To describe the effects of PMTCT on health care services and systems in SSA and assess whether the PMTCT has strengthened or weakened health systems in SSATo describe the integration of PMTCT and its extent within broader programs and health systems.The global scale-up of Prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012. However, the epidemic continues to challenge maternal and paediatric HIV control efforts in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and AIDS. This systematised narrative review describes the effects of PMTCT programs on other health care services and the implications for improving health systems in SSA as reported in the existing articles and scientific literature. The following objectives framed our review:Articles published in English and French over the period 1st January 2007  to 31 November 2016 on PMTCT programs in SSA were sought through searches of electronic databases (Medline and Google Scholar). Articles describing the impact (positive and negative effects) of PMTCT on other health care services and those describing its integration in health systems in SSA were eligible for inclusion. We assessed 6223 potential papers, reviewed 225, and included 57.The majority of selected articles offered arguments for increased health services utilisation, notably of ante-natal care, and some evidence of beneficial synergies between PMTCT programs and other health services especially maternal health care, STI prevention and early childhood immunisation. Positive and negative impact of PMTCT on other health care services and health systems are suggested in thirty-two studies while twenty-five papers recommend more integration and synergies. However, the empirical evidence of impact of PMTCT integration on broader health systems is scarce. Underlying health system challenges such as weak physical and human resource infrastructure and poor working conditions, as well as social and economic barriers to accessing health services, affect both PMTCT and the health services with which PMTCT interacts.PMTCT services increase to some extent the availability, accessibility and utilisation of antenatal care and services beyond HIV care. Vertical PMTCT programs work, when well-funded and well-managed, despite poorly functioning health systems. The beneficial synergies between PMTCT and other services are widely suggested, but there is a lack of large-scale evidence of this. The global scale-up of Prevention of Mother-To-Child Transmission (PMTCT) services is credited for a 52% worldwide decline in new Human Immunodeficiency Virus (HIV) infections among children between 2001 and 2012 .This systematised narrative review describes the impact and integration of PMTCT programs on other health care services. We begin with an overview of prevention of mother-to-child transmission of HIV in the context of global AIDS control efforts, as well as an introduction to the concepts of integration of “vertical” or disease-based programs into broader health systems. We then present and discuss the findings of our review after having presented the methodology.The highest prevalence of HIV infection is in sub-Saharan Africa, where rates of both prevalent and new infections are consistently higher among women than men and most women are now diagnosed during pregnancy or at delivery through antenatal and perinatal care . The MotSince MTCT can be prevented through antiretroviral therapy (ART), a global campaign for its virtual elimination was launched on 21 May 2009 as one of the top priorities for the World Health Organisation (WHO), the Joint United Nations Programme on HIV and AIDS (UNAIDS), the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) . The polPMTCT, also called “prevention of vertical transmission”,  has beenThis PMTCT cascade reduces the chances for HIV to pass from an HIV-positive mother to her baby during pregnancy, labour, or delivery, or through breastfeeding , 6, 11. These multiple actors with their diverse agendas and policies initially delivered PMTCT services as a stand-alone and externally funded programme. The programmes progressively won the interest of governments and are now increasingly supported through public funding in many countries, while still requiring substantial donor support . With tiThe worldwide expanded access to PMTCT services prevented more than 670,000 children from acquiring HIV from 2009 to 2012 . In 2012Based on these promising PMTCT figures in SSA, it is possible to envisage achieving virtual elimination of MTCT. In addition, one could expect to see effects of PMTCT programs on other health care services because PMTCT is now largely implemented through existing maternal health programs and services. However, effects on health services and systems are likely to be uneven and complex.PMTCT is a complex intervention with many involved actors and policies, flows of knowledge, materials, technologies and funds, interacting at global, national and local levels , 21. BeyIf we conceptualise PMTCT as a service within a “continuum of care” approach addressing different periods of women’s and children’s life course, PMTCT programs could be seen to have potential beneficial synergies with other reproductive, maternal and child health interventions such as Sexually Transmitted Infection (STI) control, early childhood immunisation, antenatal and delivery care, family planning, nutrition supplementation . For exaThe potential impact of PMTCT on health services may go beyond maternal and child health specialities and may involve other health care services indirectly, with potential opportunities to enhance overall quality of care but also posing threats such as brain drain and redirection of resources from programs not related to HIV in contexts where there is already weak infrastructure. This raises questions regarding the appropriate approaches to address the challenges regarding the accessibility, equity, and quality of healthcare in the efforts to facilitate service delivery and strengthen health systems .The global monitoring framework and strategy put in place towards elimination of new HIV infections in children , reflectThe 2003 work of Oliveira-Cruz et al. on the synergies between vertical and horizontal health interventions , remainsThere is no internationally recognised definition of integrated care and to further complicate analysis, some researchers who address what could be considered as integrated service delivery do not use “integration” as a keyword . IntegraIn terms of implementation practices, PMTCT interventions may be carried out in one or more of the following health services: (1) antenatal clinic, (2) delivery/obstetric/labour ward care, (3) postnatal care, (4) neonatal/new born care, (5) paediatric/infant care, (6) nutritional programs, (7) HIV testing and support centres, (8) HIV treatment centres, (9) reproductive/gynaecological services, (10) sexually transmitted infection clinics, (11) family planning, (12) primary health care which in many settings may be largely focused on conditions such as malaria, acute respiratory infection, diarrhoea and malnutrition, (13) Emergency care, (14) Tuberculosis clinics, (15) Malaria clinics , (16) Immunisation, (17) or other service . It is wOne example that demonstrates the need for cooperative efforts to avoid negative effects of a vertical program on health systems and communities relates to the universal child immunisation goals. A study in six countries in Africa and Asia documented how a top-down model in immunisation interventions ended up creating conflicts between local demand and targets of immunisation policy, leading the authors to argue for more intersectoral collaboration if a specific programme is delivered and managed in a vertical way . This exBuilding on this overview of PMTCT and health system integration, this review sought to describe: (1) the effects of PMTCT on health care services and systems in SSA (2) the integration of PMTCT within broader programs and health systems and extent to which it occurred, and a related question (3) whether health systems as a whole have been strengthened or weakened in countries of SSA.To describe the impact of PMTCT on health care services and systems in SSA and assess whether the PMTCT has strengthened or weakened health systems in SSAThis systematically conducted narrative review  was baseSearch 1: (prevention of mother to child transmission or MTCT or PMTCT or (Transmission* or spread*)) adj3 (Mother* adj3 child*)) or HIV or AIDS or acquired immune deficiency syndrome).mp. .Search 2: .mp. .Search 3: .mp. .We searched Medline and Google Scholar databases for papers published in English or French between 1st January 2007  and October 2016. We complemented the Medline search with the Google scholar database, looking for any extra articles or grey literature such as policies and programme evaluations important to our review objectives. The following combined search terms were used:The identified papers through these three combined searches were all exported to Endnote bibliographic software .The search strategy did not explicitly require the terms “impact” and “integration” because we felt that some studies might address “impact” and “integration” indirectly, through services description. We defined impact based on the existence of one or more areas of public health action framework as demonstrated through the five aspects of Frieden’s 2010 pyramid that underlies intervention with potential health impact . These fWe designed the review inclusion and exclusion criteria for the purpose of retaining all studies pertaining to comprehensive PMTCT components throughout health systems in SSA as discussed in the WHO PMTCT strategy . We lookPapers - Research articles published in peer-reviewed scientific journals, grey literature and commentaries dealing with PMTCT in pregnant women in SSA were accepted for inclusion. (ii) Participants - Women at risk of transmitting HIV infection to their children. This could include pregnant women or those at risk of pregnancy and their children, regardless of HIV status. (iii) Interventions - All interventions to prevent or reduce HIV MTCT, including but not limited to strategies for antiretroviral therapy and replacement feeding. PMTCT collaboration with other health care services especially maternal and child health (MCH) were included. The following types of articles were excluded: (i) Studies focusing on countries other than SSA countries, (ii) Studies focusing on general HIV/AIDS prevention or other health care services without reference to PMTCT and (iii) Editorials or commentaries generally describing the PMTCT programs on one or more pre-specified healthcare services without studying its effects or integration.The abstracts of pertinent papers were then retrieved following these inclusion criteria before selecting the full articles: (i) All three reviewers agreed on search strategy and inclusion and exclusion criteria. The initial database was created from the compiled electronic searches by one reviewer. All citations were firstly screened by title and abstract and duplicate citations were eliminated. The full texts of potentially eligible papers were then independently obtained for further screening. After resolving differences in data extraction or interpretation through consensual discussions based on the above stated inclusion and exclusion criteria, the final retrieval of papers was conducted. The following study characteristics and data were extracted from included papers: authors, year of publication and country of study, study types or designs, paper’s focus interface with PMTCT, brief topic of investigation and main results. The findings were organised according to the objectives and referred to as ‘themes’ pertaining to each of two review objectives.Throughout the whole selection process, the impact of PMTCT programs on other health care services or vice versa was reported in order to describe to how and to which extent it occurred. Integration of PMTCT programs with other health care services at different levels was also described across all included papers. Two guidelines on global scale-up of the PMTCT were also retrieved.We identified 6223 citations and ultimately retained 57 articles, in addition to the PMTCT guidelines mentioned above. These two guidelines are: 1) The global plan for elimination of new HIV infections among children by 2015 and keeping their mothers alive, and 2) The PMTCT strategic vision 2010–2015: preventing mother-to-child transmission of HIV to reach the United Nations General Assembly Special Session (UNGASS) and Millennium Development Goals , 43. TheTable Thirty-two articles recorded the positive and negative effects of PMTCT on other health care services as a major theme in the article’s title and/or discussion, out of fifty-seven , 45–74. Integration as a theme was found in twelve papers on PMTCT integration in ANC, postnatal care (PNC) and child care , 95–98, PMTCT has been promoted by WHO as a reliable solution to paediatric HIV. As a comprehensive approach developed based on the four components, the scaling up of PMTCT became a cornerstone of countries’ HIV prevention, care and treatment programs . As mentSeveral issues surrounding the PMTCT roll-out are reported to adversely impact PMTCT outcomes  and thesHealth systems link people with promotive, preventive, curative, rehabilitative or palliative health services to address health problems. The effectiveness of this linkage depends on many factors, including those outside the health sector as well as within the various components of a health system , 100. WeHealth care providers and funders across SSA have shown interest and engagement to make PMTCT services more and easily accessible to women and children , 84, 101Studies in this review pointed to these shortcomings and deficiencies in service delivery, especially for the components regarding the uptake of PMTCT programs such as antenatal HIV testing and receipt of test results, ARV prophylaxis and postnatal mother-infant follow up , 106. CaAnalysing the effects of PMTCT on other health care services is often framed in terms of a debate over whether the roll-out of HIV/AIDS services including PTMTC did or did not strengthen the existing health systems and services. Studies in our review demonstrated the advantages of scaling up HIV services in terms of saving many lives, training health providers, and funding some key services like MCH, but the same findings highlighted the various shortcomings of HIV/AIDS interventions in health systems of low and middle-income countries and particularly in SSA , 106. SoEven though some programs remain disease-specific, our review found that PMTCT programs and other health services mutually interact. PMTCT integration within general health care services in low and middle income countries has also been recommended to boost the utilisation of these interventions . Some stPMTCT integration has for example, positively influenced maternal and child care services regarding service availability, accessibility and utilisation . Evjen-OWhile identifying and describing the effects of PMTCT on other health services and health systems or the integration of PMTCT and its extent within broader programs and health systems, collaborations and involvements at different levels emerged to be crucial. Since health services are not only provided by the public sector, our search included other organisations offering PMTCT services and other actors involved in offering such services outside of the public sector. We identified examples of service delivery provided by NGOs , or deliThe review aimed to document the possible effects of PMTCT on health care services and systems and the integration of PMTCT within broader programs and health systems in the available literature in SSA. The analysis of available evidence regarding the two main aspects of this review, namely PMTCT impact and integration, supports a generally positive evaluation of positive synergies with MCH as well as other health services, suggests increasing partial integration of PMTCT within health systems, and offers inconclusive arguments on whether health systems as a whole have been strengthened or weakened by the PMTCT programs in countries of SSA. The discussion below addresses three issues that must be further studied and analysed in order to increase the likelihood that health systems will be demonstrably strengthened: the availability and quality of information, synergies and impacts within and beyond the health sector and the need to engage programmes and services beyond MCH, sexual and reproductive health, and TB.Beyond the structural limitations on the positive impact that PMTCT programs might have on health systems in SSA, there is also a crucial continuing problem of accurate and timely information as highlighted by Theuring et al., (22), and a lack of rigorous research regarding the effects of PMTCT programs on health care systems or vice versa. While all included papers contributed to one or another dimension of the research questions, only two among 32 retained articles that recorded the impact of PMTCT, explicitly and directly focused on or addressed the impact of PMTCT on other health services and on health systems , 16. ThiLikewise, in their 2011 Cochrane review, Lorainne Tudor Car and colleagues did not find any study that evaluated the PMTCT interventions integration with other health care services to improve health outcomes . In anotThe included papers provided moderate evidence of mutual benefits between the PMTCT services and the existing health care services and they recommended a close relationship and more integration in order to maximise the advantages of working together and to mitigate some of the challenges of controlling HIV, a lifelong condition, in the conditions facing SSA , 14, 27.As seen in the results section, the failure of PMTCT to demonstrably strengthen health systems is associated and sustained by the underfunded and poorly managed health care settings . HIV couThe reality of plural health systems and multiple actors must also be addressed in research, policy, and practice. In SSA, the private for-profit sector and charitable and faith-based health care providers including mission hospitals and NGOs play an important role , 91 and Beyond general statements of goals of collaboration and consideration of intervention context, there should be a clear strategy to strengthen local responses to HIV which are often ignored by the top–down style adopted in order to comply with requirements of “the global funding architecture” . This reMalaria, severe anaemia, diarrheal diseases and acute respiratory diseases are some of the leading causes of death among women and children in many of SSA countries , 113 incIn the cited systematic review of Lorainne Tudor Car et al.  on integThis a comprehensive and complex review that included a range of issues related to PMTCT impact and its integration on other health services and systems. Even though it was rigorously conducted, not all PMTCT implementation details could be reviewed in this single paper.The regional HIV prevalence and other crucial factors, such as relationships with donors and international researchers as well as publication outputs, are highly variable across countries and regions in SSA. Most of the identified studies covered eastern and southern Africa. Central and western parts of Africa are less covered in publications, a situation that makes it difficult to generalise this review’s findings to those regions. Studies reporting good service delivery and adherence may also not reflect the full impact of PMTCT when implemented at scale at a national level. Some areas within countries may also have been left out in the retrieved studies.As this review sought articles specifically addressing PMTCT and health services and systems, it may have missed publications reflecting recent increased attention and funding for health system strengthening through HIV programmes, which did not specifically address PMTCT. These papers may yield insights into broader health system challenges and promising approaches to integration of other HIV programmes, potentially including PMTCT.PMTCT improves maternal and child health through preventing the spread of HIV infection in SSA countries. There is evidence of a positive impact of PMTCT on primary care for mothers and children, beyond HIV. The provision of PMTCT services increases the availability, the accessibility and the utilisation of antenatal care and other health care services, especially when the intervention is linked to PMTCT programs as part of mainstream MCH services. However, this review also documented a large number of challenges involved both in implementing and in understanding the effects of PMTCT integration. Without robust information systems and rigorous and systematic research on the health system as a whole as well as on its various services and activities, evidence will continue to be fragmented and firm conclusions will continue to be impossible to draw.While some vertical programs persist, PMTCT services are increasingly being integrated at different levels within routine health services and the health systems. Our study documented the challenges and weaknesses that face health care services and health systems in connection with PMTCT services. These range from structural, governance and resourcing challenges within and between countries, to weak information reporting systems and require more and better coordination and collaboration within and beyond HIV programs, directly related health services, communities, the plural health sector, and other sectors at national and global levels. These broad health system and social challenges cannot be solved by PMTCT interventions alone and there is a need of working together or collaborating with other sectors out of health system.


Despite progress in scaling up antiretroviral treatment, HIV prevention strategies have not been successful in significantly curbing HIV incidence in Latin America. HIV prevention interventions need to be expanded to target the most affected key populations with a combination approach, including new high impact technologies. Oral pre-exposure prophylaxis (PrEP) is recommended as additional prevention choice for individuals at higher risk of infection and could become a cost-effective prevention tool. We discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention strategies in Latin America.Although demonstration projects are ongoing or being planned in a number of countries, to date no Latin American country has implemented a public PrEP programme. The knowledge of policymakers about PrEP implementation needs to be strengthened, and programmatic guidance and cost estimate tools need to be developed to support adequate planning. Despite high levels of awareness among health providers, especially if engaged in HIV or key population care, willingness to prescribe PrEP is still low due to the lack of national policies and guidelines. Key populations, especially men who have sex with men, transgender women and sex workers, have been engaged in demonstration projects, and qualitative research shows high awareness and willingness to use PrEP, especially if accessible in the public sector for free or at affordable price. Concerns of safety, adherence, effectiveness and risk compensation need to be addressed through targeted social communication strategies to improve PrEP knowledge and stimulate demand. Alliance among policymakers, civil society and representatives from key populations, healthcare providers and researchers will be critical for the design and successful implementation of PrEP demonstration projects of locally adapted delivery models. The use of mechanisms of joint negotiation and procurement of antiretrovirals could reduce costs and significantly increase the cost-effectiveness of PrEP.PrEP is an additional prevention tool and should be implemented in combination and synergy with other prevention interventions. PrEP programmes should target high-risk individuals from key populations for higher cost-effectiveness. Demonstration projects may generate strategic information for and lead to the implementation of full-scale PrEP programmes. ConsideAmong newly available tools, daily oral pre-exposure prophylaxis (PrEP) with tenofovir/emtricitabine (TDF/FTC) has been proven safe and effective to prevent HIV among men who have sex with men (MSM), transgender women (TGW), heterosexuals at high risk, uninfected partners in serodiscordant couples and injection drug users –11. In 2To date, PrEP demonstration projects have been expanded worldwide; however the United States remains the only country in the Americas to have started large-scale implementation of PrEP regulated by normative bodies and based on clinical guidelines –16.Considering that the HIV epidemic in Latin American countries is mainly concentrated in key populations, frequently hidden epidemics involving hard-to-reach individuals with inequitable access to services and victims of stigma, discrimination and criminalization in some cases, HIV prevention interventions should be focused, acceptable and tailored to the needs of these most affected groups ,18. As pThe purpose of this paper is to discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention policies and programmes in Latin America.Since the implementation of the first proof-of-concept multicountry trial in MSM, which included sites in Peru, Brazil and Ecuador, an open-label follow-up continued enrolling MSM and TGW to evaluate PrEP uptake, adherence, safety and effectiveness ,21. DespBrazil is currently carrying out multiple demonstration projects. The PrEP Brasil Project , coordinated by the Oswaldo Cruz Foundation, initially implemented in Rio de Janeiro and São Paulo in partnership with non-governmental organizations (NGOs), is expanding to additional sites in Porto Alegre and Manaus . The objective of this project is to assess the uptake, safety and feasibility of free access to PrEP for high-risk MSM and TGW, aiming at generating information for the subsequent PrEP implementation in the public sector. In addition, a demonstration project in MSM, sex workers and drug users is being planned to start in 2016 in multiple sites  .In Peru, oral PrEP is prescribed on demand to a few MSM who can purchase antiretroviral (ARV) medications , and a larger demonstration project among MSM and TGW is being planned at three sites  in late 2016 . Other PrEP projects are being implemented in Mexico City at Clínica Condesa, where PrEP is offered to a limited number of male sex workers and other MSM , and Guatemala City by the NGO Amigos Contra el SIDA .vis-à-vis the implementation of PrEP was also reflected in the 2015 Rio de Janeiro Call to Action, a consensus statement endorsed by representatives from governments, academia, health services and civil society from 26 Latin American and Caribbean countries. This statement includes regional goals and targets for HIV prevention, one of which refers to the implementation of PrEP projects in 10 countries by 2020 [The cautious attitude of Latin American countries  by 2020 .The introduction of PrEP requires engaging policymakers. Qualitative research conducted in Peru in 2010 to 2011 showed that less than 50% of policymakers interviewed were aware of PrEP . AlthougAwareness and willingness to provide PrEP services among healthcare providers is critical. In a survey conducted in Peru in 2012, 57.5% of providers were aware of PrEP, although awareness was higher in ART prescribers (81.3%), in those that were providing care to more than 50 MSM (80.4%), or to at least 50 HIV-positive persons (77.1%). On the other hand, only 44.6% reported willingness to prescribe PrEP, and the likelihood increased if national policies and guidelines were issued (70.3%), if more evidence on effectiveness (68.5%) and more friendly regimens were available (62.2%) . Health Finally, awareness, acceptability and willingness to use PrEP among target populations is key to shape the demand for PrEP. Research conducted in 2015 among 68 MSM in urban sites in Mexico showed that 100% of participants were aware of PrEP and 70% were willing to use it if available for free or offered at an affordable price . In Brazil, although approximately 60% of 734 MSM from Rio de Janeiro interviewed in 2014 to 2015 were aware of PrEP, 95% stated they would be very interested in using it if it were available in the public sector . In PeruAdditional challenges for the implementation of PrEP programmes in Latin America are related to the cost of medicines and regulatory aspects. Many Latin American countries have been utilizing mechanisms of joint price negotiation and procurement of ARVs for ART programmes with significant price reduction; for example, the generic fixed-dose combination of TDF/FTC is currently available through the Strategic Fund (SF) of the Pan-American Health Organization (PAHO) at a price of US$5.37 per pack (30 tabs) . HoweverGaps still exist in the extent and consistency of condom use in key populations in Latin America: 65% of FSW report using a condom with the last client ; 47% of MSM report using a condom in the last episode of anal sex  .Considering that MSM frequently engage in unprotected anal intercourse –42, MSM Mathematical models provide further evidence in support of PrEP programmes targeting key populations. A study conducted in Peru to assess the population-level impact, cost and cost-effectiveness of PrEP in MSM and TGW in Lima showed that with a relatively low PrEP coverage (5%), over 8% of new infections could be averted if individuals at higher risk were prioritized (TGW and sex workers) and guaranteeing adherence levels observed in clinical trials. However, when the averted downstream costs of ARVs are included in the model, most PrEP scenarios become cost-effective . If we cPrEP awareness among policymakers, in particular national HIV programme managers, has certainly increased over time . NeverthImplementing PrEP may require in most countries an initial phase of formative assessment to define target populations and criteria to identify PrEP candidates at higher risk, assess acceptability and likely uptake of PrEP, as well as a demonstration project to test feasibility and effectiveness of locally adapted models of delivery. For the design of PrEP delivery models, the alliance and collaboration among policymakers, civil society and representatives from key populations, health service providers and research groups will be critical.The experience gained from demonstration projects will provide strategic information for the full-scale implementation of PrEP. Modelling tools for the projection of population-level estimates of PrEP needs, as well as other programmatic costing tools, will contribute to more accurate budgeting and planning.In addition, strengthening the PrEP literacy of potential users through targeted social communication strategies will be critical to disseminate information about the purpose and rationale for the use of ARV medicines to prevent HIV (not STIs), eligibility criteria, dosing and monitoring requirements, and the combination with other preventive tools for greater preventive benefit. Such strategies will stimulate demand for PrEP among most appropriate candidates , minimize expectations and demand from people not at higher risk, and ensure the successful introduction of cost-effective PrEP programmes.Furthermore, national protocols on the use of PrEP need to be developed for healthcare providers, together with comprehensive training packages that include aspects of HIV risk-assessment for PrEP eligibility, as well as prescription, delivery and monitoring guidelines. Provision of person-centred care for key populations, taking into account their needs and vulnerabilities, addressing aspects of sexual orientation and gender identity, sexual behaviour and sexual health in a stigma- and discrimination-free environment, should also be included in training packages to promote access to care in key populations and improve the assessment of individuals that will most likely benefit from PrEP and the overall cost-effectiveness of PrEP programmes .The implementation of PrEP programmes should be integrated within existing HIV prevention services for key populations to minimize the need for additional resources while ensuring access to the comprehensive package of services that safe and effective PrEP implementation requires: periodic HIV screening, renal function monitoring, adherence counselling, promotion of STI/HIV prevention and provision of condoms and lubricants, and effective and timely linkage to care in case HIV infection occurs ,45.Finally, the feasibility and sustainability of PrEP programmes also requires minimizing the financial burden of the procurement of ARVs (TDF/FTC), especially as national programmes face the challenge of decreased donor funding and increased domestic expenditure for ARV medicines while adopting the new WHO “treat all” recommendation. The anticipated financial burden of PrEP programmes may be another factor for the cautious approach to PrEP by policymakers. In contrast, joint negotiations and pooled procurement mechanisms, such as the PAHO SF, may offer an opportunity for more efficient use of resources and significant savings by acquiring WHO prequalified generic ARVs for both ART and PrEP at competitive prices.Through the implementation of demonstration projects, as well as monitoring and evaluation of the several local initiatives of PrEP delivery currently underway, it will be possible to generate more evidence on the most effective service-delivery models in the context of different types of health services , community-based services or a combination of both, as well as models based on public-private partnership. Implementation research should also assess the effectiveness of PrEP prescription and monitoring by medical providers , compared to models based on task-shifting to other health cadres or lay providers, especially in case of community NGO-based models.In addition, demonstration projects will offer an opportunity to address additional research topics, such as integration of STI screening and management, alternative testing options  and non-daily regimes (e.g. “on demand” PrEP), as well as knowledge gaps . Participating in global and regional research networks will assure that research methodologies are harmonized for comparison among countries and compilation of data for regional and global analysis.Considering the epidemiological context of the HIV epidemic in Latin America and the available evidence from cost-effectiveness studies, we anticipate that PrEP implementation may achieve higher impact on HIV prevention when targeting individuals at significantly higher risk of HIV exposure within most affected key populations identified in each country.If Latin American countries intend to pursue the goal of ending AIDS as a public health problem by 2030, HIV combination prevention strategies need to be expanded and focused on the most affected populations, tailored to their needs and updated to include all available innovative tools of proven efficacy. PrEP is certainly one additional option and should be implemented in combination and synergy with condom/lubricant programmes and traditional behaviour change strategies, while addressing the unfinished business of scaling up HIV testing and access to ART. Finally, addressing criminalization, stigma and discrimination against key populations is an overarching imperative to create an enabling environment to ensure equitable access to the whole range of HIV prevention, care and treatment services.


The aim of this study was to characterize the role of the USA in the global exchange of wildlife and describe high volume trade with an eye toward prioritizing health risk assessment questions for further analysis. Here we summarize nearly 14 years (2000–2013) of the most comprehensive data available (USFWS LEMIS system), involving 11 billion individual specimens and an additional 977 million kilograms of wildlife. The majority of shipments contained mammals (27%), while the majority of specimens imported were shells (57%) and tropical fish (25%). Most imports were facilitated by the aquatic and pet industry, resulting in one-third of all shipments containing live animals. The importer reported origin of wildlife was 77.7% wild-caught and 17.7% captive-reared. Indonesia was the leading exporter of legal shipments, while Mexico was the leading source reported for illegal shipments. At the specimen level, China was the leading exporter of legal and illegal wildlife imports. The number of annual declared shipments doubled during the period examined, illustrating continually increasing demand, which reinforces the need to scale up capacity for border inspections, risk management protocols and disease surveillance. Most regulatory oversight of wildlife trade is aimed at conservation, rather than prevention of disease introduction. Major drivers of human–animal contact allowing pathogen exchange include animal domestication for companionship and food production, anthropocentric alteration of the environment and the global movement of animals and goods. Approximately one-quarter of human deaths are caused by infectious disease and nearly 60% of infectious diseases are considered zoonotic ; most of these (>70%) are caused by pathogens of wildlife origin  and World Organisation for Animal Health (OIE) joint report 2004]. Lack of wildlife trade surveillance and proper systematic management of the data available represents a major gap to understand and determine high-risk pathways of potentially adverse organisms’ introduction. In order to properly assess this threat to the USA, we must (1) better understand the scope of the trade in terms of species, volume, condition and origin; (2) determine high-risk pathways of introduction for further assessment; and (3) understand the regulatory framework that exists to manage these threats.The goal of this study is to characterize the wildlife trade entering the USA as a baseline for understanding the magnitude of the potential threat these activities may pose to the environment, animals and humans. Although reports exist in the literature, to our knowledge this is the broadest summary  aimed at supporting risk assessments surrounding US wildlife trade importation.Wildlife trade is one of the largest and most complex commerce exchanges in the world. The legal global trade in wildlife and wildlife products involves the movement of billions of plants and animals comprising an economic value estimated at US $300 billion per annum Ahlenius . The illFundamental terms such as “legal” and “illegal,” “formal” and “informal” may be subjective and based upon which regulations are applied and the context of the trade . In some cases, legal trade is well recorded by border officials while in other cases it is largely ignored. Confiscated illegal trade is often reported but undetected illegal shipments regularly go unrecorded. Legality of wildlife trade in most instances does not correlate with disease risk posed, as the majority of wildlife trade regulations  are in place to conserve certain species or regulate economies rather than protect health.Although wildlife trade is often lumped into a single entity, this enterprise is comprised of a multitude of products such as food, trophies, pets, fashion, medicine, artifacts and aphrodisiacs. Within each category exist a range of specialty market value chains that vary in motivating economics, cultural and societal origins, geographic source and destination, transportation type and route, trader and consumer identities, behavioral practices, species volume and condition, local and international legality. This results in vastly variable threats including loss of biodiversity, invasive alien species, food security and emergence of both high- and low-consequence pathogens. Thus, threats can only be quantified in response to specific questions .Timber and plants are estimated to comprise nearly 70% of the known (broadly defined) wildlife global trade value, leaving non-aquaculture fisheries products responsible for 28% and ornamental fish, mammals, herpetofauna and other species responsible for roughly 2% (US $5.27 billion)  are the top importing consumers , monitoring legality of wildlife trade is comparable in complexity to weapons trade. In the majority of instances, the legality of trade of wildlife at the international and national level is determined by authorities tasked with conservation rather than public or animal health protection. Specifically, unpermitted trade of CITES-listed species across international borders comprises the bulk of what is considered and/or reported as global illegal wildlife trade.As with legal trade of wildlife, species are traded illegally as exotic pets, specialty foods, traditional medicines, trophies and fashion items. Drivers of this illicit trade vary from financial to cultural to relic.Because the drivers and components of illegal wildlife trade are highly variable, the perpetrators do not fit any one category nor does their trade behavior follow a single pathway. Diverging networks include local village hunters, criminal groups engaged in drugs or terrorism, government officials and other economically driven sellers and consumers (Hayman and Brack http://www.cites.org/eng/resources/trade.shtml).CITES maintains a database of reported trade of CITES-listed species only. The database is managed by the United Nations Environment Programme–World Conservation Management Center (UNEP–WCMC) and currently holds 7 million records of trade involving 50,000 scientific names of taxa listed by CITES. Currently, more than 500,000 trade records are reported annually  request to the US Fish and Wildlife Service (USFWS) which in turn records details of the imports into the Law Enforcement Management Information System (LEMIS) database. This database includes both CITES and non-CITES species considered to be wildlife per the USFWS definition (50 CFR 14.4). This database therefore holds records of all declared wildlife imports to the USA and, theoretically, details of illegal imports confiscated by authorities at US ports of entry. Although some wildlife species are regulated by other US agencies such as the United States Department of Agriculture (USDA), Centers for Disease Control and Prevention (CDC), and Food and Drug Administration (FDA), imports of wildlife as defined by USFWS are also tracked in LEMIS despite this overlap in jurisdiction. Therefore, the LEMIS system represents a comprehensive data source for incoming wildlife to the USA (with few exceptions such as bushmeat items that are not determined to be of CITES origin). LEMIS data are maintained by USFWS for 5 years.Additionally, there are data held by national governments that vary widely in their format and scope, and rely largely upon efforts of authorities given national laws and priorities. These data are often not available to the public but some summaries may be found in gray literature reports. All importers of wildlife to the USA are mandated to submit a 3–177  and entered into a propriety database structure curated by EcoHealth Alliance (EHA). The dataset, entitled “WILDb,” includes taxonomical, geographic and count information for each shipment that entered the USA and its territories, allowing for pathway analyses to be conducted on a global level for wildlife that entered the USA. The results presented here are a preliminary analysis of this comprehensive database of wildlife trade into the USA. The dataset continues to be periodically updated.As of January 2015, WILDb included a total of 5,207,420 individually identifiable wildlife shipments entering the USA between January 1, 2000, and August 6, 2013. The number of annually declared wildlife shipments doubled during the period examined  individuals plus 24,449,892 (2.5%) kg were recorded as live upon entry. Thus, for the period 2000–2012, there was an annual average of 224.9 million  live animals plus an additional 1.8 million kilograms of live animals imported into the USA as recorded in the LEMIS database.We selected the top ten categories represented by the data for illustration of the most frequent wildlife taxa imported to the USA. The majority of wildlife shipments (by taxon) contained mammal products . Since many species traded may be wild-caught or captive-raised, it remains difficult for authorities to identify false reporting of wild versus captive and true country of origin, despite visual inspection and means of import. The reported countries of origin from 2000 to 2013 for all declared US wildlife imports by shipment are shown in Figure The data contained reported both “country of origin” and “country of export.” This reporting is by the importer/exporter, and therefore, country of origin may be falsely reported without means for authorities to verify source. The stated origin of imported Rana catesbiana)—a conservatively estimated 360,000 frogs—imported mainly for food, nearly 30 million live pheasants (Phasianus colchicus spp.), approximately 150,000 live macaques, in addition to live bats for research and Asiatic chipmunks for pets in fewer numbers. Vietnam was the exporter of 300 shipments of live macaques to the USA during the period examined. Taiwan exported approximately 450,000 finch-like live pet birds including canaries and goldfinches, and Indonesia exported over 85,000 kg of “edible-nest swiftlet” nests to the USA.China and Southeast Asia was a primary region of origin for US wildlife imports. The vast majority of both live and non-live wildlife imported from this area were aquatic, invertebrate and herpetofauna species. Indonesia was responsible for exporting the most live wildlife shipments to the USA during the period examined, comprised mainly of these aforementioned species. However, live mammals and birds were also imported. Examples of identified live species imported from China included over 120,000 kg of live American bullfrogs   included sturgeon (caviar), baby harp seal pelts, Indian peafowl (peacock) feathers, white tailed deer products such as antler, elephant ivory , sea turtle products , crocodilians , musk deer , and reptile and ostrich products .While most illegal shipments presented at the Mexican border, the majority of illegal specimens  that presented at ports of entry originated in China. Such items included deer and bear medicinal items, macaque scientific specimens, live aquatic species and reptiles. Documented origins of illegally imported live wildlife to the USA by specimen are illustrated in Figure unpubl. data). To our knowledge, this is the most comprehensive report of US wildlife trade importation for this time period and of this scale. The most remarkable finding of this review is that the number of declared wildlife shipments into the USA has doubled since 2000. The economic value of wildlife imports paralleled this increase in shipments, rising 108% from 1998 to 2007  consist of aquatic species and herpetofauna; given that these animals are often shipped together in large numbers, they are in high demand by consumers and a number of other factors . The fact that these species are likely to be shipped live and in large numbers means that a significant number could survive even given long distance shipment from Asia. The survival of large numbers of highly stressed live animals entering the USA increases the overall risk of disease introduction.The majority of individual specimens entering the USA, most of which were aquatic species, were from China and Southeast Asia. The degree to which such shipments pose a risk to US natural resources in terms of aquatic pathogen introduction is likely dependent upon their final destination and disposition, as well as how water used in shipments is disposed. Mammal and bird species were also imported from this region, with several notable imports such as swiftlet nests, over half of which were imported since the 2005 emergence of H5N1 highly pathogenic avian influenza (HPAI) , itself a significant global consumer of illegal wildlife. From 2003 to 2004, the EU executed over 7000 seizures including 3.5 million CITES-listed items , and a large portion of the data did not include species level identification. Further, codes often overlapped and/or several different codes were used to describe a single species. Currently, WILDb contains 14,074 unique species codes. EHA was able to ascertain some level of taxonomic information for over 98% of the data entries despite the fact that the majority of these did not provide specific species identification. This study was further limited to wildlife imports that were either accepted or rejected by authorities and did not include illegal shipments that evaded authorities as those go inherently unrecorded and unrecognized.Given the sheer volume of live wildlife and wildlife product imports to the USA, and the fact that most refused shipments were due to CITES status and not based upon the risk of disease introduction, we believe it is prudent to further assess risk of pathogen introduction via wildlife trade. The current regulatory atmosphere for this goal is highly fragmented. The USFWS currently does not focus primarily on disease prevention, but on conservation status; the CDC currently focuses on specific health risks associated with non-human primates, African rodents and bats; and the USDA regulates non-domestic hoofstock, birds and few other specific mammals that originate in countries positive for reportable diseases. These species are regulated for specific diseases and thus may be approved entry if deemed safe.Brucella ssp., as well as economically important livestock diseases. Introducing disease purposefully or accidentally need not utilize illegal trade since regulations concerned with pathogen introduction via trade are focused mainly on domestic species (regulated by CDC and USDA) and not enforced by the agency primarily monitoring wildlife trade into the USA (USFWS).Many countries of origin for legal and illegal wildlife imports to the USA include “hotspots” of emerging and reemerging infectious and zoonotic pathogens  wildlife law enforcement network, the USA “does not participate in international efforts to regulate international wildlife trade to prevent disease transmission or invasive species, as no such international organization currently exists” (Wyler and Sheikh unpubl. data).In 2014, President Obama issued the National Strategy for Combating Wildlife Trafficking to guide federal agencies in the global fight against wildlife trade. Yet even after the recent Ebola outbreaks in Africa, disease has not been a priority in this fight. The USA does adhere to the World Trade Organization’s (WTO) Sanitary and Phytosanitary (SPS) Agreement, which regulates the international trade in animals, animal products and plants, and is a member of the OIE, which sets international health standards for animals and animal products, recently including wildlife. In an attempt to support this effort, EHA recently worked with the OIE to develop a comprehensive list of proven wildlife hosts of OIE-listed diseases in order to inform member countries of the broad range of potential carriers of diseases of importance and to raise awareness surrounding potential wildlife trade health risks  large volumes of live aquatic species, (2) wild animal host species not currently regulated  and (3) species closely related to domestic agriculture  that may enter the USA for multiple purposes were prioritized by this working group for further assessment.


Despite the remarkable regenerative capacity of bone, the regeneration of large bone defects and the repair of nonunion bone fractures remain a major challenge in orthopaedic surgeries. Bone is the second most commonly transplanted tissue with over 1.5 million bone graft surgeries being performed annually in the United States , 3. GiveStem cell-based bone tissue engineering offers a promising approach for regenerating critical sized bone defects or repairing nonunion bone fracture. Understanding and recreating a signalling environment to control the differentiation of stem cells into the bone lineage would be of great importance. The components in bone microenvironment, which include a mineral phase , an organic phase (composed of 90% collagen type I), a cellular phase , and a soluble factor phase (growth factors and/or cytokines), provide a specific and balanced signalling network, which contribute to the innate bone metabolic and anabolic activities and maintain the structure and functions of the bone. Substantial efforts, therefore, have been made to mimic the bone tissue microenvironmental components for controlling the commitment of stem cells into osteogenic lineage cells for bone tissue regeneration. For example, by mimicking the bone nanostructure to engineering bone-related biomaterials, researchers have incorporated nanocrystals into biomaterials and demonstrated that they are effective in regulating various cellular functions including cell adhesion, proliferation, and differentiation , 5; in aIn this special issue, some cutting-edge original researches as well as review articles related to priming stem cell fate into the osteogenic lineage via mimicking the bone components  were introduced and provided the readers with the updated knowledge and progression in the topic of bone microenvironment, stem cells, and bone tissue regeneration.ZuFu LuJenneke Kleine-NulendBin Li


Animal-source foods (ASF) have the potential to enhance the nutritional adequacy of cereal-based diets in low- and middle-income countries, through the provision of high-quality protein and bioavailable micronutrients. The development of guidelines for including ASF in local diets requires an understanding of the nutrient content of available resources. This article reviews food composition tables (FCT) used in sub-Saharan Africa, examining the spectrum of ASF reported and exploring data sources for each reference. Compositional data are shown to be derived from a small number of existing data sets from analyses conducted largely in high-income nations, often many decades previously. There are limitations in using such values, which represent the products of intensively raised animals of commercial breeds, as a reference in resource-poor settings where indigenous breed livestock are commonly reared in low-input production systems, on mineral-deficient soils and not receiving nutritionally balanced feed. The FCT examined also revealed a lack of data on the full spectrum of ASF, including offal and wild foods, which correspond to local food preferences and represent valuable dietary resources in food-deficient settings. Using poultry products as an example, comparisons are made between compositional data from three high-income nations, and potential implications of differences in the published values for micronutrients of public health significance, including Fe, folate and vitamin A, are discussed. It is important that those working on nutritional interventions and on developing dietary recommendations for resource-poor settings understand the limitations of current food composition data and that opportunities to improve existing resources are more actively explored and supported. The latest global estimates suggest 795 million people to be chronically undernourished, with substantial geographic variation in progress towards international development goals. The spectrum of nutrition-related disorders includes wasting, stunting and micronutrient deficiencies, with the prevalence of stunting being a critical indicator of progress in child survival, reflecting long-term exposure to suboptimal health and nutrition. An increasing incidence of overweight, obesity and non-communicable diseases is also emerging in many low- and middle-income countries (LMIC), where the coexistence of under- and over-nutrition now occurs and is termed the ‘double burden of malnutrition’.Under-nutrition remains a pervasive issue of the current century, with profound implications for individual growth, development and survival, incidence of acute and chronic diseases, and national economic productivity and wealth1. The12 that are difficult or impossible to obtain in adequate amounts from plant-source foods alone. Despite concern by some about the environmental and nutritional implications of increased ASF consumption predicted to accompany population and income growth, there is scope for ASF to enhance the nutrient adequacy of traditional diets based on cereals and tubers in resource-poor settings(–). The inclusion of ASF in the diet has been shown to promote growth and improve cognitive function, physical activity and health(–), and among pregnant women it has been shown to support fetal growth and development and enhance maternal nutrition in preparation for lactation.There is an increasing focus on the role of nutrition-sensitive interventions, including food-based approaches, which use locally available and culturally acceptable products, to achieve sustainable improvements in human nutrition. Animal-source foods (ASF) are known to provide protein of high biological value and micronutrients such as Fe, Zn and vitamin Bods alone,6. D. Measurement error or incorrect assumptions occur at all stages of dietary assessment, including misreporting habitual food intakes, elevated nutrient requirements due to high levels of infection and errors in food composition data. In this article, we focus on systematic errors present in food composition databases that may result in incorrect estimations of dietary adequacy, especially in LMIC populations where the intakes of ASF are increasing. The merits and limitations of various food security and nutrition indicators and their implications for understanding the nutritional status of individuals and communities should be recognised, but are beyond the scope of this article.The development of meaningful food-based recommendations for dietary improvement relies on an assessment of existing diets, an understanding of the food resources accessible to a given population, the population’s nutrient requirements and accurate data on the nutrient content of available food items13. Me. In a comparison of three different commonly used data sources of the macronutrient content of foods consumed in Uganda, Baingana draws attention to the marked variation in results obtained, and contends that inappropriate food composition data have the potential to ‘undermine or misdirect research or nutrition efforts’.Information on the macronutrient and micronutrient content of food items is used both to estimate the nutrient content of current diets and to formulate guidelines for increasing dietary adequacy. Food composition data are available through national and regional food composition tables (FCT) and, increasingly, in electronic formats. Although such resources have value in understanding the effects of diets on health, growth and development and devising diets for individuals and populations, their limitations need to be understood16. In proposes ten criteria for a comprehensive food composition database. The data should be (1) representative, (2) of sound analytical quality, including comprehensive coverage of both (3) foods and (4) nutrients, with (5) clear food descriptions and (6) data should be presented in a consistent, unambiguous manner, (7) showing origins of data at a nutrient level, (8) in an easy-to-use format, which is (9) compatible with existing international standards and (10) has few missing data.The International Network on Food Data Systems (INFOODS), led by the FAO, has been tasked with coordinating efforts to improve the quality of food composition data globally. Many LMIC currently lack capacity for nutrient analysis, which limits the availability of country-specific food composition data. It is among the aims of INFOODS to ensure that the large body of available food composition data is of sufficient quality to be combined with directly analysed values. To achieve this, the FAO16 pro. In the case of ASF, the composition of products derived from intensively raised animals of commercial breeds may differ from those of indigenous livestock in resource-poor settings, which are typically reared in low-input production systems, sometimes on mineral-deficient soils and commonly not receiving balanced feed. A crucial shortfall of many national or regional food composition databases, including those released in recent years, is their reliance on a small number of existing data sets – often from more high-income nations and sometimes from analyses conducted decades previously.As biological materials, foods exhibit variations in composition. Differences in the nutrient content of a given item may be due to environmental conditions, crop variety or animal breed, stage of maturity, processing methods and cooking techniques,18. , this study focuses primarily on whether databases are representative of national or regional diets and whether data may be considered of sound quality for the context in which they are intended to be used. Using poultry products as an example, comparisons are made between compositional data from three high-income nations, and the implications of using data from different sources are discussed. Focus is given to three micronutrients because their content in ASF items differed markedly between references: vitamin A, which is relevant because of the widespread occurrence of deficiency globally; vitamin B12, found naturally only in ASF; and folate, which is of particular relevance to women of reproductive age because of its role in preventing neural tube defects during embryonic development in early pregnancy.This article reviews selected FCT currently in use within sub-Saharan Africa, first examining the spectrum of ASF reported and then considering the source of data for each item. Of criteria for reliable composition data proposed by the FAO15, thWest African Food Composition Table, A Food Composition Table for Central and Eastern Uganda, Food Composition Table for Use in The Gambia, Food Composition Tables for Mozambique, Tanzania Food Composition Tables, Lesotho Food Composition Table and ‘Nutritive value of foods of Zimbabwe’. Data from the Food Composition Table for Use in Africa were also reviewed, but owing to large sections of missing nutrient information they were deemed insufficiently complete for inclusion in the comparative analysis.The FAO INFOODS directory provides details of available food composition data according to geographic location, as well as international databases. Many of the resources listed are no longer in print and are difficult to access. For the purposes of this analysis, national and regional food composition data for sub-Saharan Africa accessible online in the English language were examined. Databases meeting criteria for inclusion  were as follows: Lists of ASF were compiled from each of the selected databases. Meat and meat products, fish and shellfish, milk, eggs and insects were included in both raw and, where available, cooked or processed forms. FCT entries based on recipes that include ASF as an ingredient (e.g. ‘fish relish with coconut milk’) and commercially processed meat-based entries  were excluded from this analysis.meat flesh, defined as skeletal muscle with any attached fat, connective tissue, nerves, vessels, blood and skin; offal including blood, brain, heart, intestines, kidneys, pancreas, spleen, thymus, tongue and tripe, but excluding meat flesh, bone and bone marrow; other carcass components, covering entries that include bone, such as chicken heads and feet; fish and shellfish; milk; eggs; and insects.ASF items from each reference were divided into seven categories:  and skin26; of. In the absence of comprehensive national food consumption survey data, food balance sheets are recognised to provide guidance on the domestic availability of foods and their contribution to diets during FCT compilation. Although the supply of an ASF category will not always be expected to correspond to the number of FCT entries , comparisons have been made between the availability of food and its inclusion in FCT lists.National food balance data corresponding to the year of publication of each database were collated for evaluating how effectively the range of ASF items matched the reported food supply27. In. These include original analytical values, derived from the published literature or unpublished laboratory reports based on valid methodology and local food items; imputed values, whereby data are estimated from analytical values for a similar food or for another form of the same food; calculated values, which apply accepted yield factors and nutrient retention factors for the relevant cooking methods to data from other sources; borrowed data, drawn from other tables or databases where reference to original sources may or may not be provided; and items of unspecified source.In a second aspect of the analysis, ASF entries were classified according to the data source for each food item, on the basis of types of compositional data as defined by Greenfield & Southgate16. ThEntries have been further categorised according to the region from which compositional data originated: Africa, the USA, the UK, Europe or Asia. For data borrowed from other FCT, the original sources have been consulted where possible, and it is indicated where this has not been possible. Many of the ASF items listed in the Gambian and West African databases have been compiled from multiple sources, and the degree to which each source has contributed to an entry is often not evident. In order to summarise the origins of data in these cases, all countries contributing to a database entry have been given equal weighting , and the total number of items from each region has been rounded to whole numbers.McCance and Widdowson’s: The Composition of Foods Integrated Dataset, the 28th release of the United States Department of Agriculture National Nutrient Database and the Australian Food, Supplement and Nutrient Database. The three sets of published values for macronutrients and selected micronutrients  were compared per 100 g edible portion of light and dark chicken meat, chicken liver and whole chicken eggs, in their raw forms.On the basis of a predominance of data from UK and US sources, a third exercise was undertaken comparing nutrient content of selected poultry products in the most recent food composition databases from these two countries with a third data set, from Australia. Data were drawn from the UK’s recently updated The databases examined varied substantially in the number of food items included. The comparatively more extensive FCT for West Africa and Central and Eastern Uganda contain 113 and 126 ASF entries, respectively, whereas the Gambian reference includes only thirteen. The Gambian database has a strong emphasis on local recipes and prepared dishes, and reports only a very limited number of individual food items. There is also a notable lack of detail in the description of food items in this reference, such as ‘egg’ and ‘meat, boiled’, both of unspecified livestock species.n 9) and Mozambique , compared with Zimbabwe  and Lesotho (n 0). In Lesotho, the number of meat flesh entries is matched by the number of offal entries , whereas in all other databases there are two or more times more meat flesh than offal entries. Other carcass components, which include chicken heads and feet of chicken, cattle and small ruminants, are only found in the tables for Uganda  and Lesotho .Differences can be seen in the number and relative proportion of entries in the seven ASF categories in each of the databases, as outlined in . High reported levels of offal supply in Lesotho and Uganda  are matched by high numbers of offal FCT entries , whereas the low reported offal supply in Mozambique and The Gambia (0·58 kg/capita per year for both) is also reflected in their national FCT databases . Similar patterns are seen for fish and shellfish, where both the high per capita supply in West Africa and Uganda and the low supply in Lesotho and Zimbabwe are reflected in the number of related FCT entries.The range of livestock species whose milk is included in the databases varies, from cattle only (Tanzania and The Gambia) to cattle and goats  and cattle, goats and camels (West Africa). The majority of FCT provide data only for chicken eggs, with only two references including duck eggs (Lesotho and Mozambique) and one including turkey eggs (Lesotho). Insects including termites, locusts, crickets and caterpillars are found in four of the seven databases examined .n 39), whereas the newer references report a larger number of items in cooked or processed forms, most prominently in the Ugandan FCT . Databases were also examined for the breadth of animal species contributing to the ASF listed, as presented in The preparation state of ASF entries is listed as the percentage of food items that were raw, cooked or processed in each FCT . The ZimThe databases varied in their inclusion of details on the origins of published data, including sampling methodology, analytical techniques and the source of borrowed nutrient values; five of the seven tables  provided an indication of the data source for individual food entries, whereas the remaining two (for Tanzania and Zimbabwe) provided only general information about the data compilation process and a list of references used.n 87) of the ASF entries have been borrowed directly from other databases, and the remainder have been calculated by applying conversion factors to borrowed values for food items in their raw form, to reflect changes in moisture content and nutrient losses due to cooking. Of all ASF entries, 88·9 % (n 112) are from the USA. In the West African FCT, directly-borrowed values constitute 41·6 % (n 47) and calculated values constitute 57·5 % (n 65) of all compositional data. Sources of data are given at the nutrient level, with a majority of ASF entries having been compiled from multiple sources. Approximately 31·1 % of data were derived from the USA, 24·5 % from European sources and 21·2 % from within the African continent. ASF entries in the Gambian database also include those composed of multiple data sources. Of the limited number of ASF reported (n 13), the vast majority are borrowed , with relatively balanced input from British databases, Gambian literature sources and Platt’s 1962 reference for foods ‘commonly used in tropical countries’. Data sources for this last reference are not readily available, but are indicated to include a combination of primary analysis, published literature and alternative international databases. The Lesotho database identifies six of its total 283 entries to have been analysed directly, none of them ASF. This reference also has a strong reliance on data from alternative databases , with a predominance of ASF entries coming from South African  and US  references.In the Ugandan database, 69·0 % (ountries’31. Dan 4). Dried forms of four species of fish  were sourced from Mozambican markets in December 2008 and transported to Finland for analysis. A further four entries in the database have been calculated using these values.The Mozambique FCT is the only database examined to include ASF data from primary analysis of local foods . Additional food items have been imported from databases from Egypt, India, Indonesia, Mexico and Senegal, as well as from US, UK and South African sources. There is no mention of data from in-country analysis.The Tanzanian FCT does not report the sources of data for individual food items. The reference was developed using the World Food Dietary Assessment System, whereby information is imported from a series of six databases, considered representative of foods consumed in developing countries. The Kenyan database, which serves as the primary source for the Tanzanian FCT, uses nutrient values from references published in the 1960s,31. , USA and Australia were reviewed for selected poultry products. Differences were noted in the listing of food items in raw or cooked forms, the differentiation of various meat components of a carcass and, importantly, the inclusion of skin or fat. 12, folate, vitamin E, Fe, Zn and Se) in raw forms of dark and light chicken meat, chicken liver and whole eggs.Compositional data from the UK28, US12 levels also varied across databases with the content in eggs reported to be 1·5 times higher in Australia and three times higher in the UK, compared with US values. In chicken liver, Australia- and US-reported levels of vitamin B12 were equivalent but less than half of the levels in the UK reference.Beyond the expected variability between results of any two analyses, prominent and inconsistent differences were noted in a number of nutrients. Vitamin A levels in chicken liver varied widely between references, with retinol activity equivalents ranging from 3296 µg in the US database, to 9700 µg in the UK and to 12 007 µg in Australia. Variation was also seen in folate content of liver, with the UK and Australian references reporting levels 1·7 and 2·5 times higher than the US reference value, respectively. Vitamin B12 and folate have been used to determine the contribution of a whole hard-boiled chicken egg to daily nutrient targets for people of various ages and physiological states, as presented in The implications of reported differences in nutrient content may be considered in terms of their contribution to an individual’s daily requirements. Reference nutrient intakes (RNI) for vitamin A, vitamin Bnd folate32 hav) would meet the vitamin A requirements of a child aged 1–3 years for 13 d based on Australian reference values, compared with 4 d using US data. A breast-feeding mother’s daily folate needs are reported to be contained in 17 g of liver in Australia and 45 g in the USA.. In the international development arena, such tools are of particular value to those involved in programmes seeking food-based solutions to nutritional challenges. To assess the validity of existing references and establish their role in guiding efforts to improve food and nutrition security, this article considers (a) whether databases reflect the spectrum of foods consumed within a given country or region, (b) whether the origins of published data and details of the foods analysed make them appropriate for use in the intended area and (c) the reliability of original data sources.Among the objectives of compiling national or regional FCT is the creation of reliable resources to meet the needs of users, which might include ‘government agencies, nutrition scientists, health and agriculture professionals, policymakers and planners, food producers, processors, retailers and consumers’34. InPatterns in ASF consumption change over time, according to availability, access and a broad range of socio-economic and cultural factors. Short-term variation in diets may be seen between seasons, as well as longer-term variation according to climatic factors. Rigorous approaches to understanding diets, which consider the impact of seasons, agro-ecological zones, sex and socio-cultural factors, should underpin any national or regional food composition database. Introductory remarks to many of the FCT express an intention to present resources that represent local diets. The Gambian database reports an effort to cover foods typically consumed in rural areas, although the focus is on dishes  rather than individual ingredients. The Ugandan resource, developed during a Consultative Group on International Agricultural Research project, includes all food items captured from two dietary intake surveys of women and children aged 6 months to 7 years, from three districts in the country’s Central and Eastern regions. Approaches to compiling food lists in other databases are less explicitly described. Although some similarities can be seen between national food supply data and the spectrum of food items in the FCT reviewed, it is unclear whether differences between databases reflect true differences in the types of foods consumed in various African countries.. Although studies from Somalia suggest that many forms of offal are considered inferior meat because of their lower cost and are mainly consumed by women , offal is reported to be widely consumed and considered both palatable and culturally acceptable. With liver identified as among the best local food sources to improve dietary quality of young children, there would be great advantage in broadening the range of micronutrient-rich organ meats in FCT to allow their inclusion in dietary recommendations in LMIC.There is a paucity of published data on the range of ASF consumed by African populations, including the breadth of carcass components eaten and the use of products from animals other than domestic livestock. Patterns of offal consumption vary with availability, cost, cultural beliefs, socio-economic attitudes and nutritional knowledge35. Al; however, there remains much less reference in the published literature to the consumption of wild foods of animal origin. Although inter-country differences may exist in their availability and cultural acceptability, non-domesticated animals and insects contribute to nutrition security in many resource-poor settings. The harvest of wildlife provides a valuable source of meat for hundreds of millions of rural people living in poverty, often protecting against chronic under-nutrition where alternative sources of ASF are scarce or prohibitively expensive. Insects have been an important wild source of protein and other macronutrients and micronutrients for thousands of years, particularly in remote rural areas and in tropical countries with high biodiversity, and are the focus of current attention as an environmentally sustainable and nutritious complement to traditional protein sources.There has been some interest in the relative importance and nutrient content of edible indigenous plants in supplementing cereal-based diets of rural populations in Africa,39;  and studies in Lusaka Province, Zambia, found 171 wild food species (eighty-seven ASF) that contribute to local diets. Such findings have been generated from focus group discussions and interviews with community members to develop food lists in local languages, understand seasonal availability and food preparation methods, and working with national research institutions or museums to determine the scientific names and classifications of the food items identified. Among the seven databases examined in this article, there is substantial variation in the inclusion of non-domesticated animals and insects. The Mozambican reference includes a single, wild ASF entry (rodent), whereas the West African reference provides data on caterpillars, locusts, winged ants and crickets. A lack of nutrient compositional data on the full spectrum of ASF from which a food-insecure household might benefit is a limitation of several references, as well as restricts the potential for knowledge of available food resources to be translated into guidelines for dietary improvement.Projects seeking to document the food resources accessible by a given population have revealed great diversity in the range of items consumed throughout the year. An ethno-biological inventory of foods in Baringo District, Kenya, identified 226 edible species (thirty-eight ASF)44 and. The resulting reliance on existing references is evident in the 2010 Tanzanian FCT, based largely on databases compiled in the 1960s despite national capacity for nutrient analysis at institutions such as Sokoine University of Agriculture, the Tanzania Food and Nutrition Centre, Tanzania Veterinary Laboratory Agency and Tanzania Food and Drug Authority.Despite the INFOODS programme’s strong focus on improving the quality, availability, reliability and use of food composition data globally, it remains evident that a majority of compositional data – including data published in recently released regional and national references – is drawn from other databases in geographically distant locations. Details of the source of data are sometimes lacking, and it is not always clear whether values are original data or borrowed or imputed from other sources. Of the FCT examined, only one included any original analysis of local ASF items and a large amount of data has been derived from outside Africa, and overwhelmingly from the USA. A lack of funding has consistently been highlighted by the INFOODS African Regional Data Centre (AFROFOODS) as the major obstacle for generating original analytical data46. Th. Most nutrients are said to be affected, due to differences in their distribution in lean meat and associated fat. Elsewhere, genetic strain has been identified as a crucial factor affecting meat quality. Such observations affirm the limitations of applying international reference data to indigenous breed livestock raised in low-input systems in resource-poor settings.Even when original analytical and sampling methods are sound, this practice of ‘data recycling’ overlooks the potential for significant variation in the nutrient content of food items of both plant and animal origin. Introductory notes accompanying the UK database suggest the major source of variation in meat composition to be differing fat content, both as a result of husbandry and food preparation techniques27. Mo. Scavenging village chickens may achieve a balanced diet under some conditions, eating crop residues after the harvest and fresh plant material, insects, worms and molluscs during the wet season. In areas with unimodal, irregular or limited rainfall, however, there are likely to be times of environmental food shortage during the dry season, when birds are at risk of inadequate nutrition.Taking chickens as an example, marked physical differences are evident between local breed poultry raised in small free-ranging flocks in rural African communities, typically largely or wholly reliant on environmental feed sources, and those of genetic lines selected for rapid growth and high feed conversion ratios, reared on balanced feed rations in commercial production systems. Among commercial poultry producers, it is recognised that nutrient requirements differ significantly between broiler (meat-producing) and layer (egg-producing) birds and between different stages of the life cycle49. Sc, confinement of domestic livestock and provision of high-energy feed. Although poultry has historically been regarded as a lean option compared with red meat, the modern broiler chicken has been reported to provide several times more energy from fat than from protein and contains a ratio of n-6:n-3 fatty acids of as high as 9:1 – a shift away from the lower ratio advised for decreasing the risk of CHD.Documented changes in the carcass composition and yield of commercial breed chickens over time have been attributed to genetic selection51, co and others attributing variation to diet. In the case of eggs, such studies have focused on cholesterol and PUFA levels, and not on other micronutrients of public health significance. As for any food, variation in water content is a major determinant of the nutrient density of eggs and relates to both the ratio of yolk:white and the solids content of each component. Evaluation of the effect of egg size, hen age and genetic strain on solid content has shown smaller eggs and older hens to be associated with a higher solid content. This might appear to be a favourable finding for the nutrient density of village chickens’ eggs, typically smaller and produced by older hens than their commercial counterparts; however, the absence of published data on the nutrient content of poultry products from resource-poor settings remains a major gap.Interest in the impact of livestock production systems on the nutrient content of food products has grown in recent years, as consumer concerns about welfare standards have prompted a shift away from traditional battery cages for hens and indoor housing of pigs towards free-range systems. The effect on nutrient levels remains unresolved, with some studies showing no significant differences,56 aAlso of concern is the variation that exists between compositional data from developed nations, including in micronutrients of public health significance. As databases continue to be revised and updated, individual entries are often comprised of compositional data from multiple analyses conducted years or decades apart. Data on the vitamin A content of raw chicken liver are based on analyses from the early 1980s, 2003 and 2005 for the UK, US and Australian references, respectively. Details of analytical techniques are found in general comments accompanying each database, and suggest no methodological reason for a 3·5-fold difference between US and Australian values. The apparent disparity between nutrient levels in the products of commercially reared chickens from different nations – of similar genetic lines, each receiving feed intended to meet nutritional requirements while minimising excessive nutrient excretion – further highlights the variability that might be expected in the nutrient content of scavenging chickens in resource-poor settings., almost 150 g of cooked spinach or approximately 220 g of boiled orange-fleshed sweet potato. In this context, where intakes of vitamin A are marginal or low and even small portions of ASF have the potential to meet an individual’s requirements, 2–3-fold differences in compositional data become more relevant. The value of reliable data on locally available resources should not be underestimated.Calculations to determine the required daily intake of ASF items to meet specific nutrient requirements may appear to undermine the significance of data variability – for example, when considering the difference between a 7 and 24-g portion of chicken liver to meet a breast-feeding mother’s daily vitamin A requirements  to be assessed for quality and integrated into national or regional databases. Research and development projects that use food-based approaches might also be encouraged to undertake analysis of local items of interest, with a view of incremental expansion of national databases.It is clear that limitations of FCT are not restricted to resource-poor settings. There are global efforts to standardise and harmonise food composition data, including work coordinated by the European Food Information Resource association and the FAO to establish protocols and improve data quality and database searchability59. ToThe INFOODS programme and its regional data centres have done much to raise the profile of FCT activities and support capacity-building through training courses and institutional collaborations; however, there remains a strong need for funding – both through the support of donor agencies and commitment from national governments – to generate new location-specific compositional data. Accurate information on the nutrient content of locally available food items will better guide work in nutrition-sensitive and cost-efficient interventions and enable the development of meaningful guidelines for improving dietary adequacy.


Public health technical expertise is of crucial importance to inform decision makers’ action in the field of health and its broader determinants. Improving education and training of public health professionals for both practice and research is the starting point to strengthen the role of public health so that current health challenges can be efficiently tackled. At the Association of Schools of Public Health in the European Region (ASPHER) Deans’ & Directors’ 2017 Annual Retreat, we presented the structure and management of public health training system in Italy, and we reported recent data on Italian public health specialists’ educational experience, employment opportunities and job satisfaction. Public health training in Italy is implemented in the context of the post-graduate medical education residency programme in Hygiene and Preventive Medicine, delivered by 34 University-based Schools of Public Health. We report relatively high employment rates across the county and wide spectrum of career opportunities for young public health specialists. However, job security is low and training expectations only partially met. We call upon other Schools of Public Health to scale up the survey within the broad ASPHER community in a shared and coordinated action of systematically collecting useful data that can inform the development of public health education and training models, their implementation and fruitful interaction with population health, health systems and services. As a matter of fact, public health technical expertise is of crucial importance to inform decision makers’ action in the field of health and its broader determinants.In times where health systems’ sustainability is undermined by populations’ ageing, ongoing economic crises, increased burden of chronic diseases and healthcare costs, national and international health authorities have underlined the importance of investing in public health policies –4. As stPublic health training’s opportunities and programmes in different countries differ by structure, contents, curricular pathway, entry requirements and quality and are usually shaped and managed on the basis of national education systems and national health services’ features. At the Association of Schools of Public Health in the European Region (ASPHER) Deans’ & Directors’ Annual Retreat hold on May 31–June 2, 2017, we presented the case of Italy, describing the Italian public health training model and reporting the findings of a recent survey we conducted to explore Italian public health specialists’ training experience, employment opportunities and job satisfaction.Public health workforce employed in the Italian National Health service (INHS) mainly consists of public health specialist medical doctors; a much more limited share includes public health nurses and veterinaries, occupational physicians, prevention technicians and health care assistants. This medically centred distribution reflects the structure of public health training in Italy, which is embedded in the post-graduate medical education system. The post-graduate medical education system consists of 50 different residency programmes in clinical, surgical and non-clinical sectors. Non-clinical residency programme includes: (i) Hygiene and Preventive Medicine, (ii) Occupational health, (iii) Legal medicine and (iv) Medical statistics.The post-graduate medical residency in “Hygiene and Preventive Medicine”  is currently a 4-year training programme, delivered by University-based schools accredited jointly by the Italian Ministry of Education and the Ministry of Health. There are 34 SPHs in Italy Fig. , locatedEvery year, a Ministerial Decree defines the number of available SPH contracts (around 200 per year), as well as the national entry requirements and application process rules. The application process is managed at the national level, acceptance being based on academic performance. In 2009, acknowledging the need of skilled public health professionals, the PH residency programme was recognized as ‘strategic for the Italian National Health Service’ and awarded additional contracts. Available contracts are funded by the Ministry of Health, and distributed across Italian Regions on the basis of the estimated INHS staff needs  of the target population, 91% accessed the questionnaire. The overall response rate was 49%, with homogeneous geographical distribution.Building up on previous surveys' findings and with the aim of collecting recent data useful to plan and implement improvements of public health training in Italy, we conducted a nationally representative cross-sectional study among PH residents who specialized in the last 2 years (between October 2014 and July 2016). Specific objectives were to assess their training experience, employment opportunities and current job satisfaction. The online survey was carried out with the support of SItI, and the survey tool was built and piloted by a scientific committee of the Board of Directors of the Italian Schools of Public Health. The target population was contacted via email through the national PH From the picture we took, recent PH specialists in Italy have an average of 35.2 years (DS 4.8 - range 29–60) and are females in 67.2% of cases. More than two thirds (76%) of them are employed, with a neat North-South employment rate gradient . When stratifying data by graduation cohort, 2 years after graduation 93.5% of public health specialist is employed. However, only 5.8% of young PH specialists have a permanent contract, 59% holding different types of temporary contracts and 11.2% opted to stay in training pursuing a PhD degree  works in Hospitals’ Medical Directions, of which 20% in the public sector and 17% in INHS-accredited private hospitals or clinics, or a PhD (1.6%). Sixty-three percent of respondents reported to be SItI members and 28% to be members of the European Public Health Association (EUPHA). Of note, 44% of employed PH specialists judged his/her PH training experience partially inadequate in relation to current professional tasks. In particular, when asked what changes in PH training curricula would have helped them to be more competent and prepared in their jobs, the following suggestions consistently emerged (open questions’ feedback): a more comprehensive curriculum, incorporating strategic public health competencies (i.e. leadership and public speaking skills), more intensive training in quantitative data analysis (i.e. biostatistics and epidemiology), more credits awarded for frontal lectures and practical sessions. With regard to training internships and rotations, respondents declared they would have benefitted from an earlier start of professionalization activities in a wider variety of public services both in hospitals and local health authorities. Similarly, they felt they would have benefitted from a greater interaction with public health professionals during training, greater international exposure and deeper inter- and intra-SPHs exchange with both faculty and peers (detailed figures and data are available elsewhere )  hold a public health specialty, one other third holding clinical specialties and the remaining one third holding other degrees, including law, economics and political sciences degrees .Overall, we report relatively high employment rates for PH specialists in Italy and a wide variety of employment opportunities. However, our data show that young PH specialists are rarely contracted with permanent positions or tangible prospects of long-term career progressions; perceived job and salary satisfaction are only partially fulfilled. Public health training experience in the context of the PH residency programme varies within and between the 34 Italian Schools of Public Health. Both quantitative and qualitative findings from our survey have been shared and disseminated among the Board of Directors of the Italian Schools of Public Health to initiate a critical fruitful debate on how to improve public health programmes to better meet public health practice needs and take prompt and evidence-supported action.We (i) described the structure and management of public health training system in Italy, and we (ii) reported recent data on Italian public health specialists’ educational experience, employment opportunities and job satisfaction. Although the latter has been explored in other European and international settings, including Canada, France, Japan, the UK, and the USA , 19, no