Correspondence
of IDUs in Athens were infected with HIV according to a respondent-driven sampling survey.4 The increased spread of HIV in IDUs started recently. Molecular analyses showed the circulation of new HIV strains during the outbreak and the clustering of infections in IDUs, thus differentiating transmission patterns before and after 2010 in Greece.2,4 This outbreak has been an opportunity for collaboration between the Hellenic Centre for Disease Control and Prevention, the Greek Organisation Against Drugs, and other stakeholders to contain the epidemic. Questioning the existence of the HIV outbreak in IDUs could deprive public health authorities of essential resources, putting IDUs and other populations at risk. GN, ST, and CB are employees of the Hellenic Centre for Disease Control and Prevention (HCDCP). TK is President of the Board of Directors of HCDCP. MM declares that he has no competing interests.
Georgios Nikolopoulos, *Sotirios Tsiodras, Chryssoula Botsi, Meni Malliori, Tzeni Kremastinou [email protected] Hellenic Centre for Disease Control and Prevention, 15123 Athens, Greece (GN, ST, CB, TK); Athens University Medical School, Athens, Greece (ST, MM); and Greek Organisation Against Drugs, Athens, Greece (MM) 1 2
3
4
Alexopoulos EC. HIV infections and injecting drug users in Greece. Lancet 2013, 382: 1095. Paraskevis D, Nikolopoulos G, Tsiara C, et al. HIV-1 outbreak among injecting drug users in Greece, 2011: a preliminary report. Euro Surveill 2011; 16: 19962. European Centre for Disease Prevention and Control. Risk assessment on HIV in Greece. http://ecdc.europa.eu/en/publications/ Publications/20121130-Risk-AssessmentHIV-in-Greece.pdf (accessed Oct 30, 2013). EMCDDA. HIV outbreak among injecting drug users in Greece. http://www.emcdda.europa. eu/publications/ad-hoc/2012/greece-hivupdate (accessed Oct 30, 2013).
Redefining global health-care delivery Jim Yong Kim and colleagues1 provide an important framework for fostering integration and value in global healthcare delivery. We, however, believe that greater emphasis could be placed on 694
the breadth with which this framework is implemented. The provision of care in lowincome and middle-income countries (LMICs) is burdened by several hurdles including shortages in trained personnel, insufficient access to and provision of resources, and limitations in infrastructure. These hurdles restrain all vertical care pathways. Integration might serve as a promising solution to maximise use of available personnel and resources. We advocate that this occur at the interspecialty level,2 combining infectious disease, primary care, and surgical care facilities, rather than intraspecialty collaboration alone, integrating for example HIV and tuberculosis care. 3 Interspecialty collaboration has already shown promise. In Mongolia, WHOled integration of surgical care with primary health-care services enhanced surgical coverage and improved basic infrastructure.2 Similarly, in South Africa, integration of antiretroviral therapy services and antenatal care increased treatment initiation during pregnancy.4 Furthermore, although we agree that defragmentation of global health vertical care pathways is paramount, this should not be limited to health-care delivery and service-based research, but should apply to a substantially broader spectrum. Global health requires collaboration between basic, social and political sciences, epidemiology, health partnerships, and on-site services. On the basis of the already successful biomedical translational pipeline,5 we believe that converging and structuring these efforts, forming a science-to-service, evidence-based, global health translational framework, might focus global health initiatives, aiding sustainability, avoiding waste, and improving efficacy. We declare that we have no competing interests.
*Mahiben Maruthappu, Ashton Barnett-Vanes , Joseph Shalhoub, Alexander Finlayson [email protected]
Harvard University, Cambridge, MA 02138, USA (MM); Imperial College London, London, UK (AB-V, JS); and Cancer Epidemiology Unit, University of Oxford, Oxford, UK (AF) 1 2
3
4
5
Kim JY, Farmer PE, Porter ME. Redefining global health-care delivery. Lancet 2013; 382: 1060–69. Henry JA, Orgoi S, Govind S, Price RR, Lundeg G, Kehrer B. Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia. World J Surg 2012; 36: 2359–70. Hotez PJ, Mistry N, Rubinstein J, Sachs JD. Integrating neglected tropical diseases into AIDS, tuberculosis, and malaria control. N Engl J Med 2011; 364: 2086–89. Stinson K, Jennings K, Myer L. Integration of antiretroviral therapy services into antenatal care increases treatment initiation during pregnancy: a cohort study. PLoS One 2013; 8: e63328. Zerhouni EA. Translational and clinical science—time for a new vision. N Engl J Med 2005; 353: 1621–23.
In their Health Policy article, Jim Yong Kim and colleagues1 present a practical and coherent approach for delivering quality care to those facing both poverty and serious illness. The delivery of efficient and effective care to those living within a synergistic clustering of epidemics, or syndemic,2 is indeed a challenge—one that nurses caring for individuals with HIV/AIDS know well. Implementing valuebased chains that recognise the need for shared delivery infrastructure, alignment of delivery with local context, and attention to the social and economic determinants of health will require governments, healthcare administrators, health-care providers, and donors to step away from traditional siloed approaches for specific conditions. We endorse Kim and colleagues’1 call for integration to occur with attention to the local context, across diseases and intervention, within and between health clinics and hospitals and among providers (including physicians, nurses, and community health workers). To accomplish this goal we want to emphasise the crucial need to embrace a shift to interprofessional collaboration, shared care, and shared decision making. Nursing has been intimately involved in the gains achieved in preventing and www.thelancet.com Vol 383 February 22, 2014
of IDUs in Athens were infected with HIV according to a respondent-driven sampling survey.4 The increased spread of HIV in IDUs started recently. Molecular analyses showed the circulation of new HIV strains during the outbreak and the clustering of infections in IDUs, thus differentiating transmission patterns before and after 2010 in Greece.2,4 This outbreak has been an opportunity for collaboration between the Hellenic Centre for Disease Control and Prevention, the Greek Organisation Against Drugs, and other stakeholders to contain the epidemic. Questioning the existence of the HIV outbreak in IDUs could deprive public health authorities of essential resources, putting IDUs and other populations at risk. GN, ST, and CB are employees of the Hellenic Centre for Disease Control and Prevention (HCDCP). TK is President of the Board of Directors of HCDCP. MM declares that he has no competing interests.
Georgios Nikolopoulos, *Sotirios Tsiodras, Chryssoula Botsi, Meni Malliori, Tzeni Kremastinou [email protected] Hellenic Centre for Disease Control and Prevention, 15123 Athens, Greece (GN, ST, CB, TK); Athens University Medical School, Athens, Greece (ST, MM); and Greek Organisation Against Drugs, Athens, Greece (MM) 1 2
3
4
Alexopoulos EC. HIV infections and injecting drug users in Greece. Lancet 2013, 382: 1095. Paraskevis D, Nikolopoulos G, Tsiara C, et al. HIV-1 outbreak among injecting drug users in Greece, 2011: a preliminary report. Euro Surveill 2011; 16: 19962. European Centre for Disease Prevention and Control. Risk assessment on HIV in Greece. http://ecdc.europa.eu/en/publications/ Publications/20121130-Risk-AssessmentHIV-in-Greece.pdf (accessed Oct 30, 2013). EMCDDA. HIV outbreak among injecting drug users in Greece. http://www.emcdda.europa. eu/publications/ad-hoc/2012/greece-hivupdate (accessed Oct 30, 2013).
Redefining global health-care delivery Jim Yong Kim and colleagues1 provide an important framework for fostering integration and value in global healthcare delivery. We, however, believe that greater emphasis could be placed on 694
the breadth with which this framework is implemented. The provision of care in lowincome and middle-income countries (LMICs) is burdened by several hurdles including shortages in trained personnel, insufficient access to and provision of resources, and limitations in infrastructure. These hurdles restrain all vertical care pathways. Integration might serve as a promising solution to maximise use of available personnel and resources. We advocate that this occur at the interspecialty level,2 combining infectious disease, primary care, and surgical care facilities, rather than intraspecialty collaboration alone, integrating for example HIV and tuberculosis care. 3 Interspecialty collaboration has already shown promise. In Mongolia, WHOled integration of surgical care with primary health-care services enhanced surgical coverage and improved basic infrastructure.2 Similarly, in South Africa, integration of antiretroviral therapy services and antenatal care increased treatment initiation during pregnancy.4 Furthermore, although we agree that defragmentation of global health vertical care pathways is paramount, this should not be limited to health-care delivery and service-based research, but should apply to a substantially broader spectrum. Global health requires collaboration between basic, social and political sciences, epidemiology, health partnerships, and on-site services. On the basis of the already successful biomedical translational pipeline,5 we believe that converging and structuring these efforts, forming a science-to-service, evidence-based, global health translational framework, might focus global health initiatives, aiding sustainability, avoiding waste, and improving efficacy. We declare that we have no competing interests.
*Mahiben Maruthappu, Ashton Barnett-Vanes , Joseph Shalhoub, Alexander Finlayson [email protected]
Harvard University, Cambridge, MA 02138, USA (MM); Imperial College London, London, UK (AB-V, JS); and Cancer Epidemiology Unit, University of Oxford, Oxford, UK (AF) 1 2
3
4
5
Kim JY, Farmer PE, Porter ME. Redefining global health-care delivery. Lancet 2013; 382: 1060–69. Henry JA, Orgoi S, Govind S, Price RR, Lundeg G, Kehrer B. Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia. World J Surg 2012; 36: 2359–70. Hotez PJ, Mistry N, Rubinstein J, Sachs JD. Integrating neglected tropical diseases into AIDS, tuberculosis, and malaria control. N Engl J Med 2011; 364: 2086–89. Stinson K, Jennings K, Myer L. Integration of antiretroviral therapy services into antenatal care increases treatment initiation during pregnancy: a cohort study. PLoS One 2013; 8: e63328. Zerhouni EA. Translational and clinical science—time for a new vision. N Engl J Med 2005; 353: 1621–23.
In their Health Policy article, Jim Yong Kim and colleagues1 present a practical and coherent approach for delivering quality care to those facing both poverty and serious illness. The delivery of efficient and effective care to those living within a synergistic clustering of epidemics, or syndemic,2 is indeed a challenge—one that nurses caring for individuals with HIV/AIDS know well. Implementing valuebased chains that recognise the need for shared delivery infrastructure, alignment of delivery with local context, and attention to the social and economic determinants of health will require governments, healthcare administrators, health-care providers, and donors to step away from traditional siloed approaches for specific conditions. We endorse Kim and colleagues’1 call for integration to occur with attention to the local context, across diseases and intervention, within and between health clinics and hospitals and among providers (including physicians, nurses, and community health workers). To accomplish this goal we want to emphasise the crucial need to embrace a shift to interprofessional collaboration, shared care, and shared decision making. Nursing has been intimately involved in the gains achieved in preventing and www.thelancet.com Vol 383 February 22, 2014
