The Centers for Disease Control and Prevention have recommended routinely testing patients (aged 13–64) for HIV since 2006. However, many physicians do not routinely test. From January 2011- March 2012, we conducted 18 in-depth individual interviews and explored primary care physicians’ perceptions of barriers and facilitators to implementing routine HIV testing in North Carolina. Physicians’ comments were categorized thematically and fell into five groups: policy, community, practice, physician and patient. Lack of universal reimbursement was identified as the major policy barrier. Participants believed endorsement from the United States Preventive Services Tasks Force would facilitate adoption of routine HIV testing policies. Physicians reported HIV/AIDS stigma, socially conservative communities, lack of confidentiality, and rural geography as community barriers. Physicians believed public HIV testing campaigns would legitimize testing and decrease stigma in communities. Physicians cited time constraints and competing clinical priorities as physician barriers that could be overcome by delegating testing to nursing staff. HIV test refusal, low HIV risk perception, and stigma emerged as patient barriers. Physicians recommended adoption of routine HIV testing for all patients to facilitate and destigmatize testing. Physicians continue to experience a variety of barriers when implementing routine HIV testing in primary care settings. Our findings support multilevel approaches to enhance physician routine HIV testing in primary care settings.

Background Several factors have been identified as being associated with increased adherence to antiretroviral therapy, including sero-status disclosure; however, studies examining the effect of disclosure on ART adherence in Ethiopia have had inconsistent findings. This systematic review and meta-analysis therefore aims to estimate the pooled effect of disclosure on adherence to ART among adults living with HIV in Ethiopia. Methods We performed a systematic search for articles reporting on peer-reviewed, quantitative, English-language observational studies of reporting the association between self sero-status disclosure and good ART adherence in adults living with HIV/AIDS in Ethiopia during published from 2010 to 2015. We searched four electronic databases: PubMed/Medline, the World Health Organization’s Hinari portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases) for studies from December 1, 2017 to January 30, 2018. We also searched university repositories and conference abstracts for unpublished studies. We conducted a meta-analysis for the pooled effect of adherence using a random effects model in Stata version 14 and assessed publication bias using the Egger’s test for funnel plot asymmetry. Results Our search returned in 179 studies, of which seven (3.9%), were eligible and included in the final meta-analysis. The seven included studies were conducted from 2010 to 2015. Our analysis found that disclosure had a significant effect on the adherence to ART in adult patients living with HIV. Patients who disclosed were 1.64 times more likely to have good adherence to ART compared with those who did not (OR: 1.64, 95% CI: 1.11, 2.42). The small number of studies eligible for review and differences in study definitions of adherence and disclosure were the main limitations of this study. Conclusion This review found a statistically significant positive effect of disclosure status on the adherence to ART in adult patients living with HIV in Ethiopia. This suggests that Ethiopia’s national treatment and prevention programs should redouble efforts to encourage self-disclosure among people living with HIV/AIDS. Encouraging supportive social environments for disclosure, and promoting partner notification and partner disclosure support initiatives might be particularly helpful in this regard.

Nearly two decades after sanitation was identified as a global priority under the Millennium Development Goals, more than 4 billion people still lack access to safely managed sanitation and two-thirds of all human waste generated remains unsafely disposed. While the Sustainable Development Goals include ambitious targets for sanitation coverage, the current pace of progress will bring us far short of these aims. Despite sanitation's economic promise of 9-fold investment returns and numerous cross-sectoral benefits --from girls' education to environmental health --realizing universal and sustainable sanitation access is proving to be an elusive task.Over the past 20 years, sanitation research has grown broader in scope and deeper in complexity through diverse disciplinary approaches. Originally, sanitation research was entirely focused on containing fecal waste and preventing diarrheal diseases --placed squarely in the domain of environmental engineering and public health. However, the literature on sanitation has since expanded into economics, urban planning, cultural studies, gender studies, and beyond. While this diversity has extended the scope of traditional sanitation research, adding richness to our understanding of this complex topic, it has also rendered the term "sanitation" more nebulous. Such diverse perspectives have led to myriad, and even contradictory, definitions of what sanitation is, what it does, and what it is good for. As a result, we find that ideas about the designated functions of sanitation systems and the priorities of sanitation policy vary widely among academics, policymakers, NGOs, and community members.We review the full range of disciplines that now houses sanitation research with the goal of understanding the overlaps and disparities among and between these perspectives. Our review:(1) examines and systematically summarizes the interdisciplinary conversation around sanitation;(2) facilitates within-disciplinary understanding of cross-disciplinary definitions and priorities; and (3) recommends a more complete framework for sanitation for decision makers as well as for future research. Our aim for this work is to help those in the sanitation sector avoid the pitfalls and disciplinary silos that contributed to the failure to meet the Millennium Development Goals for sanitation as well as the current shortcomings in meeting SDG 6.2.

Exposures to industrial chemicals are widespread and can increase the risk of adverse health effects such as cancer, developmental disorders, respiratory effects, diabetes, and reproductive problems. The amended Toxic Substances Control Act (amended TSCA) requires the U.S. Environmental Protection Agency (EPA) to evaluate risks of chemicals in commerce, account for risk to potentially exposed and susceptible populations, and mitigate risks for chemicals determined to pose an unreasonable risk to human health and the environment. This analysis compares EPA’s first 10 chemical risk evaluations under amended TSCA to best scientific practices for conducting risk assessments. We find EPA’s risk evaluations underestimated human health risks of chemical exposures by excluding conditions of use and exposure pathways; not considering aggregate exposure and cumulative risk; not identifying all potentially exposed or susceptible subpopulations, and not quantifying differences in risk for susceptible groups; not addressing data gaps; and using flawed systematic review approaches to identify and evaluate the relevant evidence. We present specific recommendations for improving the implementation of amended TSCA using the best available science to ensure equitable, socially just safeguards to public health. Failing to remedy these shortcomings will result in continued systematic underestimation of risk for all chemicals evaluated under amended TSCA.

The well-established safety profile of the tuberculosis vaccine strain, Mycobacterium bovis bacille Calmette-Guérin (BCG), makes it an attractive vehicle for heterologous expression of antigens from clinically relevant pathogens. However, successful generation of recombinant BCG strains possessing consistent insert expression has encountered challenges in stability. Here, we describe a method for the development of large recombinant BCG accession lots which stably express the lentiviral antigens, human immunodeficiency virus (HIV) gp120 and simian immunodeficiency virus (SIV) Gag, using selectable leucine auxotrophic complementation. Successful establishment of vaccine stability stems from stringent quality control criteria which not only screen for highly stable complemented BCG ⌬leuCD transformants but also thoroughly characterize postproduction quality. These parameters include consistent production of correctly sized antigen, retention of sequence-pure plasmid DNA, freezethaw recovery, enumeration of CFU, and assessment of cellular aggregates. Importantly, these quality assurance procedures were indicative of overall vaccine stability, were predictive for successful antigen expression in subsequent passaging both in vitro and in vivo, and correlated with induction of immune responses in murine models. This study has yielded a quality-controlled BCG ⌬leuCD vaccine expressing HIV gp120 that retained stable full-length expression after 10 24 -fold amplification in vitro and following 60 days of growth in mice. A second vaccine lot expressed full-length SIV Gag for >10 68 -fold amplification in vitro and induced potent antigen-specific T cell populations in vaccinated mice. Production of large, well-defined recombinant BCG ⌬leuCD lots can allow confidence that vaccine materials for immunogenicity and protection studies are not negatively affected by instability or differences between freshly grown production batches. The immense global burden of human immunodeficiency virus (HIV) infection necessitates the development of an efficacious vaccine. There is increasing interest in the use of live recombinant bacterial vectors as HIV vaccines due to the inherent advantages of utilizing a replicating antigen delivery system that is itself an effective adjuvant (1, 2). Previous studies have examined the use of live Gram-positive and Gram-negative bacterial vectors, including recombinant Salmonella, Listeria, Streptococcus, and Escherichia coli, for heterologous expression of HIV antigens, with varying success (3-8).Mycobacterium bovis BCG is the most widely administered vaccine in the world (9). Its extensively documented safety in immunocompetent individuals, relatively low production cost, and well-established infrastructure for vaccine administration make it an ideal candidate for use as an anti-HIV vaccine vehicle (10-12). In addition to the logistical advantages of using BCG, mycobacterial antigen delivery systems possess inherent adjuvant properties which activate innate immunity (13,14). Mycobacteria such as BCG ...

Background Understanding, characterizing, and quantifying human exposures to environmental chemicals is critical to protect public health. Exposure assessments are key to determining risks to the general population and for specific subpopulations given that exposures differ between groups. Exposure data are also important for understanding where interventions, including public policies, should be targeted and the extent to which interventions have been successful. In this review, we aim to show how inadequacies in exposure assessments conducted by polluting industries or regulatory agencies have led to downplaying or disregarding exposure concerns raised by communities; that underestimates of exposure can lead regulatory agencies to conclude that unacceptable risks are, instead, acceptable, allowing pollutants to go unregulated; and that researchers, risk assessors, and policy makers need to better understand the issues that have affected exposure assessments and how appropriate use of exposure data can contribute to health-protective decisions. Methods We describe current approaches used by regulatory agencies to estimate human exposures to environmental chemicals, including approaches to address limitations in exposure data. We then illustrate how some exposure assessments have been used to reach flawed conclusions about environmental chemicals and make recommendations for improvements. Results Exposure data are important for communities, public health advocates, scientists, policy makers, and other groups to understand the extent of environmental exposures in diverse populations. We identify four areas where exposure assessments need to be improved due to systemic sources of error or uncertainty in exposure assessments and illustrate these areas with examples. These include: (1) an inability of regulatory agencies to keep pace with the increasing number of chemicals registered for use or assess their exposures, as well as complications added by use of ‘confidential business information’ which reduce available exposure data; (2) the failure to keep assessments up-to-date; (3) how inadequate assumptions about human behaviors and co-exposures contribute to underestimates of exposure; and (4) that insufficient models of toxicokinetics similarly affect exposure estimates. Conclusion We identified key issues that impact capacity to conduct scientifically robust exposure assessments. These issues must be addressed with scientific or policy approaches to improve estimates of exposure and protect public health.

This case series analyzes characteristics of methylene chloride–related fatalities in the United States from 1980 to 2018.

Background Hazard identification, risk assessment, regulatory, and policy activity are usually conducted on a chemical-by-chemical basis. Grouping chemicals into categories or classes is an underutilized approach that could make risk assessment and management of chemicals more efficient for regulators. Objective and methods While there are some available methods and regulatory frameworks that include the grouping of chemicals (e.g.,same molecular mechanism or similar chemical structure) there has not been a comprehensive evaluation of these different approaches nor a recommended course of action to better consider chemical classes in decision-making. This manuscript: 1) reviews current national and international approaches to grouping; 2) describes how groups could be defined based on the decision context (e.g., hazard/risk assessment, restrictions, prioritization, product development) and scientific considerations (e.g., intrinsic physical-chemical properties); 3) discusses advantages of developing a decision tree approach for grouping; 4) uses ortho-phthalates as a case study to identify and organize frameworks that could be used across agencies; and 5) discusses opportunities to advance the class concept within various regulatory decision-making scenarios. Results Structural similarity was the most common grouping approach for risk assessment among regulatory agencies (national and state level) and non-regulatory organizations, albeit with some variations in its definition. Toxicity to the same target organ or to the same biological function was also used in a few cases. The phthalates case study showed that a decision tree approach for grouping should include questions about uses regulated by other agencies to encourage more efficient, coherent, and protective chemical risk management. Discussion and conclusion Our evaluation of how classes of chemicals are defined and used identified commonalities and differences based on regulatory frameworks, risk assessments, and business strategies. We also identified that using a class-based approach could result in a more efficient process to reduce exposures to multiple hazardous chemicals and, ultimately, reduce health risks. We concluded that, in the absence of a prescribed method, a decision tree approach could facilitate the selection of chemicals belonging to a pre-defined class (e.g., chemicals with endocrine-disrupting activity; organohalogen flame retardants [OFR]) based on the decision-making context (e.g., regulatory risk management).