Pneumonia, diarrhea and measles are the leading causes of death in children worldwide, but have a disproportionately low share of international funding and media attention Lexis Nexis, Factiva, and Google News Archive were searched for the diseases AIDS, TB and Malaria and for lower funded pediatric diseases: childhood pneumonia, diarrhea, and measles. A sample of news articles across geographic regions was also analyzed using a qualitative narrative frame analysis of how the media stories were told.The news databases There were significantly more articles addressing the Global Fund diseases compared to the lower funded pediatric diseases between 1981 and 2008 . There were also notable differences in the framing of media narratives: 1) There was a high proportion of articles with the primary purpose of raising awareness for AIDS, TB and malaria (46.2%) compared with only 17.9% of the pediatric disease articles. 2) Nearly two-thirds (61.5%) of the AIDS, tuberculosis and malaria articles used a human rights, legal or social justice frame, compared with 46.2% for the lower funded pediatric disease articles, which primarily used an ethical or moral frame.This study demonstrates that lower funded pediatric diseases are presented differently in the media, both quantitatively and qualitatively, than higher funded, higher profile diseases. Clearly, variations in the burden of disease are well documented and many organizations and efforts have been developed in an attempt to respond to and lower the burden of disease on children. This is an area were the relationship between scientific data and social responses can be investigated. For instance, the substantial burden of disease from childhood pneumonia has been recognized but the disconnect between the disease burden and funding level for research and in development aid has been highlighted  [2], [3]Policy decisions about funding do not occur in a sociopolitical vacuum. The media play an important role in both providing information to policy makers as well as influencing public deliberation on public health issues Previous media content analyses have examined the news coverage of neglected diseases like leishmaniasis and trypanosomiasis and high profile diseases like AIDS. However these studies have been conducted on specific topics rather than in comparative analyses The diseases of the GFATM - AIDS, tuberculosis and malaria - were chosen for comparison to neglected childhood diseases because of their high profile and substantial piece of total global health funding. While AIDS and tuberculosis and especially malaria affect children as well as adults, these diseases were singled out because of their success in attracting both funding and media attention. Diarrhea and childhood pneumonia were chosen as key pediatric diseases, given their tremendous burden of disease and disproportionate underfunding. Measles was also included in the study, as a childhood disease with a relatively low profile on the world stage, a proven low-cost intervention, and relative underfunding Google News Archive, Factiva and LexisNexis News. Online news sources were utilized given their ease of access and the broad search capabilities of online search engines. A Project for Excellence in Journalism has also demonstrated a heavy emphasis of online news (as opposed to print and other media) on foreign news - particularly relevant given the global scope of this project News articles for this media analysis were selected using the following online databases and search engines: Historical trend analysis which involved a quantitative analysis of articles from 1981 to the present published on each of the diseases. The quantitative sample included all the articles available in online databases of print media - that is, online sources of newspapers as well as traditional print media articles available online; 2) a Content and narrative analysis of a sample of current online articles across geographical regions from January 1, 2008 to August 1, 2009 to understand the range of current sociopolitical dialogue around these diseases. This smaller sample allowed in-depth analysis of the selected media pieces: using a qualitative frame analysis to investigate how these stories are presented in the media. The sufficiency of qualitative sampling is determined by whether the thematic findings are repeated and predictable patterns emerge. If the initial sample had been insufficient based on these criteria, more articles would have been selected.There were two major categories of analysis: 1) a The search terms used in both the broad historic analysis and the geographic sample were: “childhood pneumonia”, “diarrhea/diarrhoea”, “measles”, “HIV, HIV/AIDS”, “TB/tuberculosis” and “malaria”. While these search terms are broad, they allowed for more standardized chronological comparison. The use of additional terms under the rubric of these overarching disease categories, such as rotavirus in addition to diarrhea, would have expanded the search, but cross-comparison across time and topic would be problematic given, for example, that advances specifically related to the rotavirus vaccine are relatively recent. For each disease category, the search terms “child”, “children”, and “pediatric” was added to generate a list of articles relating to a pediatric population. A single reference to these pediatric population terms was the minimum requirement for such articles to be included as mentioning or referencing children in the quantitative analysis. Whether the articles were primarily focused on such pediatric populations was assessed in the qualitative frame analysis of the articles.Google News Archive was used with the disease-specific search terms. These terms were searched from the period of 1981- the emergence of HIV/AIDS - to December 31, 2008. To clarify whether the disease terms were a prominent focus of the article, rather than just appearing once , a search for the terms in the headline or the first paragraph was done using the search engine Factiva. Total direct funding of these diseases from 1996–2003 (for which data are available) was compared to the number of articles as well as disease burden as measured by disability adjusted life years (DALYs), to analyze any possible correlation between funding, media coverage, and burden of disease.To determine trends in the number of media articles over time covering the lower funded pediatric diseases as compared to AIDS, tuberculosis and malaria, the search engine To choose global media with the broadest reach and greatest prominence, the top circulating newspapers in each of the World Health Organization (WHO)'s six geographic areas were sampled and coded by geographical region. Papers with leading circulations in these regions, and their online English language editions, were identified based on World Association of Newspapers listings. For these leading papers, the top hits on the search engines for the search terms (e.g. “childhood pneumonia”) were used Sampling from the six WHO geographic regions was meant to help account for varying socio-cultural and geographic factors in media coverage (maximum variation sampling). With six diseases  being compared, a sample of three articles of each of the six diseases from the top circulating papers of each of the WHO regions were screened, for a total of 108 articles targeted for inclusion.Articles were selected based on inclusion of the disease-specific search terms in the full-text. These terms had to be mentioned at least twice in the article to be included in that category of health topic. Articles were searched using the online search engines for the time period from January 1, 2008 to August 1, 2009. 78 news articles met the inclusion criteria. Of these, 39 met inclusion criteria for childhood pneumonia, diarrhea or measles (lower funded group), and 39 met inclusion criteria for AIDS, tuberculosis or malaria (higher funded group).Both quantitative content analysis and qualitative frame analysis were employed. The full coding framework is available in the The articles selected for analysis, in to being categorized by the six diseases being compared, were also coded by: type ; age of affected population; and media ownership.how issues are presented in the media. Such analysis is crucial to understanding meanings and effects on audiences Frame analysis takes into account In addition, because perceptions of economic costs may influence public policy, articles were analyzed for costs mentioned. Given that misperceptions of the efficacy of proven interventions may cause underfunding, articles were also analyzed for interventions mentioned as well as their reported impact.Three coders coded the selected articles using the coding sheet. Inter-rater reliability was tested for agreement by coders cross-coding the same articles and comparing percent category agreement. Using an iterative process, intercoder reliability achieved a reliability of .72. That is, an initial sample of articles was coded as a test of the coding framework. Initial intercoder reliability was .51; further revision of the coding framework, training of coders, and review to achieve consensus on framing analysis led to a reliability of 0.72, which is considered acceptable for exploratory studies such as this one.2) test.Statistical analysis of categories with significant differences was performed using a chi-square  as compared to childhood pneumonia, diarrhea or measles  .While the total number of articles mentioning diarrhea are comparable to the number of articles on malaria or tuberculosis , the numFor each of the diseases searched, there is a large discrepancy between the amount of pediatric news coverage as a percentage of each disease's total news coverage, and the relative disease burden the pediatric population carries (measured by DALYs) .Each of the diseases where the pediatric population carries the greatest burden - malaria, pneumonia, diarrhea and measles, were underrepresented in the news media. The two diseases where the pediatric population carries the minority of the burden - HIV/AIDS and tuberculosis - were, if anything, “over-represented” in the media. This was most marked for HIV/AIDS, where the percent of news coverage for the pediatric population was double the pediatric disease burden percentage, as measured by DALYs (36.6% of the AIDS news coverage versus 18.0% of the disease burden).When media coverage for each of the six diseases is compared to both disease burden and funding, there appears to be a correlation between media coverage and amount of funding rather than disease burden .  .Other quantitative content analysis showed no significant differences between the pediatric diseases and the AIDS, tuberculosis and malaria group of articles in regard to the article type  and whether the news source was publicly or privately owned. In both groups there was a strong trend towards news sources with mixed ownership .In the qualitative narrative frame analysis of the news stories as a whole, there was an even distribution of tone in terms of negativity, neutrality and positivity . Twice aThere was a higher proportion of articles with the purpose of raising awareness in the AIDS, TB and malaria group (46.2%) than articles on childhood pneumonia, diarrhea and measles (18.6%).Economic costs and interventions mentioned in the articles were part of the coding framework for analysis, but not enough instances were noted in the articles for any meaningful comparison.The differences in the narrative analysis between the lower funded pediatric group when compared to AIDS, tuberculosis and malaria, suggest differences in the meta-stories/sub-themes and the protagonists . Sixty-oThis study found that while there are similarities in the presentation of global health news stories, there are important differences between the quantity and the qualitative framing of stories for highly funded global infectious diseases as compared to lower funded primarily pediatric diseases, which have as much or greater burden of disease.Similarities in media coverage across all the topics include the types of news sources, the newspaper sections where these stories appear, and the general tone of these stories. Most of the news stories included broad statistical data, usually suggesting potential risk of these diseases to the audience, and frequently in a national context. These stories often revolve around a new initiative or plan, with either an implicit or explicit plea to the audience for these initiatives, and are more likely to suggest a resolution to the problem than not. This hopefulness is an interesting contrast to the tone of the articles, which as a whole are more likely to be negative than positive.There are also key differences between coverage of the different diseases. The most glaring is the sheer volume of news coverage about the diseases of The Global Fund To Fight AIDS, Tuberculosis and Malaria (GFATM), which dwarf the number of stories about the disease with the greatest burden: childhood pneumonia. Measles was also underrepresented, but not to the same degree. Of interest is the relatively high number of articles mentioning diarrhea overall, but this could be related to adult diarrhea associated with travel and tourism. When headlines and first paragraphs are searched for diarrhea, the number of articles actually focusing on childhood diarrhea is relatively small, and more closely mirrors the other lower funded pediatric diseases. Furthermore, when the number of articles for diarrhea is disaggregated for infant and other pediatric populations, this paucity of news coverage is even more pronounced.News stories on AIDS, tuberculosis and malaria also tend to have a higher profile protagonist  working as part of a global health or social justice movement, and a more global story dimension. A Kaiser Family Foundation study of media coverage of HIV/AIDS from 1981–2002 bears out this shift in focus from domestic disease to a global perspective, at least in terms of the AIDS pandemic A striking finding is how little focus there is on children in the media covering diseases that afflict mostly pediatric populations. Of interest, and the most glaring example, is malaria, where 95.5% of the disease burden is carried by children, but where focus on the pediatric population accounts for only 16.0% of the media coverage Google News Archive over time for all of the diseases searched. This may be due to the rise of the internet over this time period, with more venues for news stories, as well as more uploading of material over time. This could also be due to the already observed international bent of online media - with the increase in online news sources more international coverage leads to more stories about diseases with a global impact. Could this increase also be due to a general increase in funding for these diseases overall? In particular, the advent of the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), the President's Emergency Plan for AIDS Relief (PEPFAR), and the Bill and Melinda Gates Foundation could have played a role in this trend in funding and subsequent increase in media coverage for the higher funded diseases. The rise in the number of HIV/AIDS articles around 2000 is most striking, and this study likely underestimates the number of articles referencing AIDS . Malaria and tuberculosis hew to this rising curve of AIDS articles over time most closely, and the possibility of a “coat-tail” effect should be considered. Specifically, the lumping together of these higher funded diseases in the GFATM may have broadened not only their funding, but media coverage as well through the announcements of new initiatives and policies engendered by this money.There are a number of possible explanations for the quantitative differences observed in this study. There is a strong trend for an increase in the number of “hits” using The qualitative differences in this study also raise interesting questions. This study observes trends towards a human rights movement and social justice framework within the AIDS, tuberculosis and malaria articles, as well as a trend towards raising awareness. This may be led by the inherent nature of the AIDS epidemic, with all of the issues of gender and sexual preference discrimination, as well as the mobilization of previously disenfranchised groups playing a role. AIDS activism has historically utilized a human rights framework to great effect. When the data in this study are disaggregated, the malaria and tuberculosis articles seem to hold to this activist/global movement framework, but this, again, may be related to the grouping of these diseases in the GFATM. Likewise, the moral, “right thing to do” framework of the lower funded disease articles may be due to the inherent nature of these primarily pediatric diseases, where there is no real child activist movement.Examples of these types of thematic analyses reveal the challenges inherent in qualitative analysis. Some articles were relatively easy to classify. For example, the following is the opening paragraph categorized as a human rights/legal/social justice meta-story: “HIV/AIDS high-risk groups, who are already reluctant to seek medical help for reproductive health services for fear of stigma, risk greater discrimination if the state includes religious values in articles regulating reproductive health services, a doctor warns.” As a result TB in countries with International Monetary Fund loans rose sharply, they claimed.” Other qualitative aspects of the nature of these diseases - not answered in this study - could affect media coverage. For example, is the “simpler” nature of a disease such as malaria, with only one pathogen, and relatively straightforward prevention (bed-nets) and treatment (a few days of pills) related to its greater success in attracting media attention and funding? In addition, is there nothing new, and by implication, newsworthy, in the world of childhood pneumonia, diarrhea, and measles? Prevention and treatments are known, but there are relatively few initiatives, especially in comparison with the higher funded diseases like AIDS, where people are marching in the streets, newly funded programs are constantly be announced, and exciting developments like a possible AIDS vaccine always seem to be on the horizon. For a story to “have legs”, it has to move. Lastly, the power of celebrity involvement in the funding and attention for higher profile, better funded diseases should not be underestimated.This quantitative analysis raises the question: is there a cyclical relationship between global funding and media coverage ? Activisframing this as a moral issue 2) putting a potentially complicated topic into a relatively straightforward schema for people to be able to process the information and 3) priming, that is, activating these frames in the public sphere through active campaigns and subsequent broad media coverage. A prominent tool in this media campaign was the testimony of landmine victims. But the “moral/right thing to do” framing has appeared to have had little success in generating either significant funding or media attention for certain neglected diseases. Perhaps this is because there are no real childhood pneumonia, diarrhea or measles victims to testify - they either succumb to the disease or get better.The trends suggested in the qualitative analysis raise questions for activists and policymakers in terms of framing. Which framework is advantageous: a “moral/right thing to do” or a “legal”, “human rights” framework? There are examples where both moral and human rights or legal frameworks can be successful. The “moral/right thing to do” framework can be a potentially powerful way to change public policy. A notable example affecting pediatric populations is the Ottawa Treaty to ban antipersonnel landmines Evidence for a legal, human rights approach to a pediatric disease is suggested by the success of the suit brought by the media savvy Treatment Action Campaign (TAC) in South Africa to change governmental policy on providing nevirapine to reduce mother to child transmission of HIV Whether a human rights approach for pediatric populations can be broadened from a purely legal approach to a media and funding framework remains to be seen. But our analysis suggests there may be much to learn for policymakers from the history of such successes, warranting further study. A dichotomy does not need to exist between those seeking childhood pneumonia funding and those seeking funding for AIDS and other diseases. Rather, the success of agenda setting by the AIDS community may be duplicated in other contexts.Google News Archive are unstable as tools and depend on the proprietary algorithms used that are continually changed; thus results of searches for a defined time period can differ over time. Relative numbers are thus more pertinent than absolute numbers.There are a number of limitations to this study. First, the time frame for the articles in the content analysis sample was narrow, from January 1, 2008 to August 1, 2009. This sample looked at the most recent news cycle; media coverage about a topic such as AIDS is constantly in flux, and evolves over time For the qualitative frame analysis, this was a preliminary analysis of a limited number of articles that highlighted certain themes. More research is needed to investigate the trends suggested in these findings.The preliminary media analysis in this study raises a number of questions for those seeking funding and media attention for neglected pediatric populations. Should activists re-think the framing of neglected childhood diseases in the context of agenda setting for media, such as a legal, human rights or social justice framework? Should activists be engaged from the ground up ? Finally, does it make sense to expand the GFATM to include neglected diseases, based on global burden of disease and other agreed on criteria by the global public health community? This would be a way to take advantage of the “coat-tail” effect of grouping diseases with AIDS and avoid separate funding organizations when effective infrastructure and administration already exist. A notable example suggested by this study is malaria - a primarily pediatric disease with significant funding from the GFATM.Clearly, more research in this area is needed. Directions for future media research could include examining qualitative  trends over time, expanding the comparative approach of this study to other public health issues, and expanding the sample size of articles to test the theories established through qualitative analysis in quantitative studies.The media are just one potential factor in how global health policy agendas are set and funds are appropriated to fight diseases. Many other factors, beyond the scope of this study come into play. The question of whether the media merely reflect or affect global policy is also beyond the scope of this study. But this study does demonstrate quantitative and possibly important qualitative differences between highly funded “media success” diseases like AIDS, tuberculosis and malaria versus the lower funded primarily pediatric diseases childhood pneumonia, diarrhea and measles. Broad, often tragic statistics, pleas to the audience, and new discoveries and initiatives are common themes to all these news stories. To garner the world's attention like the AIDS story, a story needs a strong narrative and an identifiable voice for those that have had less presence in the media.Supporting Information S1Media analysis coding sheet.(DOC)Click here for additional data file.


P < 0.001). Considering the lack of data on morbidity related to Chagas disease and AIDS coinfection, the use of mortality data may be an appropriate sentinel approach to monitor the occurrence of this association. Due to the epidemiological transition in Brazil, chronic Chagas disease and HIV/AIDS coinfection will be further complicated and require the development of evidence-based preventive control measures.Chagas disease in patients with HIV infection represents a potentially serious event with high case fatality rates. This study describes epidemiological and clinical aspects of deaths related to Chagas disease and HIV/AIDS coinfection in Brazil, 1999–2007. We performed a descriptive study based on mortality data from the nationwide Mortality Information System. Of a total of about 9 million deaths, Chagas disease and HIV/AIDS were mentioned in the same death certificate in 74 cases. AIDS was an underlying cause in 77.0% (57) and Chagas disease in 17.6% (13). Males (51.4%), white skin color (50%), age group 40–49 years (29.7%), and residents in the Southeast region (75.7%) were most common. Mean age at death was significantly lower in the coinfected (47.1 years [SD ± 14.6]), as compared to Chagas disease deaths (64.1 years [SD ± 14.7],  Trypanosoma cruzi, is a well-known opportunistic infection in people living with HIV/AIDS [Chagas disease, caused by the protozoan parasite HIV/AIDS –6. ReactHIV/AIDS , 3, 4. NHIV/AIDS –4.T. cruzi coinfection was reported in the 1980s, but data on several issues are still scanty, such as the frequency of its occurrence, clinical and laboratorial profile of subjects with coinfection, survival rates, and mortality [The first case of HIV/ortality , 8. T. cruzi may occur not only in endemic areas, but also in wealthier regions that receive an increasing number of potentially infected migrants [Chagas disease is endemic in 21 Latin American countries. Due to migration of Latin Americans, an increasing public health impact has been observed in nonendemic countries, such as in Australia, Canada, Japan, Spain, and the United States –7, 9. Thmigrants . Despite the relevance, the clinical importance of this coinfection and its epidemiology is unknown in Brazil and other endemic countries . Here, wSIM—Sistema de Informação sobre Mortalidade). SIM data sets are based on the death certificates (Declaração de óbito), consisting of standardized forms to be filled out by the physicians in charge. Death certificates contain demographic data  and clinical information (underlying and associated causes of death).We performed a descriptive study on population-based nationwide mortality data, obtained from the Brazilian Mortality Information System .We included deaths that occurred in Brazil between 1999 and 2007, in which Chagas disease and AIDS were mentioned in the same Death Certificate, both as underlying or associated cause of death .Downloading of data sets and data processing has been described in detail previously . BrieflyChagas disease as a cause of death corresponded to the category B57 (Chagas disease), including all clinical forms of the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) . HIV/AIDIn addition, we present clinical forms of Chagas disease and HIV/AIDS that were associated with coinfection. The description was performed by disease or disorders coded according to ICD-10. Individual death certificates may have more than one clinical form of Chagas disease or AIDS.Data were stored and analysed by STATA version 11 .This study was solely based on publicly available secondary anonymous data, with no possibility of identification of individuals. Thus, approval by an ethical review board was not necessary.Between 1999 and 2007, a total of 8,942,217 deaths occurred in Brazil, with 53,930 (0.6%) deaths related to Chagas disease, and 103,075 (1.1%) related to HIV/AIDS. We identified 74 deaths in which Chagas disease and HIV/AIDS were mentioned on the same Death Certificate, either as underlying or associated causes of death. Of these coinfected cases, AIDS was an underlying cause of death in 57 (77.0%), while Chagas disease was listed in 13 (17.6%). Chagas disease and HIV/AIDS were presented as associated causes in four deaths with other underlying causes: liver cancer (2), acute myocardial infarction (1), and skin abscess (1). P < 0.001).Clinical manifestations of HIV/AIDS included other infectious and parasitic diseases (ICD-10: B20.8) (37.8%) and unspecified HIV disease (B24) 29.7%; . In ChagT. cruzi/HIV coinfection has not been systematically evaluated in the majority of endemic countries for Chagas disease [This is the first national population-based analysis of Brazilian mortality data related to Chagas disease and HIV/AIDS coinfection. In fact,  disease . The dat disease . The mag disease . Triatoma infestans) and the control of transmission by blood transfusion [The epidemiology of Chagas disease has changed in recent decades, with a shift to older age groups, as a consequence of the control of its main vector  also presents variations between regions in the country, with lower coverage mainly in the North and Northeast Regions [Due to the lack of systematic data on morbidity related to Chagas disease and AIDS coinfection, the use of mortality data may be an appropriate sentinel approach to monitor the occurrence of this association. Mortality data can be considered as valid in Brazil, as they are well recorded in DATASUS database and undergo quality control , 17. LimWe consider data as highly representative, since all death certificates during the period 1999 to 2007 were included, in a country of continental dimensions.The use of multiple causes of death allowed to describe the magnitude and epidemiological characteristics of mortality related to Chagas disease and HIV/AIDS coinfection in Brazil. Due to the ongoing epidemiological transition from the predominance of infectious diseases to more chronic and lifestyle-related ones in Brazil, chronic Chagas disease and HIV/AIDS coinfection require comprehensive and reliable information that supports the development of preventive control measures. There is a clear demand for comprehensive care from primary service providers to reference centers and to structure a network of comprehensive care to deal with this situation, with the mobilization that goes from primary care to highest level of technological complexity.


Alcohol consumption is causally linked to nonadherence to antiretroviral treatment that in turn causes an increase in HIV/AIDS mortality. This article presents a method to calculate the percentage of HIV/AIDS deaths attributable to alcohol consumption and the associated uncertainty.By combining information on risk relations from a number of published sources, we estimated alcohol-attributable fractions (AAFs) of HIV/AIDS in a stepwise procedure. First, we estimated the effect of alcohol consumption on adherence to antiretroviral treatment, and then we combined this estimate with the impact of nonadherence on death. The 95% uncertainty intervals were computed by estimating the variance of the AAFs using Taylor series expansions of one and multiple variables. AAFs were determined for each of the five Global Burden of Disease regions of Africa, based on country-specific treatment and alcohol consumption data from 2005.The effects of alcohol on HIV/AIDS in the African Global Burden of Disease regions range from 0.03% to 0.34% for men and from 0% to 0.17% for women, depending on region and age category. The detrimental effect of alcohol consumption was statistically significant in every region and age category except for the North Africa/Middle East region.Although the method has its limitations, it was shown to be feasible and provided estimates of the impact of alcohol use on the mortality outcome of HIV/AIDS. Alcohol has been identified as a major risk factor for mortality and burden of disease in past comparative risk assessments within Global Burden of Disease studies ,2. In paEvidence indicates a strong association between alcohol and HIV/AIDS ,6, but pAntiretroviral therapy has led to a change in the natural history of HIV -10. LimaAdherence is impacted by multiple variables such as injection drug use, forgetfulness, suspicions about treatment, complicated dosing regimens, number of pills required, decreased quality of life, and work and family responsibilities . AlcoholDespite the demonstrated role of alcohol use on antiretroviral medication adherence, research on and modeling of the effect of alcohol use on the HIV/AIDS burden of mortality and disease remain limited . This arWe conducted an analysis using data from the five Global Burden of Disease (GBD) regions of Africa. These regions were chosen for their high variation in both prevalence of HIV/AIDS and adult per capita estimates of alcohol consumption. These regions are defined as follows:• North Africa/Middle East: Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Occupied Palestinian Territory, Oman, Qatar, Saudi Arabia, Syria, Tunisia, Turkey, United Arab Emirates, Western Sahara, Yemen• Sub-Saharan Africa, Central: Angola, Central African Republic, Congo, the Democratic Republic of the Congo, Equatorial Guinea, Gabon• Sub-Saharan Africa, East: Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mayotte, Mozambique, Rwanda, Somalia, Sudan, Tanzania, Uganda, Zambia• Sub-Saharan Africa, South: Botswana, Lesotho, Namibia, South Africa, Swaziland, Zimbabwe• Sub-Saharan Africa, West: Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Côte d'Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Saint Helena, Sao Tome and Principe, Senegal, Sierra Leone, Togo2006 Report on the Global AIDS Epidemic [Country data on the proportion of people who are in need of antiretroviral therapy and receive such treatment were obtained for 2005 from the Epidemic . RegionaIn order to establish the prevalence of nonadherence, we adopted an estimate of 40.1% for the rate of nonadherence to antiretroviral treatment , provided by Lima and colleagues ,22. This1 = risk of people in antiretroviral treatment adhering on an arbitrary scale3.13 = risk of people in antiretroviral treatment not adhering to treatment1.85 = risk of people in antiretroviral treatment overall (assuming 0.401 nonadherent)4.88 = risk of people not in treatmentMultiple sources were used to characterize the relationship between alcohol consumption and nonadherence to antiretroviral therapy and the effect of nonadherence on HIV/AIDS-related mortality. To characterize the effect of alcohol consumption on antiretroviral adherence, we used the odds ratio of 0.60  from the meta-analysis performed by Hendershot and colleagues ,22 for aContinuous modeling of the effects of alcohol use on adherence ,25 was iThe attributable fraction (AF) is defined as:where P represents prevalence of exposure and RR represents the relative risk for exposure compared to no exposure. Depending on the design of the original epidemiological study, the RR information could be derived from hazard ratios, risk ratios, or odds ratios.However, for the AAF of mortality due to not adhering to antiretroviral therapy for people with HIV/AIDS, the lack of research and limited information available on the effects of alcohol on HIV/AIDS forced us to calculate the AAFs for HIV/AIDS-related mortality in several steps .First, we calculated the adherence attributable fraction (AdAF) using a definition of nonadherence as adherence to antiretroviral therapy less than 95% of the time. The AdAF represents the fraction of HIV/AIDS-related deaths attributable to nonadherence to antiretroviral therapy, and is calculated as follows:adher is the proportion of people adhering to treatment more than 95% of the time, Pna is the proportion of people adhering to treatment less than 95% of the time, and RRna is the relative risk of mortality for those who are not adhering compared to those who are.where PSecond, we calculated the nonadherence due to alcohol attributable fraction (NAAAF) - the proportion of nonadherence due to alcohol consumption - as follows:drink is the proportion of drinkers among the antiretroviral-treated HIV-infected population, Pabs is the proportion of abstainers, and RRdrink is the relative risk of nonadherence for drinkers compared to nondrinkers. Table where PFinally, we needed to know the proportion of deaths of people under treatment compared to the total number of deaths in the population due to HIV infection. Because the exact numbers are not known, we estimated this proportion using the hazard ratio for deaths in people without treatment compared to people with treatment. This proportion of deaths of people undergoing treatment (PDT) was calculated as follows:treat is the proportion of HIV-infected people receiving treatment, Pnontreat is the proportion of HIV-infected people not receiving treatment, and HRnontreat is the hazard ratio of people without treatment. It should be noted that hazard ratio and relative risk are synonymous in this case. These three proportions can be combined to calculate the AAF for HIV/AIDS mortality for a given population.where PIt is possible to derive a mathematical expression of the variance of the AAFs when the variances of each parameter making up the final expression are known. Calculating the variance of the AAF of HIV/AIDS-related mortality requires the combination of several steps. Because these steps involve Taylor series expansions, they yield only an approximation of the real variance. We calculated the variance of the AAFs by calculating the variance of the simplest combinations first, which were then used in more complex functions. The derivations of the variance of two distributions and the derivation of the variances using Taylor series expansions can be found in 'additional file In the literature, the uncertainty intervals for AFs due to risk factors based on meta-analyses are usually computed using a Monte Carlo-type method . The MoThe AAF samples are obtained by randomly generating each parameter using the information we have on its distribution. The main advantage of this method is its broad range of applications. The method can be applied to virtually any field and any function and is especially useful in cases in which an algebraic solution to a problem is impossible to derive. Our AAF, however, is a relatively simple function of several independent variables that makes the use of Monte Carlo samples unnecessary. Indeed, an algebraic solution, when possible to obtain, should always be preferred to a simulation, as the results are more precise and require fewer resources. In fact, the results obtained with this method are generated instantaneously on any computer and do not require the use of servers or the handling of large datasets, as is usually the case with a Monte Carlo analysis. In addition, a decomposition of sources of variation and their relative contribution to overall variance can be obtained more readily. Even though it is possible to derive only an approximation of the variance of the original function using second order Taylor series expansions, the assumption that the spread of the function around its mean value is relatively small guarantees an accurate result. The variations around the point estimate of each AF function depend only on the variance of the parameters used; therefore, knowledge of these parameters is important. It should be noted that for large variances of each parameter, the error in the variance of the final function will increase as the assumption of small variations is not satisfied. This is not specific to the analytic expression derived here, but would also affect a Monte Carlo method for which a convergence would not be ensured unless a very large number of data points are collected . Finallyna and RRna described in the previous section, we derived a mathematical expression for the variance of AdAF and NAAAF using Taylor series expansions. The complete derivations can be found in 'additional file Using the variances of PFor AdAF:whereAnd for NAAAF:whereThe variance of the proportion of deaths of HIV-infected people under treatment (PDT) cannot be derived using the above methods. Since the variance of PDT is a function of two variables, we used a Taylor series expansion performed in two dimensions. These derivations are shown in additional file Ptreat and DHRnontreat are the partial derivatives of the PDT function with respect to Ptreat and HRnontreat and can be expressed as follows:where DIn this manner, the variances of all three components of the final AAF function are determined. Using the variances for AdAF, NAAAF, and PDT, the variance of the AAF can be determined by the variance of (AdAF·NAAAF) PDT  for men aged 15 to 34 years, and 0.27  for men aged 35 to 54 years. In women, the highest AAFs are observed in the sub-Saharan Africa regions; however, unlike the men, the AAFs are very similar for the East, South, and West regions.This method allows a systematic computation of partial AAFs for HIV/AIDS in any given population, including the 95% uncertainty intervals. Despite the limited information available, the results show a clear negative impact of alcohol on adherence to an antiretroviral treatment regime and consequently on the outcome of the disease, especially in the sub-Saharan regions of Africa. Although the AAFs are relatively low, HIV/AIDS was responsible for 58.5 million DALYs in 2004 , indicatThe very broad categories used to describe alcohol consumption and adherence to antiretroviral therapy do not allow us to distinguish between moderate and heavy drinking or different percentages of nonadherence, and future research will be necessary to estimate a more accurate AAF for HIV/AIDS mortality. Ideally, AAFs would be estimated by using a continuous distribution of alcohol consumption and the risk relations for adherence to antiretroviral treatment associated with each level of consumption, as well as by specific patterns of drinking, such as heavy occasional drinking . Modelinhttp://apps.who.int/globalatlas/default.asp. Since we expect alcohol consumed as part of heavy drinking patterns to interfere more with antiretroviral treatment than moderate patterns of drinking [These results may not be relevant for all parts of Africa. Many Africans completely abstain from alcohol, while many of those who drink tend to do so heavily, resulting in comparatively small variations in drinking patterns among drinkers drinking ,33, our It is important to note that both the proportion of drinkers as well the proportion of people on antiretroviral therapy influence the AAF. Indeed, even though the proportion of drinkers in the sub-Saharan Africa, South region, is lower than in the sub-Saharan Africa, West region, the proportion of people in treatment is larger in the South region, which yields a larger overall AAF for this region. It is very likely that alcohol also has an effect on the progress of the disease in people without treatment that we did not estimate, but today's research does not allow us to deduce causality or quantify such an effect . ImproviAlthough the presented method could be improved by better definition and quantification of exposure, it provides an evidence-based conservative estimate of the impact of alcohol use on HIV/AIDS mortality and highlights the importance of further research in this field. It also points to the need to integrate alcohol prevention measures  into theThe authors declare that they have no competing interests.GG, KS, and JR conceptualized the overall article, contributed to the methodology, identified sources for risk relations and exposure, and contributed to the writing. GG was responsible for the derivations. All authors have approved the final version.Appendix 1 outlines the derivation of the AAF variance for HIV. The derivations of the variance of the multiplication of two independent random variables and the derivations of the variances of AdAF, NAAAF, and PDT, using Taylor Series expansions for one or multiple variables, are described.Click here for file


EHP 120(8):1100–1106; Tello et al.].Human and veterinary antibiotics enter the environment through wastewater effluent, agricultural use of manure and treated sewage for fertilizer, and leakage from waste storage facilities. This antibiotic pollution may exert selective pressure on bacteria to develop drug resistance, which is especially concerning if it develops in pathogenic bacteria. A new study weighs known bacterial antibiotic sensitivities against the backdrop of antibiotic concentrations measured in the environment and suggests that resistance in clinically relevant bacteria may not be kept in check by current risk assessment action levels [Ciprofloxacin, erythromycin, and tetracycline were selected for the analysis from among the approximately 150 compounds for which minimum inhibitory concentrations (MICs) have been reported for different bacteria. An MIC is the amount of antibiotic needed to inhibit bacterial growth. Each of the three antibiotics affects a wide range of bacteria and represents a distinct class of antibiotics used in humans and animals. Concentrations of each antibiotic in various environmental compartments, or media, had been documented previously.Current guidelines for environmental risk assessment reflect the phase I action limits of the International Cooperation on Harmonisation of Technical Requirements for Registration of Veterinary Medicinal Products. This program, which evaluates the safety of veterinary drugs, calls for environmental risk assessment of antibiotics whose concentrations exceed 1 ppb in aquatic compartments or 100 ppb in terrestrial compartments. These guidelines have been implemented in regulations in the United States, Europe, Japan, and Australia.The researchers compared information on antibiotic levels in the environment with information on the MICs of clinically relevant bacteria to determine if current levels of antibiotic pollution might be high enough to promote the development of resistance. Within aquatic compartments, only a small fraction of the 27 bacterial genera included in the study were predicted to be affected by environmental concentrations of antibiotics, and results suggested that the phase I action level would protect against resistance. However, current levels of antibiotic pollution in terrestrial compartments—particularly in river sediments, liquid manure, and farmed soil—may be high enough to favor the evolution of bacterial resistance.The conclusions may be limited by long-term selective pressure and by the fact that MIC tests do not represent environmental conditions. Furthermore, the authors did not address bioavailability or the potential influences of antibiotic mixtures, metals, or disinfectants. Nevertheless, the potential for antibiotic pollution to increase antibiotic resistance in clinically relevant bacteria has important implications for public health and environmental health policy, and the authors demonstrate a possible framework for answering important outstanding questions about the environmental impact of antibiotics.


In the context of HIV prevention interventions, counseling has proved a valuable operational tool. This method is characterized by the application of knowledge, personal qualities, skills  and communication techniques . The interview give the person counseling-user to make choices and changes in situations perceived as difficult to deal with his problems in an active way and its difficulties. The above constitutes the methodological basis of HIV / AIDS Helpline telephone counseling done by the National Institute of Health, established in 1987.The intervention of telephone counseling provided by AIDS HELP LINE Italian is structured in three phases: initial, intermediate and final. The actions that characterize the three phases of the telephone counseling are as follows:- Accommodating the person / service user and present the Service- To focus the problem and find a shared goal- Provide information scientifically accurate, current and customized- Propose and agree on possible solutions- Summarise and check what has emerged and what has been agreed- Saying goodbye properly, make themselves available for further contacts and enter into the relationshipThe Italian AIDS Helpline uses a data-entry software that allows you to collect data on calls received. The data are handled anonymously and analyzed in aggregate form.People - users in over 24 years, have turned to the AIDS Helpline Italian ISS are 671,823, of these 73.9% were males aged between 20-39 years (78.0%), reside in Central Italy, declare themselves heterosexual (55.1%) and raise questions regarding information on the procedures for transmitting HIV (27.2%) and ITER diagnostics (25.3%).The intervention of telephone counseling conducted by the AIDS Helpline Italian while placing no longer in a state of emergency and as a social alarm in the '80s, however, the data show that a significant number of people are taking advantage of telephone counseling intervention to express their information needs, clarify doubts and get information about the psycho-social-health services on national territory involved in the prevention, diagnosis and treatment of AIDS.


December 1st marks World AIDS Day with the theme ‘Getting to zero’. Three years ago, UNAIDS articulated what was then considered to be an ambitious vision, the aspiration for zero new HIV infections and zero-AIDS related deaths underpinned by zero discrimination. As we imagine the Post-2015 development agenda, we can and should reconceptualise this vision as a set of concrete goals.This Viewpoint argues that today’s rapidly changing world, including its shifting geo-political and economic landscape, requires policy responses that are context-sensitive. We highlight the Shared Responsibility-Global Solidarity agenda, as pioneered by the African Union in its recent Roadmap on AIDS, tuberculosis, and malaria, to illustrate ways in which global health can be re-thought to tackle twenty-first century challenges. In light of the emerging debate on what a Post-2015 development agenda and accountability framework should look like, we argue that the AIDS response offers lessons as a pathfinder which can pave the way for global health responses in which the most marginalised are at the centre of the debate, human rights are protected under the rule of law, strong accountability is in place for results for people, and community and participatory processes are the norm. These hard-learned and -won principles of the AIDS response are critical if we are to realize a world in which there is zero inequality and health justice for all. December 1st marks World AIDS Day with the theme ‘Getting to zero’. Three short years ago, UNAIDS articulated what was then considered to be an ambitious vision – the aspiration for zero new HIV infections, zero discrimination and zero-AIDS related deaths. As we imagine the Post-2015 development agenda, we now can and should reconceptualise this vision as a set of concrete goals.In 2011, for the first time in the history of the AIDS response, the number of people receiving antiretroviral therapy in low- and middle-income countries (just over 8 million) outweighed those needing treatment, but without access.The Economist’s shift from labelling Africa ‘the hopeless continent’[Yet the world is changing. Many traditional providers of Overseas Development Assistance are reducing commitments in the context of the Eurocrisis and its ensuing wake of financial turmoil. In the case of the AIDS response, international assistance from donor governments and philanthropies has remained stable over the past three years at around $8.2 billion. This shntinent’ in 2000,ntinent’. It is tAIDS has always been a pathfinder and it can continue to blaze a trail as the international community articulates what sustainability means and how to achieve it in a Post-2015 framework. Jim Yong Kim, President of the World Bank, alluded to this potential when he encouraged the international community to “join me in harnessing the moral power and practical lessons that the AIDS movement has produced to speed progress against that other global scourge, poverty”. ExperieRoadmap on Shared Responsibility and Global Solidarity for AIDS, Tubercolosis and malaria response in Africa, AIDS can lead to system-wide solutions for Tubercolosis, malaria and other infectious diseases. More specifically, the AIDS response can pave the way for Africa to enhance its industrial platform through developing its pharmaceutical sector, while emphasising with renewed vigour the importance of inclusive processes and heightened accountability for effective health governance. The Roadmap outlines three action ‘pillars’ – diversified financing, access to medicines and enhanced governance – through which Africa together with its development partners, can deliver sustainable health across the Continent[The potential of AIDS to act as a pathfinder is being seized by African leaders. As articulated in the African Union’s ontinent.The Roadmap also pioneers the concept of shared responsibility and global solidarity as an innovative paradigm for development. Rather than a discrete agenda, shared responsibility-global solidarity provides a new way of thinking about global health now and in the years after 2015. Its following elements are particularly instructive in this respect:Shared responsibility is not just about diversifying financing for development. In Africa, for example, it is also about developing the Continent’s pharmaceutical sector to ensure pharmaceutical security and building the knowledge economy. In this context, the African Union’s Pharmaceutical Manufacturing Plan for Africa (PMPA) should be supported and its effective implementation facilitated.Shared responsibility entails obligations across both nations and sectors. It involves increased cooperation and the integration of efforts between the public and private sectors and civil society.Global solidarity means working together to confront global challenges. In the case of AIDS, increased country ownership depends on the sustained commitment of global partners while the transition to greater ownership unfolds.Neither shared responsibility nor global solidarity can be achieved in isolation. The two must come together to reinforce one another.The power-imbalance embedded in development as charity is increasingly considered morally unacceptable. Shared responsibility-global solidarity moves away from traditional donor-recipient relationships towards novel forms of development cooperation and governance as exemplified by South-South and triangular cooperation.Increasing interdependence and complexity mark the canvas upon which global health in a Post-2015 environment will be painted – requiring brushstrokes which are at once bold yet nuanced and flexible. Shared responsibility and global solidarity provides a context-sensitive approach to ensure sustainable and equitable results in the rapidly changing development landscape.Achieving the ‘three zeroes’ is possible and shared responsibility-global solidarity can provide a means to get there. It can also provide new ways to re-think global health and to bring the lessons of the AIDS response behind a bid to achieve zero inequality and a world of health justice for all.The authors declare that they have no competing interests.KB conceived the article and contributed to the writing; RB contributed to the writing; MHN contributed to the writing. All authors read and approved the final manuscript.


Estimates of relative efficacy between alternative treatments are crucial for decision making in health care. When sufficient head to head evidence is not available Bayesian mixed treatment comparison models provide a powerful methodology to obtain such estimates. While models can be fit to a broad range of efficacy measures, this paper illustrates the advantages of using continuous outcome measures compared to binary outcome measures.Using a case study in rheumatoid arthritis a Bayesian mixed treatment comparison model is fit to estimate the relative efficacy of five anti-TNF agents currently licensed in Europe. The model is fit for the continuous HAQ improvement outcome measure and a binary version thereof as well as for the binary ACR response measure and the underlying continuous effect. Results are compared regarding their power to detect differences between treatments.Sixteen randomized controlled trials were included for the analysis. For both analyses, based on the HAQ improvement as well as based on the ACR response, differences between treatments detected by the binary outcome measures are subsets of the differences detected by the underlying continuous effects.The information lost when transforming continuous data into a binary response measure translates into a loss of power to detect differences between treatments in mixed treatment comparison models. Binary outcome measures are therefore less sensitive to change than continuous measures. Furthermore the choice of cut-off point to construct the binary measure also impacts the relative efficacy estimates. Meta-analysis has developed to be a widely used tool to combine trials evaluating the same intervention. This allows more powerful conclusions when a single study group is too small, and it fits naturally in the Bayesian framework where the inclusion of all available evidence into an analysis is anticipated . A naturThe variance of an indirect comparison is typically larger than the variance of a comparable direct comparison; the variance increases with every indirect link in the chain. It is therefore crucial to make the greatest use of available data.Using a case study in rheumatoid arthritis this paper presents a MTC model on a range of efficacy measures illustrating the increased power of continuous outcome measures in such models compared to using binary measures. For the presentation of the analysis we follow the checklist suggested by Spiegelhalter et al. .Dichotomized outcome measures are widespread in medical research. The perceived advantage of simplicity in the interpretation comes at a cost, however . The losIn this work we demonstrate the consequences of dichotomized outcome measures in the context of MTC modelling. It has been pointed out that dichotomization can be used when designing trials to quantify a treatment effect ,11. ThisRheumatoid arthritis (RA) is a chronic, progressive and disabling auto-immune disease, causing swelling and damaging cartilage and bone around the joints. Any joint may be affected but it is commonly the hands, feet and wrists. Common symptoms are joint swelling, pain, morning joint stiffness, poor sleep, fatigue and weight loss .α) are the first of the biologic treatment groups used in RA. There are currently five anti-TNF agents licensed for RA in Europe; adalimumab, certolizumab, etanercept, golimumab and infliximab. All of these agents have demonstrated considerable efficacy in placebo controlled randomized controlled trials (RCTs) in patients who have had an inadequate response to conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) such as methotrexate (MTX) or sulphasalazine.Over the past decade, enhanced understanding of the molecular pathogenesis has led to the development of biologic agents that target specific parts of the immune system. These innovative treatments have altered the path and face of RA and outcomes for patients and society. Tumour necrosis factor alpha antagonists , an extension of meta-analysis. Different methodologies have been described for MTC; one such method uses Bayesian hierarchical models. Such models provide more flexibility than classical methods to include more data and handle more complex modelling structures .αinhibitors and placebo for a range of outcome measures.The aim of this analysis is to demonstrate the advantage of using continuous measures in MTC models compared to using binary measures. In the present analysis a MTC model is fitted to estimate all pair-wise comparisons among the five TNF-Nixon et al.  have devWhile binary measures are useful for demonstrating a certain level of efficacy in clinical trials, we will show that the loss of information when changing from the underlying continuous scale to the binary outcome measure results in a loss of power to detect differences between treatments in MTC analyses.Fitting models for a continuous improvement measure and a discretised version thereof as well as for binary outcome measures and a continuous version of these illustrates the enhanced power to detect differences of continuous measures compared to binary measures.The chosen outcome measures are based on the ACR criteria and the HAQ score. Details are described in the next section.In order to estimate the relative efficacy between treatments one has to decide on a measure of disease activity and improvement. Commonly used measures in RA are the ACR criteria, the Disease Activity Score (DAS) and the HAQ score. Table The ACR response criteria is a binary combination measure including the number of tender and swollen joints, patient’s global assessment, physician’s global assessment, pain, degree of disability and level of acute-phase reactant. In order to achieve an ACR 20, ACR 50 or ACR 70 result, an improvement of 20%, 50% or 70% respectively is required in the swollen and tender joint counts as well as in 3 of the 5 remaining dimensions ,19.Continuous measures based on the ACR criteria have been introduced including the meanACR and the ACR hybrid measure . The meaThe HAQ score represents the result of a self-report questionnaire in which patients rate their ability to perform daily life activities such as washing one’s hair or getting in and out of a car. Values range from 0 to 3 in steps of 0.125, where high values indicate a more severe disease status. The improvement in HAQ score is measured on a continuous scale.For the purpose of demonstrating the enhanced power of continuous measures in MTC models we have defined a discretised version of the HAQ score: HAQ 20 and HAQ 50. They are defined analogously to ACR 20 and ACR 50. A patient achieves a HAQ 20 outcome, if his HAQ score has improved by at least 20%; a 50% improvement is required for HAQ 50.swollen28), tender joint count (tender28) (out of 28 defined joints), an evaluation of the patients general health (GH) and the erythrocyte sedimentation rate (ESR). The score is obtained using the formula . The interval for non responders is very broad covering a wide range of extreme values. The baseline analysis therefore assumes a conservative mean value of 0.00 for this group. This yields the control group estimates in Table The models calculate the relative efficacy among all anti-TNF agents and placebo. Relative efficacy for the continuous measures (HAQ improvement and ACRcont) was measured as difference in improvement. Relative improvement was modelled as a multiplier to baseline HAQ score. Odds ratios were calculated for the binomial measures ACR 20, ACR 50, ACR 70 and HAQ 20 and HAQ50. Thirteen trials were included for the HAQ analysis and sixteen for the ACR analysis.The MTC results are summarised in forest plots; in Figure The key point is that all differences between agents detected by the binary HAQ measures are also detected by the continuous HAQ improvement measure, while not all differences detected in the continuous HAQ model are detected using the binary HAQ data; the differences detected by the binary HAQ measures are subsets of the differences detected by the continuous HAQ improvement measure. This is also demonstrated in the ACR analysis. It illustrates the point made that a continuous measure of effect has a greater power to detect a difference between treatments in an evidence synthesis.This analysis illustrates the enhanced sensitivity to change of continuous measures in MTC models compared to using binary outcome measures, which was recently highlighted for epidemiological studies . While bMTC models are often utilized when faced with a choice of agents rather than for demonstrating efficacy. In the above application, for example, it is already known that all of the anti-TNF agents provide improvement in the treatment of RA. What remains is to determine whether some of these agents work better than others. Therefore it would be of interest to know whether an agent provides a 30% improvement or a 60% improvement. When looking at the ACR 20 outcome, no difference would be seen between the two response rates.The above analyses have shown two things. Firstly, the enhanced power to detect differences of a continuous measure as opposed to a binary measure was shown for both, the HAQ and the ACR measures. Secondly, the choice of cut-off level  has shown to have a strong impact on the results. Different significant results were detected when choosing different cut-offs; even the sequence of treatments when ordering from best to worse changes.It may be argued that binary outcomes are clear and easy to interpret. However, where binary outcome measures are required, results based on continuous measures can be transformed subsequently using cut-off points, .From a clinical point of view these results show that a MTC model based on continuous outcome measures provides greater precision of estimates of efficacy. This is of great benefit when carrying out an economic evaluation.The trials included for the analysis were conducted over a time period of 10 years. The model was extended to a meta-regression to include potential confounding parameters such as duration of disease, number of previous DMARDs and year of publication. None of these were found to have a significant impact and therefore were not included in the main analysis.Different prior distributions on the between trial variance parameter allowing for a wider range of values were tested, but did not alter the conclusions. Varying the precision parameter of the normal prior distributions for the remaining parameters between 1,000 and 100,000 did not alter the results either.The continuous ACR response underlying the binary ACR 20, ACR 50 and ACR 70 measures is estimated using the mean ACRcont response for each of the four responder groups. For the baseline analysis meanACR was used as the underlying continuous effect. In a sensitivity analysis a model was fit using the ACR hybrid as the underlying effect. This did not alter the results much, however, adalimumab was not found to be superior to infliximab in this scenario. There was substantial uncertainty regarding the mean ACRcont response in the control arms, as no patient level data was available. An additional model has been fit assuming the mean response in each group to be the same for treatment arms and control arms. While this did influence the biologic treatment effect versus control, the relative efficacy between biologic treatments was not affected much. Again, these models did not detect a difference between adalimumab and infliximab. Outcomes of the various MTCs can be accessed in Additional file The scale chosen for dichotomized outcome measures has been shown to influence outcomes of MTC models . In addiDoses across treatments and treatment arms varied, which has not been accounted for in the analysis. Generalising the model to include a meta-regression for dose would raise difficulties of comparability; doses across treatments are hard to compare as well as within one treatment when the same dose is given, but with different frequency.The analysis only includes RCT evidence. However, there exists a large body of observational data collected via registries and open label studies. The inclusion of such evidence is possible within this framework, helping to reduce uncertainty further .Patient level data allowed the estimation of mean ACR response within each of the responder groups. While this provided some additional information towards estimating the continuous ACR response measure, it did not replace the full information lost. The estimated ACRcont measure is still subject to high uncertainty. Patient level data of the RCTs included in the analysis would allow the exact calculation of the continuous ACR measure.The evidence network has a star design, which does not allow testing of the assumption of treatment exchangeability. Baseline characteristics across the trials were compared and and the model was extended to a meta-regression to explain the potential influence of differing demographics.This paper confirms the effectiveness of anti-TNF agents in the treatment of RA. The study illustrates the enhanced ability to detect differences between treatments when using continuous measures and shows the high dependency of MTC outcomes on the cut-off level when using binary data.Rather than steering away from binary measures, we would like to advocate the additional reporting of underlying continuous effect measures in clinical trials to facilitate further analyses. The importance of the involvement of statisticians in the choice of clinical measures has been recently highlighted .The authors declare that they have no competing interests.SS is responsible for the study concept and design, designed and implemented the MTC models and participated in the systematic review and data extraction. RR is responsible for the study concept and design and carried out the systematic review and data extraction. CW oversaw the design and implementation of the MTC models. All authors contributed to the interpretation of findings. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2288/12/167/prepubBugs code. Additional file providing the WinBUGs code and input data for the MTC model.Click here for fileBaseline Demographics. Mean Baseline Demographics of randomized controlled trials for anti-TNF agents.Click here for fileSensitivity Analysis (1). Additional file providing outcomes of the sensitivity analysis conducted on the continuous ACR measure.Click here for fileSensitivity Analysis (2). Additional file providing outcomes of the sensitivity analysis conducted on the risk ratio scale.Click here for file


MET genetic alteration, mutation, or amplification in oropharyngeal squamous cell carcinoma (OPSCC) could lead to development of MET selective kinase inhibitors. The aim of this study was to assess the frequency and prognostic value of MET gene mutation, amplification, and protein expression in primary OPSCC.Identification of A retrospective chart review was conducted of patients treated for single primary OPSCC between January 2007 and December 2009. Pre-treatment OPSCC tissue samples were analyzed for MET mutations, gene amplification, and overexpression using Sanger sequencing, FISH analysis, and immunohistochemistry respectively. Univariate and multivariate analyses were used to analyze correlations between molecular abnormalities and patient survival.143 patients were included in this study. Six cases (4%) were identified that had a genetic variation, but previously described mutations such as p.Tyr1235Asp (Y1235D) or p.Tyr1230Cys (Y1230C) were not detected. There were 15 high polysomy cases, and only 3 cases met the criteria for true MET amplification, with ≥10% amplified cells per case. Immunohistochemistry evaluation showed 43% of cases were c-MET negative and in 57% c-MET was observed at the tumor cell level. Multivariate analysis showed no significant association between MET mutation, amplification, or expression and survival.Our study shows a low frequency of MET mutations and amplification in this cohort of OPSCC. There was no significant correlation between MET mutations, amplification, or expression and patient survival. These results suggest that patient selection based on these MET genetic abnormalities may not be a reliable strategy for therapeutic intervention in OPSCC. Head and neck cancer (HNC) is the sixth most common cancer in the world, with approximately 635,000 new cases worldwide in 2008.MET is a receptor tyrosine kinase located on chromosome 7q31 that encodes several functional domains: the semaphoring (SEMA) domain (ligand-binding), juxtamembrane (JM) domain (regulatory), and the tyrosine kinase (TK) domain.MET is the hepatocyte growth factor/scatter factor (HGF/SF).HGF/MET signalling leads to various cellular responses, such as increased cell growth, cell motility, survival, angiogenesis, wound healing, tissue regeneration, and invasion/metastasis.MET activation can occur via multiple molecular events including: gene mutation, gene amplification, protein overexpression, or ligand dependent autocrine and paracrine loop.MET is overexpressed in various solid tumors MET overexpression, suggesting that the HGF/MET pathway plays a role in carcinogenesis.HGF/MET signalling could also interfere with response of oropharyngeal squamous cell carcinoma (OPSCC) to radiotherapy (RT).MET genetic alterations have been previously reported in HNC. MET Y1235D mutation  was found in 15 out of 138 patients (11%) with OPSCCMET Y1235D mutation and another mutation in the MET activation loop (Y1230C) were also detected in neck lymph nodes metastases from a primary HNSCC tumor.MET in 13.5% of the cases, and an increased MET gene copy number (>10 copies) in 3 out of 23 cases.Furthermore, MET genetic alteration, mutation, or amplification is present in a significant subset such as OPSCC is of high interest. This could lead to development of MET selective kinase inhibitors, since genetic alterations are often responsible for oncogenic addiction. There are various recent clinical trials that have already demonstrated the effect of MET inhibitors in patients with a variety of advanced or metastatic tumors, including non-small-cell lung cancer, and breast, prostate, liver, and renal cancer.MET gene mutation, amplification, and protein expression in OPSCC.The identification of a cancer type in which The Gustave Roussy Cancer Institute (IGR) Institutional Review Board gave approval for this study. Written informed consent was obtained from included patients, and patient confidentiality was protected throughout the study.A retrospective chart review was conducted for patients treated for a single primary OPSCC between January 2007 and December 2009 at the IGR. Patients with recurrences, multiple, synchronous, or metachronous lesions were excluded from this study.Pretreatment tissue samples were retrieved from the IGR Biobank. Most tissue samples were obtained by surgical biopsy and fixed using AFA, while tissue samples obtained during surgical resection were fixed with 10% formalin. Based on hematoxylin and eosin (H&E) staining, tissue samples with at least 70% tumor cells were selected. DNA sequencing, fluorescence in situ hybridization (FISH) assay, immunohistochemistry (IHC), and HPV detection were done in different laboratories, in a strictly blind fashion.MET exons 2 and 13 through 21 (NM_000245.2), exons already described as known locations for oncogenic mutations, were analyzed. Sanger sequencing was done following polymerase chain reaction (PCR) amplification of target exons. The primer sequences are reported in Genomic DNA was extracted from 10 to 20 µm tissue bloc sections from tumors using the DNeasy Blood and tissue kit  according to the manufacturer's instructions. The full coding sequences of Tests were done to detect the three oncogenic HPV strains  as well as the reference gene gACTB (β-actin) as previously described by Melkane et al.MET gene was performed on 4 µm tumor sections, using the ZytoLight SPEC MET/CEN 7 Dual Color Probe  according to the manufacturer's instructions. SNU-5 (ATCC® CRL-5973™) cell line xenografts bearing MET amplification were used as positive control samples to set up the FISH staining protocol. Briefly, the probe was co-denatured for five minutes at 84°C on the slide, and then incubated overnight at 44°C. Slides were washed with post-hybridization wash buffer (0.5X SSC/0.1% SDS) for five minutes at 37°C, after which they were air-dried and counterstained with DAPI dissolved in an anti-fade mounting solution. At least 100 tumor cells were analyzed, and the number of fluorescent signals within the nuclear boundary of each evaluable interphase tumor cell was counted using an Axiophot-ZEISS fluorescent microscope at 1000× magnification. Only nuclei with unambiguous centromeric (D7Z1 locus) hybridization red signals (as control) and MET (7q31) probe green signals were scored. Tumors were classified as previously described by Capuzzo et al.MET gene present in major clone of tumor cells, or when four MET gene copies were present in less than 40% of tumor cells. The term ‘high polysomy’ was applied if four to six copies of the MET gene were present in more than 40% of tumor cells. In order to declare ‘gain of gene’, more than one or two supplementary copies of the MET gene (compared to the centromeric probe) had to be present in tumor cells. Amplification was defined as a MET gene to centromere ratio >2.FISH for the MET and p-MET immunostaining using serial tissue sections. Briefly, antigen retrieval was performed with Cell Conditioning 1 (CC1) buffer at 95°C for 8 minutes, and then at 100°C for 28 minutes. After the endogen biotins blocking step, slides were incubated with the primary anti-antibody for one hour at 24°C for the rabbit anti-human c-MET  and at 37°C for anti-p-MET (Tyr1234/1235) . A post-fixation step with glutaraldehyde (0.05% in NaCl 0.9% w/v) for 4 minutes at 24°C was done. For MET detection, the secondary antibody biotin-SP-conjugated Affinipure goat anti-rabbit  was incubated at 24°C for 32 minutes at 0.5 microg/mL. For p-MET, the secondary antibody biotin free peroxidase multimer anti-rabbit UltraMap™ was incubated at 24°C for 16 minutes. Immunostaining was done with 3,3-diaminobenzidine tetrahydrochloride (DAB) from DABMap™ chromogenic detection kit according to manufacturer's recommendations. A counter-staining step was done with hematoxylin and blueing reagent was applied. Stained slides were dehydrated and coverslipped with cytoseal XYL .We performed Investigation using xenograft tumors was done to determine the impact of fixative type on p-MET detection. SNU-5 (ATCC® CRL-5973™) tumor cell line xenografts were divided into two groups, and placed in neutral buffered formalin  or AFA  fixative.Immunostained slides were scanned using the ScanScope XT system . Digitized images were captured using the ImageScope software  at 20× magnification.Staining evaluation included the histological site of reactivity, main type of reactive cell, staining, intensity, and cell staining frequency. The negative samples were scored as 0+. The positive samples were scored with a scale of intensity from 1+ to 3+. Ranges of intensities were described as weak (0 to 1+), moderate (1+ to 2) and strong (2+ to 3+). Cell frequency was the percentage of immunostained cells, and was estimated by observation by a histologist as the median per sample. The cell frequency was divided into five categories of proportion score: 1 (0–5%), 2 (6–25%), 3 (26–50%), 4 (51–75%) and 5 (76–100%).Descriptive statistics were used to summarize the study cohort. The Kaplan-Meier method was used to estimate overall survival (OS), progression free survival (PFS) and specific survival (SS). The evaluation and selection of covariates to be included in the multivariate model for survival was done as follows. The first step was to assess the correlation between covariates, in order to avoid keeping in the model two covariates when they are highly correlated and bring similar information. A threshold of 0.4 was used for this selection. Then, univariate analyses were conducted using Cox Proportional Hazards Model on the above factors to identify the variables with the highest correlation with OS, PFS, and SS. Lastly, the multivariate Cox Proportional Hazards Model was run using the stepwise procedure with a variable entry of 5% level and a variable removal at each step of 10% level. When two covariates were highly correlated according to the threshold previously defined, only the most significant one in univariate analysis was kept for the multivariate analysis.Medical files of 150 consecutive patients with OPSCC were reviewed. Of these patients, three presented with synchronous tumor lesions, three had recurrent disease, and one patient had insufficient tissue material available for laboratory studies, and were excluded. There were 143 patients included in this study . The majThe majority of tumors were localized in the tonsillar fossae and pillars (63%), or at the base of the tongue (14%). The macroscopic aspect of the tumors was exophytic in 88 cases (62%), and ulcerative or infiltrative in 55 cases (38%). Histopathologically, approximately half of the tumors was well-differentiated, and the other half was moderately or poorly differentiated. The majority of patients presented with T3 or T4 stage tumors, and had N1-N3 lymph node metastases. There were six patients (4%) with distant metastases at the time of evaluation, all with pulmonary metastases. According to the 2010 AJCC classification system, 29/143 patients (20%) presented with early-stage (stage I and II) tumors, while a majority of 114/143 patients (80%) had advanced stage (stage III and IV) disease.Most of the patients  in this study were treated in a curative setting. Patients were treated by RT; either exclusively , or by concomitant chemoradiotherapy (CRT) , and surgery; either exclusively , or followed by adjuvant RT or CRT . The remaining six patients (5%) with distant pulmonary metastases were offered treatment with palliative chemotherapy.Exons 2, 13, 14, 15, 16, 17, 18, 19, 20, and 21 were analyzed in all 143 cases, but due to low tissue sample quality, some cases had several failed PCR's (>5 failures) and were removed from further analyses. Overall, six cases (4%) were identified that had a genetic variation .Four of these mutations were located on exon 2, one on exon 15, and one on exon 18. The p.Val136Ile mutation has been previously detected once before in a kidney carcinoma caseMET gene, 23 had low polysomy, and 15 had high polysomy of chromosome 7 , but in non-tumor cells (at margin of tissue sample). AFA fixation resulted in complete disappearance of p-MET immunostaining , and there were 57/143 (40%) deaths observed. The median OS was 5.3 years. The probabilities of surviving  at one, two, and three years were 82.4% (CI: 76.1–88.7), 67.3% (CI: 59.5–75.1) and 64.5% (56.5–72.6) respectively. There were 71 oncological events  observed in the 143 patients. The median PFS was 4.4 years. The probabilities of having an oncological event  at one, two, and three years were 68.3% (CI: 60.7–76.0), 61.8% (CI: 53.8–69.9), and 57.5% (CI: 49.2–65.8) respectively. There were 30/143 (21%) cancer-related deaths. The positive HPV status, alcohol exposure, high tumor differentiation, T3/T4 staging, N1-3 staging, presence of metastases and advanced disease (AJCC classification III/IV) were significant at 5% for OS in the univariate Cox Proportional Hazards Model. Except N1-3 staging, these variables were also significant for PFS (at 5%). Univariate analysis did not show any significant association between OS, PFS, or SS and MET abnormalities including DNA mutations, gene amplification, and protein expression in primary OPSCC. Our study shows a low frequency of MET mutations and MET amplification in OPSCC. There was no significant correlation between MET mutations, amplification, or expression and patient survival.The aim of this study was to determine the frequency and prognostic value of MET genetic variations, four of which have not been previously described, though the clinical relevance of these variations remains unclear. Unfortunately, non-tumor tissue was not available to confirm if those mutations were somatic. Overall, our MET mutation incidence (4%) was low compared to a number of other studies. For example, Seiwert et al. found a 13.5% mutation incidence in the semaphoring, juxtamembrane, and tyrosine kinase domains of the MET gene in 66 HNSCC tumor tissues, as well as MET over expression in 84% of samples.In our study six cases were identified with MET receptor was present in all cases, point mutations were not detected.Previously described HNSCC mutations such as p.Tyr1235Asp (Y1235D)MET mutations use different DNA detection techniques. Our Sanger sequencing approach is known to detect mutation from 20–30% of mutated DNA. Our cohort included only samples with more than 70% of tumor cells. Nevertheless, our Sanger approach does not detect minor clones representing less than 20% of the tumor cell, but can detect unexpected mutations. More sensitive techniques such as the technique used by Aebersold et al.MET mutations are mainly present in minor clones. One the other hand, we could also stipulate that the present French cohort had a lower rate of MET mutation that other published cohorts.Studies investigating MET amplification and 15 cases with high polysomy. A previous study found >10 MET gene copies in 3 of 23 (13%) HNSCC tumor tissues.MET gene amplification has been associated with poor prognosis in gastric and lung cancer. Lee et al. recently found 61 MET high polysomy and 13 MET gene amplification cases in a cohort of 438 gastric carcinomas. In their study, gene amplification correlated with a poor prognosis.MET gene copy number, present in 11.1% of patients (high polysomy 8.7% and gene amplification 2.4%), was a negative prognostic factor for survival.MET mutations and amplification in this OPSCC study cohort could be explained, because MET may play a larger role in disease progression in other types of cancer, such as gastric or lung cancer.We also found a low frequency of amplification, with no correlation with patient survival. Out of 97 cases, there were only three cases that met the criteria for true MET mutations and amplification in our study cohort could be that tissue samples were from primary OPSCC's, and not from metastases. There is evidence from previous studies that MET mutations are primarily involved in tumor progression to the metastatic phase.MET mutations undergo clonal expansion during metastatic spread, as their frequency increased from 2% in the primary tumors to 50% in the metastases.MET overexpression was also found to be significantly higher in tumor stages associated with enlarged or multiple (N2-N3) lymph node metastases.MET molecular abnormalities could be higher in metastatic tissue than in primary tumors, such as the tissue samples studied in our cohort.Another possible explanation for the low frequency of MET expression and survival. This is in contrast with previous studies showing that MET expression is an early event in HNC carcinogenesisMET expression was increased from 2- to 50-fold in about 70% of tumors.Protein expression analysis showed that out of 107 analyzable cases, 46 cases (43%) were c-MET negative, and 61 cases (57%) were c-MET positive at the tumor cell level. We found no significant relationship between MET expression by IHC, various guidelines were used to classify data. For example, different cut-off values have been used to determine a positive result, such as MET expression in >10% of tumor cellsMET expression in >30% of tumor cellsIn previous studies analyzing MET molecular abnormalities was a relatively large number (62%) of HPV positive patients in our sample set. HPV dependant carcinogenesis may partially explain the relatively low incidence of MET abnormalities. It is even possible that HPV is a stronger predictive biological marker than MET.MET abnormalities.Unfortunately in our study, analysis of p-MET expression was only possible for select cases, since the AFA fixative caused complete disappearance of p-MET immunostaining. In the future, AFA fixative must be avoided when p-MET IHC is done on archival biopsies. Another factor that may have affected the incidence of MET may not be a reliable prognostic biological marker in primary OPSCC, and therefore that anti-MET therapy may not be the ideal therapeutic option for these types of tumors. Except for HPV status, we lack reliable diagnostic and prognostic molecular markers for HNSCC, including OSCC. Screening for MET molecular abnormalities in primary OPSCC may not be efficient, partly because previous studies have indicated that MET abnormalities are predominantly detected in case of metastases. Detection of MET abnormalities might be more appropriate as a marker of response to treatment. In a pilot study, Druzgal et al. compared pre-treatment and post-treatment cytokine levels in HNSCC, and found evidence for a strong relationship between HGF serum levels and both therapeutic response and survival.HGF/MET in oral SCC and found significantly higher HGF concentrations in metastatic cancer tissues, than non-metastatic or normal tissue. A decline in serum HGF was seen in tumor-free survivors.MET pathway plays a role in various human cancers, though ‘MET addiction’ only occurs in a small percentage of these cancers. There are tumors that only partially depend on MET signaling for growth and metastasis, which may be more difficult to detect using biomarkers.HGF/MET expression requires further investigation to guarantee clinical benefit.Our study indicates that MET mutations and amplification in this OPSCC cohort. There was no association between MET molecular abnormalities and patient survival. Our results indicate that these MET genetic abnormalities may not be reliable prognostic biological markers in OPSCC for patient selection for anti-MET therapy.There was a low frequency of