UNC Gillings School of Global Public Health

Introduction: The global HIV response, once a model of progress and innovation, faces a profound moment. Despite four decades of pivotal scientific and programmatic advances-most notably in antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP)-the world remains off track to meet the 2025 and 2030 targets for ending AIDS as a public health threat. New acquisitions and AIDS-related deaths remain unacceptably high, particularly among key populations and in low- and middle-income countries. The abrupt U.S. funding reversals in 2025 have severely disrupted support for HIV efforts. Cuts to U.S. and international institutions have compromised HIV prevention, treatment and surveillance systems worldwide, and may already have begun reversing two decades of progress. Discussion: To avert this crisis, the HIV and public health community, together with governments and global funders, must urgently invest in scaling long-acting treatment and prevention tools, rebuild disaggregated data systems and strengthen implementation science rooted in community-led approaches. Digital health technologies offer promise to enhance service delivery, surveillance, monitoring and evaluation, especially in resource-constrained settings, but demand ethical governance and infrastructure investment. The global research ecosystem must become more evenly distributed and inclusive, with a shift towards country-led partnerships, national data sovereignty and regional co-operation. Conclusions: Looking to 2030 and beyond, the strategy to end HIV should include expanded access to long-acting ART and PrEP, sustained investments in HIV vaccine and cure research, and robust monitoring and evaluation systems. Achieving epidemic control-and ultimately ending the HIV pandemic-will require not only biomedical tools but also political will, community leadership and equitable financing. The lessons of the past underscore that sustained progress is possible, but only if we meet this moment with urgency, imagination and solidarity.

Importance:Despite treatment advances, metastatic recurrence continues to be a leading cause of morbidity and mortality. Empirical data on the incidence and survival after metastatic recurrence remain limited, as cancer registries historically do not collect data on recurrence. Objective:To estimate the cumulative incidence (CMI) of metastatic recurrence among adolescents and young adults diagnosed with earlier-stage disease and compare survival to those with metastatic disease at diagnosis. Design, Setting, Participants:This was a retrospective cohort study of adolescents and young adults aged 15 to 39 years who were diagnosed with nonmetastatic cancers from 2006 to 2018. Adolescents and young adults were identified from the California Cancer Registry linked with statewide hospitalization, emergency department, and ambulatory surgery encounters from the California Department of Health Care Access and Information. Data were analyzed from December 2023 to June 2025. Exposures:Cancer types, including melanoma, sarcoma, and breast, cervical, colorectal, testicular, and thyroid cancers. Main Outcomes and Measures:Metastatic recurrence was identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision, Clinical Modification, metastatic disease codes at least 6 months after cancer diagnosis or from an underlying cancer cause of death. Follow-up was through December 31, 2020. Results:Of a total of 48 406 adolescents and young adults (median [IQR] age at diagnosis, 33.0 [28.0-37.0] years; 67.4% female), 9.2% had metastatic disease at diagnosis, and 9.5% had metastatic recurrence. Among 43 935 adolescents and young adults who presented with nonmetastatic disease, the 5-year CMI of metastatic recurrences was highest among patients with sarcoma (24.5%; 95% CI, 22.6%-26.6%) and colorectal cancer (21.8%; 95% CI, 20.3%-23.4%) and intermediate for cervical (16.3%; 95% CI, 15.0%-17.6%) and breast (14.7%; 95% CI, 14.0%-15.4%) cancers. The CMI for metastatic recurrence increased with increasing stage at diagnosis, with 5-year CMIs higher than 30% for all stage III cancers (except thyroid). The 5-year CMI of metastatic recurrence also increased over time for cervical cancer (2006-2009: 12.7% [95% CI, 10.8%-14.8%]; 2015-2018: 20.4% [95% CI, 17.5%-23.6%]) and decreased for colorectal cancer (2006-2009: 24.4% [95% CI, 21.3%-27.6%]; 2015-2018: 19.2% [95% CI, 16.4%-22.2%]). Survival after metastatic recurrence was worse than metastatic disease at diagnosis for all cancer types, except for testicular and thyroid cancers. Conclusions and Relevance:The findings from this cohort study highlight the overall burden of metastatic disease in adolescents and young adults, expanding the knowledge of metastatic recurrences that help improve care for adolescent and young adult survivors throughout the cancer survivorship spectrum.

BACKGROUND:We investigated whether ghost gun recovery rates are significantly associated with firearm mortality rates in the following year across California's 58 counties from 2014 to 2023. METHODS:We obtained yearly county-level data on ghost guns recovered in California from The Trace's Gun Violence Data Hub. County-level firearm death counts (total, suicide and homicide) were pulled from the Centers for Disease Control and Prevention's Restricted-Use Vital Statistics Data. Spatiotemporal models quantified the covariate-adjusted associations between ghost gun recoveries per capita and firearm death rates (total, suicide and homicide) in the following year. Secondary analyses examined suicide and homicide models stratified by sex and race/ethnicity. RESULTS : For every 20 ghost guns recovered per 100 000 population, there was an associated 6.4% increase in firearm suicide rate (adjusted incidence rate ratio (aIRR): 1.064, 95% credible interval (CrI) 1.019 to 1.111) in the following year. We found no evidence of a significant ghost gun recovery association with total firearm death rate (aIRR: 1.036, 95% CrI 0.999 to 1.075) and firearm homicide rates (aIRR: 1.002, 95% CrI 0.946 to 1.064). Stratified models for firearm suicide rates suggested variations across sex and racial/ethnic groups, with significant positive associations observed for male (6.5% increase; aIRR: 1.065, 95% CrI 1.017 to 1.115), non-Hispanic white (6.2% increase; aIRR: 1.062, 95% CrI 1.005 to 1.122) and Hispanic (12.6% increase; aIRR: 1.126, 95% CrI 1.031 to 1.230) individuals. A different pattern emerged for firearm homicide death rates, where associations across demographic groups were not statistically significant. CONCLUSIONS:Practitioners concentrating on suicide prevention efforts should be advised about the threat that ghost guns may present.

BackgroundCommon mental health conditions (CMHCs) such as depression and anxiety often co-occur with noncommunicable diseases (NCDs) like hypertension and diabetes, compounding disability and mortality particularly in low- and middle-income countries (LMICs), with under-resourced health systems. This comorbidity is driven by shared behavioral risk factors including stress, isolation, tobacco use, inactivity, poor diet, and nonadherence to treatment. The World Health Organization recommends evidence-based stress reduction (EBSR), behavioral activation (BA), and motivational interviewing (MI) to address these modifiable risks, but the implementation of such multi-component behavioral interventions in community-based settings remains limited. There is a critical gap in implementation research on how best to deliver these combined interventions through community health workers (CHWs) within public health systems. This study addresses that gap by evaluating the effectiveness, implementation, and scalability of the BEhavioral Community-based COmbined Intervention for MEntal health and noncommunicable diseases (BECOME). The trial assesses clinical outcomes, implementation outcomes using the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework at patient, provider, and health system levels and conducts a comprehensive costing analysis to inform future scale-up.MethodsThis is a stepped-wedge cluster randomized controlled trial involving 20 geographic clusters across two provinces of Nepal and 700 participants aged 40 years and above with at least one CMHC and one NCD. CHWs will be trained to deliver BECOME, comprising EBSR, BA, and MI, while the control period will include enhanced usual care. Primary outcomes include changes in CMHC severity and secondary outcomes include NCD outcomes, behavioral factors, and implementation processes. Focus group discussions and in-depth interviews with CHWs, patients, healthcare providers, and health system leaders will explore intervention acceptability and mechanisms of change. Structured costing analysis will estimate the intervention costs.DiscussionParticipant recruitment began in July 2024 and is currently ongoing. We anticipate completing data collection for the primary outcome measures by January 2027, with the aim of disseminating preliminary findings within the same year. Findings from this study will provide evidence on the effectiveness and feasibility of a CHW-delivered, integrated behavioral intervention, BECOME, for CMHCs and NCDs in LMICs, informing potential scale-up.Trial registrationClinicalTrials.gov, NCT06449521, Registered on 25 April 2024, https://register.clinicaltrials.gov/prs/beta/studies/S000DZJN00000112/recordSummary.

Randomized trials are used to evaluate health care interventions because they minimize confounding and selection bias through randomization. Harms reporting in trials remain suboptimal, despite established guidelines. To improve transparency and clinical relevance, trialists should share information about harms-whether assessed systematically or nonsystematically. Nonsystematically assessed adverse events warrant greater attention, as they are often underreported or inconsistently documented. Trialists should specify what was measured, when, and by whom. For each study arm, tables or data should be available that include all harms observed. For dichotomous outcomes, tables or data should include the number of people who experienced each harm in each group: the number of participants at risk of harms (ie, randomized individuals); the number of deaths; participants with one or more adverse events; withdrawals (discontinuations) due to harms; and the total number of events, if appropriate. Thresholds should not be used to limit the sharing of information about harms. Zero events should be included for harms systematically assessed. For combined adverse events, such as the proportion of participants with one or more serious adverse events, researchers should report or share data for all component events (eg, deaths, major cardiovascular events, cancers, infections, and psychiatric events). Better harms reporting could improve evidence synthesis, enhance interpretability, and support informed clinical decision-making as well as patient safety.