UCLA Luskin School of Public Affairs

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

The COVID-19 pandemic brought the dual crises of disease and the containment policies designed to mitigate it. Yet, there is little evidence on the impacts of these policies on women in lower-income countries, where there may be limited social safety nets to absorb these shocks. We conduct a large phone survey and leverage India's geographically varied containment policies to estimate the association between the pandemic and containment policies and measures of women's well-being, including mental health and food security. On aggregate, the pandemic resulted in dramatic income losses, increases in food insecurity, and declines in female mental health. While potentially crucial to stem the spread of COVID-19, the greater prevalence of containment policies is associated with increased food insecurity, particularly for women, and reduced female mental health. For surveyed women, moving from zero to average containment levels is associated with a 38% increase in the likelihood of reporting more depression, a 73% increase in reporting more exhaustion, and a 44% increase in reporting more anxiety. Women whose social position may make them more vulnerable - those with daughters and those living in female-headed households - experience even larger declines in mental health.

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One of the pillars of efforts in the US to curb HIV incidence is pre-exposure prophylaxis (PrEP). We examined racial/ethnic and sex disparities in PrEP uptake among California Medicaid enrollees. Claims data from 2019 identified enrollees and PrEP users in each racial/ethnic, sex, and age group, yielding crude uptake rates. We then predicted age-adjusted uptake rates from multivariable logit regressions and divided PrEP uptake estimates by each group's number of new HIV diagnoses to estimate PrEP-to-need ratios. Predicted uptake was highest for White (0.29 percent) and Black (0.23 percent) males and lowest (0.16 percent) for Hispanic males. Rates for males exceeded those for females; however, Black females had twice the rate of PrEP uptake of White females. Black males and females and Hispanic males had PrEP-to-need ratios that were less than one-third (4.0-6.3) those of Asian and White males and females (14.4-19.9). Low PrEP use rates and disparities in uptake threaten efforts to end the HIV epidemic. Policy makers must craft the rollout of innovations such as PrEP in a manner that narrows HIV disparities instead of widening them.

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BACKGROUND: Lack of toilets and the widespread practice of open defecation may contribute to Indias large burden of child undernutrition. OBJECTIVES: We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India. METHODS: In this observational study, we used district-level data from before (2013-2014) and after (2015-2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates. RESULTS: Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: -0.10, -0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM. CONCLUSIONS: An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign.

Local and regional governments in the U.S. rely increasingly on voter-approved local option sales taxes (LOSTs) to fund transportation capital investments, maintenance, and operations. LOSTs typically present voters with lists of local transportation projects and programs to be funded by a ¼ to 1 percent sales tax increase. Most research on LOSTs are case studies, which make generalizations about LOSTs difficult. We conducted a comprehensive, multi-jurisdictional analysis of LOST measures in California, the U.S. state with the greatest number of LOST measures. We examined 76 LOST measures put to voters between 1976 and 2016 to assess factors associated with voter support. LOSTs in California are enacted by counties, which we examined in addition to smaller intra-county geographies using both regression models and case studies. We tested several explanatory variables for association with voter support including macroeconomic and political context, planned measure expenditures, voter characteristics, and spatial distribution of proposed projects. We found that funding dedicated to public transit and returned to local jurisdictions predicts support at the county level, and that LOSTs that create new taxes—as opposed to extending or renewing existing taxes—are less popular with voters, all else equal. Our analyses of sub-county geographies revealed that political party affiliation is the strongest predictor of local voter support for LOSTs and that voters living adjacent to funded projects tended to be more supportive of LOSTs.

Pervasive overuse and degradation of common pool resources (CPRs) is a global concern. To sustainably manage CPRs, effective governance institutions are essential. A large literature has developed to describe the institutional design features employed by communities that successfully manage their CPRs. Yet, these designs remain far from universally adopted. We focus on one prominent institutional design feature, community monitoring, and ask whether nongovernmental organizations or governments can facilitate its adoption and whether adoption of monitoring affects CPR use. To answer these questions, we implemented randomized controlled trials in six countries. The harmonized trials randomly assigned the introduction of community monitoring to 400 communities, with data collection in an additional 347 control communities. Most of the 400 communities adopted regular monitoring practices over the course of a year. In a meta-analysis of the experimental results from the six sites, we find that the community monitoring reduced CPR use and increased user satisfaction and knowledge by modest amounts. Our findings demonstrate that community monitoring can improve CPR management in disparate contexts, even when monitoring is externally initiated rather than homegrown. These findings provide guidance for the design of future programs and policies intended to develop monitoring capabilities in communities. Furthermore, our harmonized, multisite trial provides sustainability science with a new way to study the complexity of socioecological systems and builds generalizable insights about how to improve CPR management.

Although pre-exposure prophylaxis (PrEP) could substantially reduce the risk of HIV acquisition among adolescent cisgender men who have sex with men (cisMSM), various barriers faced by people of color, particularly within the southern region of the U.S., may lead to racial disparities in the utilization of PrEP. Few studies, however, have explored racial/ethnic differences in PrEP use by geographic setting among adolescent cisMSM. We conducted a cross-sectional analysis examining racial disparities in PrEP use among cisMSM ages 15-24 years in New Orleans, Louisiana, and Los Angeles, California recruited between May, 2017 and September, 2019. The odds of PrEP use among AA adolescents were considerably lower than White adolescents in New Orleans (OR (95% CI): 0.24 (0.10, 0.53)), although we did not find evidence of differences in Los Angeles. Our findings underscore the need for targeted interventions to promote PrEP use among adolescent MSM, particularly among AA adolescent cisMSM living in the southern region of U.S.