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      Consensus statement on the role of health systems in advancing the long-term well-being of people living with HIV

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      1 , , 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 16 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 1 , 36 , 37 , 9 , 38 , 2 , 39 , 40 , 41 , 36 , 42 , 43 , 44
      Nature Communications
      Nature Publishing Group UK
      Health services, Quality of life, Comorbidities

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          Abstract

          Health systems have improved their abilities to identify, diagnose, treat and, increasingly, achieve viral suppression among people living with HIV (PLHIV). Despite these advances, a higher burden of multimorbidity and poorer health-related quality of life are reported by many PLHIV in comparison to people without HIV. Stigma and discrimination further exacerbate these poor outcomes. A global multidisciplinary group of HIV experts developed a consensus statement identifying key issues that health systems must address in order to move beyond the HIV field’s longtime emphasis on viral suppression to instead deliver integrated, person-centered healthcare for PLHIV throughout their lives.

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          Stigma as a fundamental cause of population health inequalities.

          Bodies of research pertaining to specific stigmatized statuses have typically developed in separate domains and have focused on single outcomes at 1 level of analysis, thereby obscuring the full significance of stigma as a fundamental driver of population health. Here we provide illustrative evidence on the health consequences of stigma and present a conceptual framework describing the psychological and structural pathways through which stigma influences health. Because of its pervasiveness, its disruption of multiple life domains (e.g., resources, social relationships, and coping behaviors), and its corrosive impact on the health of populations, stigma should be considered alongside the other major organizing concepts for research on social determinants of population health.
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            Health, Health-Related Quality of Life, and Quality of Life: What is the Difference?

            The terms health, health-related quality of life (HRQoL), and quality of life (QoL) are used interchangeably. Given that these are three key terms in the literature, their appropriate and clear use is important. This paper reviews the history and definitions of the terms and considers how they have been used. It is argued that the definitions of HRQoL in the literature are problematic because some definitions fail to distinguish between HRQoL and health or between HRQoL and QoL. Many so-called HRQoL questionnaires actually measure self-perceived health status and the use of the phrase QoL is unjustified. It is concluded that the concept of HRQoL as used now is confusing. A potential solution is to define HRQoL as the way health is empirically estimated to affect QoL or use the term to only signify the utility associated with a health state.
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              Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies

              Summary Background Health care for people living with HIV has improved substantially in the past two decades. Robust estimates of how these improvements have affected prognosis and life expectancy are of utmost importance to patients, clinicians, and health-care planners. We examined changes in 3 year survival and life expectancy of patients starting combination antiretroviral therapy (ART) between 1996 and 2013. Methods We analysed data from 18 European and North American HIV-1 cohorts. Patients (aged ≥16 years) were eligible for this analysis if they had started ART with three or more drugs between 1996 and 2010 and had at least 3 years of potential follow-up. We estimated adjusted (for age, sex, AIDS, risk group, CD4 cell count, and HIV-1 RNA at start of ART) all-cause and cause-specific mortality hazard ratios (HRs) for the first year after ART initiation and the second and third years after ART initiation in four calendar periods (1996–99, 2000–03 [comparator], 2004–07, 2008–10). We estimated life expectancy by calendar period of initiation of ART. Findings 88 504 patients were included in our analyses, of whom 2106 died during the first year of ART and 2302 died during the second or third year of ART. Patients starting ART in 2008–10 had lower all-cause mortality in the first year after ART initiation than did patients starting ART in 2000–03 (adjusted HR 0·71, 95% CI 0·61–0·83). All-cause mortality in the second and third years after initiation of ART was also lower in patients who started ART in 2008–10 than in those who started in 2000–03 (0·57, 0·49–0·67); this decrease was not fully explained by viral load and CD4 cell count at 1 year. Rates of non-AIDS deaths were lower in patients who started ART in 2008–10 (vs 2000–03) in the first year (0·48, 0·34–0·67) and second and third years (0·29, 0·21–0·40) after initiation of ART. Between 1996 and 2010, life expectancy in 20-year-old patients starting ART increased by about 9 years in women and 10 years in men. Interpretation Even in the late ART era, survival during the first 3 years of ART continues to improve, which probably reflects transition to less toxic antiretroviral drugs, improved adherence, prophylactic measures, and management of comorbidity. Prognostic models and life expectancy estimates should be updated to account for these improvements. Funding UK Medical Research Council, UK Department for International Development, EU EDCTP2 programme.
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                Author and article information

                Contributors
                Jeffrey.Lazarus@isglobal.org
                Journal
                Nat Commun
                Nat Commun
                Nature Communications
                Nature Publishing Group UK (London )
                2041-1723
                16 July 2021
                16 July 2021
                2021
                : 12
                : 4450
                Affiliations
                [1 ]GRID grid.5841.8, ISNI 0000 0004 1937 0247, Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, ; Barcelona, Spain
                [2 ]GRID grid.10347.31, ISNI 0000 0001 2308 5949, University of Malaya, ; Kuala Lumpur, Malaysia
                [3 ]GRID grid.475176.6, ISNI 0000 0004 6091 826X, International AIDS Society (IAS), ; Geneva, Switzerland
                [4 ]GRID grid.448742.9, ISNI 0000 0004 0422 9435, Homerton University Hospital NHS Foundation Trust, ; London, United Kingdom
                [5 ]Portuguese National Parliament, Lisbon, Portugal
                [6 ]GRID grid.10423.34, ISNI 0000 0000 9529 9877, Medizinische Hochschule Hannover (MHH), ; Hannover, Germany
                [7 ]GRID grid.7836.a, ISNI 0000 0004 1937 1151, The Desmond Tutu HIV Centre, ; Cape Town, South Africa
                [8 ]GRID grid.83440.3b, ISNI 0000000121901201, Royal Free London NHS Trust and University College London, ; London, United Kingdom
                [9 ]GRID grid.428062.a, ISNI 0000 0004 0497 2835, Chelsea and Westminster NHS Foundation Trust, ; London, United Kingdom
                [10 ]GRID grid.1005.4, ISNI 0000 0004 4902 0432, Centre for Social Impact, University of New South Wales, ; Sydney, Australia
                [11 ]GRID grid.410359.a, ISNI 0000 0004 0461 9142, Bridge HIV, San Francisco Department of Public Health, ; San Francisco, United States
                [12 ]GRID grid.11100.31, ISNI 0000 0001 0673 9488, Center for Research in Sexuality, AIDS and Society, , Universidad Peruana Cayetano Heredia, ; Lima, Peru
                [13 ]GRID grid.491017.a, Fundación Huésped, ; Buenos Aires, Argentina
                [14 ]GRID grid.464064.4, ISNI 0000 0004 0467 0503, Aix Marseille Univ, Inserm, IRD, SESSTIM, , Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, ; Marseilles, France
                [15 ]Global Network of People Living with HIV (GNP+), Cape Town, South Africa
                [16 ]GRID grid.7445.2, ISNI 0000 0001 2113 8111, Imperial College London, ; London, United Kingdom
                [17 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, University of Milan, ; Milan, Italy
                [18 ]Positive Voice, Athens, Greece
                [19 ]GRID grid.436087.e, National Plan on AIDS, , Ministry of Health, ; Madrid, Spain
                [20 ]HIV Legal Network, Toronto, Canada
                [21 ]GRID grid.21729.3f, ISNI 0000000419368729, ICAP at Columbia University, ; New York City, United States
                [22 ]Spanish AIDS Interdisciplinary Society (SEISIDA), Madrid, Spain
                [23 ]GRID grid.10702.34, ISNI 0000 0001 2308 8920, Universidad Nacional de Educación a Distancia, ; Madrid, Spain
                [24 ]GRID grid.7548.e, ISNI 0000000121697570, Modena HIV Metabolic Clinic, , Università degli studi di Modena e Reggio Emilia, ; Modena, Italy
                [25 ]GRID grid.13097.3c, ISNI 0000 0001 2322 6764, King’s College London, ; London, United Kingdom
                [26 ]GRID grid.1056.2, ISNI 0000 0001 2224 8486, Burnet Institute, ; Melbourne, Australia
                [27 ]GRID grid.48004.38, ISNI 0000 0004 1936 9764, Liverpool School of Tropical Medicine, ; Liverpool, United Kingdom
                [28 ]GRID grid.271308.f, ISNI 0000 0004 5909 016X, Public Health England, ; London, United Kingdom
                [29 ]GRID grid.63984.30, ISNI 0000 0000 9064 4811, McGill University Health Centre Research Institute, ; Montreal, Canada
                [30 ]GRID grid.1008.9, ISNI 0000 0001 2179 088X, Department of Infectious Diseases, , The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, ; Melbourne, Australia
                [31 ]GRID grid.416153.4, ISNI 0000 0004 0624 1200, Victorian Infectious Diseases Service, , The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, ; Melbourne, Australia
                [32 ]GRID grid.1002.3, ISNI 0000 0004 1936 7857, Department of Infectious Diseases, , The Alfred and Monash University, ; Melbourne, Australia
                [33 ]GRID grid.38142.3c, ISNI 000000041936754X, Fenway Health and Harvard Medical School, ; Boston, United States
                [34 ]GRID grid.411347.4, ISNI 0000 0000 9248 5770, Infectious Diseases Department, , Hospital Universitario Ramón y Cajal, ; Madrid, Spain
                [35 ]ESA YOUTH 2030, Nairobi, Kenya
                [36 ]GRID grid.253482.a, ISNI 0000 0001 0170 7903, City University of New York Graduate School of Public Health and Health Policy, ; New York City, United States
                [37 ]European Centre for Disease Control and Prevention, Solna, Sweden
                [38 ]GRID grid.8991.9, ISNI 0000 0004 0425 469X, London School of Hygiene and Tropical Medicine, ; London, United Kingdom
                [39 ]GRID grid.7177.6, ISNI 0000000084992262, Amsterdam University Medical Centers, , University of Amsterdam, ; Amsterdam, Netherlands
                [40 ]GRID grid.22903.3a, ISNI 0000 0004 1936 9801, American University of Beirut, ; Beirut, Lebanon
                [41 ]GRID grid.15090.3d, ISNI 0000 0000 8786 803X, University Hospital Bonn, ; Bonn, Germany
                [42 ]GRID grid.83440.3b, ISNI 0000000121901201, University College London, ; London, United Kingdom
                [43 ]GRID grid.11194.3c, ISNI 0000 0004 0620 0548, Makerere University School of Public Health, ; Kampala, Uganda
                [44 ]GRID grid.439700.9, ISNI 0000 0004 0456 9659, Central and North West London NHS Trust, ; London, United Kingdom
                Author information
                http://orcid.org/0000-0001-9618-2299
                http://orcid.org/0000-0003-3111-621X
                http://orcid.org/0000-0003-2557-4337
                http://orcid.org/0000-0002-4956-243X
                http://orcid.org/0000-0003-4901-0974
                http://orcid.org/0000-0002-8101-0790
                http://orcid.org/0000-0002-6794-4837
                http://orcid.org/0000-0001-6475-5056
                http://orcid.org/0000-0003-0073-1789
                http://orcid.org/0000-0002-8786-4658
                http://orcid.org/0000-0003-4304-7194
                http://orcid.org/0000-0002-5724-3914
                http://orcid.org/0000-0002-9681-0424
                http://orcid.org/0000-0001-9653-8689
                http://orcid.org/0000-0002-5055-3266
                http://orcid.org/0000-0002-3063-8430
                http://orcid.org/0000-0002-0330-8241
                http://orcid.org/0000-0001-8735-4124
                http://orcid.org/0000-0002-4495-6325
                http://orcid.org/0000-0002-8935-749X
                http://orcid.org/0000-0002-4091-5323
                http://orcid.org/0000-0002-2043-7133
                http://orcid.org/0000-0002-4832-9564
                http://orcid.org/0000-0001-5173-2760
                http://orcid.org/0000-0002-1379-1775
                Article
                24673
                10.1038/s41467-021-24673-w
                8285468
                34272399
                89603f18-0fe1-4f83-98af-bcc5c61c1fbb
                © The Author(s) 2021

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 9 March 2021
                : 1 July 2021
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                © The Author(s) 2021

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                health services,quality of life,comorbidities
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                health services, quality of life, comorbidities

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