Publications

The United States President's Emergency Plan for AIDS Relief (PEPFAR) has played a key leadership role in the global response to the HIV/AIDS pandemic. PEPFAR was inspired by the principles of the historic Monterrey Consensus (United Nations. Monterrey Consensus on Financing for Development, Monterrey, Mexico, March 18-22, 2002. New York: United Nations; 2002. Available at: http://www.un.org/esa/ffd/monterrey/MonterreyConsensus.pdf. Accessed April 21, 2012), which changed the underlying conceptual framework for international development, and therefore global health--a shift from paternalism to partnership that begins with country ownership and requires good governance, a results-based approach, and engagement of all sectors of society. PEPFAR began with a focus on the growing emergency of the HIV/AIDS pandemic by rapidly expanding HIV services, building clinical capacity, implementing strategic information systems, and building a coalition of partners to lead the response. Within the first years of implementation, there was a shift to sustainability, including the advent of Partnership Frameworks. The PEPFAR reauthorization in 2008 codified into law, the evolution in policies and programs for the next phase of implementation. In 2011 alone, PEPFAR supported nearly 4 million people on treatment, supported programs that provided more than 1.5 million HIV-positive pregnant women with antiretroviral drugs to prevent HIV transmission to their children, and supported HIV testing for more than 40 million people. This article provides an overview of how smart investments and partnerships across sectors and US agencies have helped achieve unprecedented results in increasing HIV/AIDS services and engaging partner countries and organizations in sharing the responsibility for an AIDS-free generation.

The President's Emergency Plan for AIDS Relief (PEPFAR) has spurred unprecedented progress in saving lives from AIDS, while also improving a broad range of health outcomes by strengthening country platforms for the delivery of basic health services. Now, a new endpoint is in sight--an AIDS-free generation--together with the opportunity to change the trajectory of global health through the investments made and lessons learned in doing this work. Less than a decade ago, many experts counseled against scaling up antiretroviral treatment in the developing world. They feared that patients would be unable to adhere to their regimens, that resistant strains of the virus would evolve and prevail, and that the need to sustain daily treatment for millions of people in poor settings would overwhelm fragile health systems. Today, over 6.6 million men, women, and children are on treatment, and incidence is dropping in many of the hardest-hit countries. By adopting a targeted approach to address one of the most complex global health issues in modern history, and then taking it to scale with urgency and commitment, PEPFAR has both forged new models and challenged the conventional wisdom on what is possible. In this article, PEPFAR and its partners are examined through new and evolving models of country ownership and shared responsibility that hold promise of transforming the future landscape of global health.

The AIDS Education and Training Centers National Evaluation Center led collaborative research to evaluate whether Minority AIDS Initiative (MAI)-funded clinical training changes clinical practice. Chart abstraction and feedback (34 clinics; n = 530) were used to assess adherence to clinical practice guidelines, identify training needs, and assess change in clinical practice (14 clinics, n = 271). Generalized estimating equations were used to account for repeated measures within each clinic. At baseline, clinics displayed 49% (95% confidence interval [CI] = 44-53) adherence to clinical practice guidelines. After feedback associated with the baseline chart review and subsequent implementation of MAI-funded clinical training, an 11% increase (95% CI = 7-16) in adherence to clinical practice guidelines was observed. MAI-funded clinical training was associated with increased adherence to clinical practice guidelines for HIV care. Chart abstraction is useful to assess clinical practice, facilitate conversations about quality improvement, and evaluate the effectiveness of clinical training.

BACKGROUND

Limited health literacy is associated with poor outcomes in many chronic diseases, but little is known about health literacy in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To examine the associations between health literacy and both outcomes and health status in COPD. PARTICIPANTS, DESIGN AND MAIN MEASURES: Structured interviews were administered to 277 subjects with self-report of physician-diagnosed COPD, recruited through US random-digit telephone dialing. Health literacy was measured with a validated three-item battery. Multivariable linear regression, controlling for sociodemographics including income and education, determined the cross-sectional associations between health literacy and COPD-related health status: COPD Severity Score, COPD Helplessness Index, and Airways Questionnaire-20R [measuring respiratory-specific health-related quality of life (HRQoL)]. Multivariable logistic regression estimated associations between health literacy and COPD-related hospitalizations and emergency department (ED) visits.

KEY RESULTS

Taking socioeconomic status into account, poorer health literacy (lowest tertile compared to highest tertile) was associated with: worse COPD severity (+2.3 points; 95 % CI 0.3-4.4); greater COPD helplessness (+3.7 points; 95 % CI 1.6-5.8); and worse respiratory-specific HRQoL (+3.5 points; 95 % CI 1.8-4.9). Poorer health literacy, also controlling for the same covariates, was associated with higher likelihood of COPD-related hospitalizations (OR = 6.6; 95 % CI 1.3-33) and COPD-related ED visits (OR = 4.7; 95 % CI 1.5-15). Analyses for trend across health literacy tertiles were statistically significant (p < 0.05) for all above outcomes.

CONCLUSIONS

Independent of socioeconomic status, poor health literacy is associated with greater COPD severity, greater COPD helplessness, worse respiratory-specific HRQoL, and higher odds of COPD-related emergency health-care utilization. These results underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes.