nursing schools. Only 12% of regional health systems collected information on the quality of the IPV response, and there are many limitations to collecting information on IPV within health services, for example underreporting, fears about confidentiality, and underuse of data for monitoring purposes. Finally, preventive activities that were considered essential were not institutionalized anywhere. Conclusions: Within the Spanish health system, differences exist in terms of achievements both between regions and between the areas assessed. Progress towards integration of IPV has been notable at the level of policy, less outstanding regarding health service delivery, and very limited in terms of preventive actions.

The European Union and global security: is the EU becoming the indispensable partner? EU Centre Singapore Background Brief No. 11, April 2014

The European Union has developed new capacity as a security actor in third countries, in particular in the area of crisis management. Over the past two decades the EU has deployed numerous missions, both of a civilian and military nature. Moreover the EU has defined its ability to intervene all along the ‘crisis cycle’, (from prevention to mediation, from peace-keeping to post-conflict reconstruction) and using all tools at its disposal (taking a ‘comprehensive approach’). However the EU is still not perceived as a major security provider globally and interventions remain limited to some geographic areas, mostly in its neighbourhood and Africa, with just a few examples further afield. The EU also tends to avoid taking direct action and seems to prefer partnership arrangements with other players. How can we explain the growing activism and number of EU’s intervention with the low impact and lack of visibility? Can we expect the EU to become more active in the future, taking on more responsibility and leading roles in addressing conflict situations? This paper will argue that the main reason for the EU’s hesitant role in crisis management is to be found in the weak decision-making provisions for EU’s security interventions, as one of the few policy areas still subject to consensus amongst 28 European Union Member States. Lack of a clearer delegation of competence or stronger coordination structures is closely linked to low legitimacy for the EU to take more robust action as a security actor. In order to overcome this legitimacy problem, and in order to facilitate consensus amongst Member States, the EU thus privileges partnership arrangements with other actors who can provide legitimacy and know-how, such as the UN or the African Union. As there is no political desire in the EU for tighter decision-making in this area, we can expect that the EU will continue to play a supporting rather than leading role in crisis management, becoming the partner of choice as it deepens its experience. However this does not mean that the EU is playing just a secondary role in the wider area of security, in particular when looking at nontraditional security. Looking at the role of the EU in Asia, where the EU has deployed just two missions, this paper will offer a broader assessment of the EU as a partner in the area of security taking into account different types of actions. The paper will argue that in order to strengthen cooperation with Asian partners in the area of crisis management, the EU will need to define better what it is able to offer, present its actions as part of an overall strategy rather than ad-hoc and piecemeal, and enter into partnership arrangements with different players in the region.

Cultivating Care: Understanding Intimate Partner Violence Experiences of Undocumented Latinas in Washington State

Thesis (Ph.D.)--University of Washington, 2016-06

Intimate Partner Violence and Pregnancy Intentions: A Qualitative Study

Aim and Objective In this qualitative study we explored women’s pregnancy intentions and experiences of intimate partner violence before, during and after pregnancy. Background Unintended pregnancies in the context of intimate partner violence can have serious health, social and economic consequences for women and their children. Design Feminist and phenomenological philosophies underpinned the study to gain a richer understanding of women’s experiences. Methods Eleven women who had been pregnant in the previous two years were recruited from community-based women’s refuges in one region of the United Kingdom. Of the eleven women, eight had unplanned pregnancies, two reported being coerced into early motherhood, and only one woman had purposively planned her pregnancy. Multiple in-depth interviews focused on participants’ accounts of living with intimate partner violence. Experiential data analysis was used to identify, analyse and highlight themes. Results Three major themes were identified: men’s control of contraception, partner’s indiscriminate response to the pregnancy, and women’s mixed feelings about the pregnancy. Participants reported limited influence over their sexual relationship and Accepted Article This article is protected by copyright. All rights reserved. birth control. Feelings of vulnerability about themselves and fear for their unborn babies’ safety were intensified by their partners’ continued violence during pregnancy. Conclusion Women experiencing intimate partner violence were more likely to have an unintended pregnancy. This could be attributed to male dominance and fear, which impacts on a woman’s ability to manage her birth control options. The women’s initial excitement about their pregnancy diminished in the face of uncertainty and ongoing violence within their relationship. Relevance to clinical practice Women experiencing violence lack choice in relation to birth control options leading to unintended pregnancies. Interpreting the findings from the victim-perpetrator interactive spin theory of intimate partner violence provides a possible framework for midwives and nurses to better understand and respond to women’s experiences of violence during pregnancy.

Dyspareunia In Hiv-positive And Hiv-negative Middle-aged Women: A Cross-sectional Study.

To evaluate whether dyspareunia is associated with HIV status in menopausal women and also to assess which factors are associated with dyspareunia in a group of HIV-positive menopausal women. A cross-sectional study was conducted with 178 HIV-negative and 128 HIV-positive women aged 40-60 years. The Short Personal Experiences Questionnaire (SPEQ) was used to collect data. Sociodemographic, clinical, behavioural and reproductive factors were evaluated, as well as factors related to the HIV infection. Dyspareunia was defined as pain during intercourse. A bivariate analysis and Poisson multiple regression analysis were performed. Overall, 41.4% of the HIV-positive women reported dyspareunia compared with 34.8% of the HIV-negative women (p=0.242). In the HIV-positive women, bivariate analysis revealed an association between dyspareunia and having a steady partner (p=0.047); the woman's partner having undergone HIV testing (p=0.020); vaginal dryness (p<0.001); muscle/joint pain (p=0.021); physical/emotional violence (p=0.049); urinary incontinence (p=0.004); and the use of lamivudine/zidovudine (p=0.048). The Poisson multiple regression analysis found an association between dyspareunia and vaginal dryness (prevalence ratio (PR)=1.96, 95% CI 1.10 to 3.50, p=0.023) and urinary incontinence (PR=1.86, 95% CI 1.06 to 3.27, p=0.031). Dyspareunia was common in this group of HIV-positive women and was associated principally with vaginal dryness and urinary incontinence. The importance of treating dyspareunia within the context of sexual health in this group of women should be emphasised and appropriate management of this issue may reduce the likelihood of lesions on the vaginal wall, which may act as a portal of entry for other infections.