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Background: Comprehensive HIV care aims at providing care and support, from HIV counselling and testing, through pre-antiretroviral (pre-ARV) care to antiretroviral therapy (ART). However, many people living with HIV (PLHIV) do not start treatment or are lost to follow-up during pre-ARV care, and subsequently initiate ART very late, with a high risk of HIV/AIDS-related mortality. Determinants of uptake/retention of PLHIV under pre-ARV care and delayed ART initiation in Uganda, where HIV and ART awareness are presumably high, are not sufficiently understood. Main aim: To investigate uptake and loss to follow-up of PLHIV under pre-ARV care and delayed ART initiation in order to inform policy and strategic planning for improved comprehensive HIV/AIDS care. Methods: Four studies (I-IV) were conducted in Iganga district, eastern Uganda. Study I used key informant interviews (KIIs) with five health workers and 10 in-depth interviews (IDIs) with PLHIV, as well as six focus group discussions (FGDs) with caretakers of the PLHIV to explore reasons for loss to follow-up under pre-ARV care. Study II was a randomised controlled trial involving 400 participants, to evaluate the effect of extended counselling on uptake of pre-ARV care. Study III used 20 IDIs with clients on ART and 10 FGDs with caretakers of ART clients to understand reasons for delayed ART initiation. Study IV was a case-control study involving 152 cases (clients who initiated ART at CD4 < 50 cells/μl) and 202 controls (clients who initiated ART at CD4 50-200 cells/μl) to assess risk factors for very late initiation of ART. Content analysis was used for qualitative data, and univariate, bivariate and multivariate analysis for quantitative data. Results: Reasons for dropping out of pre-ARV care included inadequate post-test counselling to PLHIV and competition from traditional/spiritual healers. Other reasons included transportation costs, long waiting time, lack of incentives to seek pre-ARV care by PLHIV who perceived themselves to be healthy, and gender inequality (I). PLHIV who underwent counselling by staff trained in basic counselling skills, combined with home visits by community network support agents, were 1.8 times more likely to take up pre-ARV care compared to PLHIV who received the standard care (RR 1.8; 95% CI 1.4-2.1) (II). ARV stock-outs, inadequate pre-ARV care and perceived lack of staff confidentiality were system barriers to timely ART initiation. Weak family/social support and misconceptions about ARVs were cited as individual/community barriers to timely ART initiation (III). Seeking care from traditional/spiritual healers before attending formal care (AOR 7.8; 95% CI 3.7-16.4), lack of pre-ARV care (AOR 4.6; 95% CI 2.3-9.3), subsistence farming (AOR 6.3; 95% CI 3.1-13.0) and lack of family/social support (AOR 3.3; 95% CI 1.6-6.6) were crucial risk factors for very late ART initiation (IV). Higher age (AOR 0.9; 95% CI 0.8-0.9) and being female (AOR 0.4; 95% CI 0.2-0.8) were protective factors against very late initiation of ART (IV). Discussion: Adequate post-test counselling for newly diagnosed PLHIV, combined with follow-up care by network support agents, could help retain PLHIV under pre-ARV care and allow timely initiation of ART. Trained and supervised traditional/spiritual healers could complement government efforts in offering some components of pre-ARV care. ART services should be made more affordable, accessible and user-friendly to enhance timely ART initiation. Other system deficiencies, such as stock-outs of cotrimoxazole and ARVs and lack of adequate staff also need to be addressed. There is a need for social mobilisation to address gender inequality, stigma and misconceptions about ARVs and to boost social support for PLHIV.

BackgroundLack of adherence to antiretroviral medications is one of the key challenges for paediatric HIV care and treatment programmes. There are few hands‐on opportunities for healthcare workers to gain awareness of the psychosocial and logistic challenges that caregivers face when administering daily antiretroviral therapy to children. This article describes an educational activity that allows healthcare workers to simulate this caregiver role.MethodsPaediatric formulations of several antiretroviral medications were dispensed to a convenience sample of staff at the Baylor College of Medicine‐Bristol‐Myers Squibb Children's Clinical Center of Excellence in Mbabane, Swaziland. The amounts of the medications remaining were collected and measured one week later. Adherence rates were calculated. Following the exercise, a brief questionnaire was administered to all staff participants.ResultsThe 27 clinic staff involved in the exercise had varying and low adherence rates over the week during which the exercise was conducted. Leading perceived barriers to adherence included: "family friends don't help me remember/tell me I shouldn't take it" and "forgot". Participants reported that the exercise was useful as it allowed them to better address the challenges faced by paediatric patients and caregivers.ConclusionsPromoting good adherence practices among caregivers of children on antiretrovirals is challenging but essential in the treatment of paediatric HIV. Participants in this exercise achieved poor adherence rates, but identified with many of the barriers commonly reported by caregivers. Simulations such as this have the potential to promote awareness of paediatric ARV adherence issues among healthcare staff and ultimately improve adherence support and patient outcomes.

"Although the pathogenesis of human immunodeficiency virus (HIV) infection and the general virologic and immunologic principles underlying the use of antiretroviral therapy are similar for all HIV-infected persons, there are unique considerations needed for HIV-infected infants, children, and adolescents, including a) acquisition of infection through perinatal exposure for many infected children; b) in utero exposure to zidovudine (ZDV) and other antiretroviral medications in many perinatally infected children; c) differences in diagnostic evaluation in perinatal infection; d) differences in immunologic markers (e.g., CD4+ T-lymphocyte count) in young children; e) changes in pharmacokinetic parameters with age caused by the continuing development and maturation of organ systems involved in drug metabolism and clearance; f) differences in the clinical and virologic manifestations of perinatal HIV infection secondary to the occurrence of primary infection in growing, immunologically immature persons; and g) special considerations associated with adherence to treatment for children and adolescents. This report addresses the pediatric-specific issues associated with antiretroviral treatment and provides guidelines to health-care providers caring for infected infants, children, and adolescents." ; "April 17, 1998." ; "These guidelines were developed by the Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children convened by the National Pediatric and Family HIV Resource Center . the Health Resources and Services Administration . and the National Institutes of Health . The Co-Chairs of the Working Group were James Oleske . and Gwendolyn B. Scott ."--P. ii. ; "U.S. Government Printing Office: 1998-633-228/67064 Region IV."--P. [4] of cover. ; Includes bibliographical references (p. 28-31).

AbstractThe advent of effective treatments for HIV has begun a new era in the worldwide HIV epidemic. Many new political, social, economic, medical, and psychological issues arise in the struggle to contain this epidemic. Mental health providers must understand the context in which people with HIV find themselves making decisions about their health care and the future directions of their lives.

International health experts agree that China is on the verge of an AIDS crisis. In response, the Chinese government initiated the "Four Frees and One Care" policy in 2003 to decrease economic barriers and increase access to antiretroviral therapies for people with HIV. However, long-term treatment success requires not only access, but high rates of medication adherence. This qualitative interview study with 29 persons receiving HIV care at Beijing's Ditan Hospital identified barriers to and facilitators of medication adherence. The interviews were guided by an a priori conceptual model of adherence with four components: access, knowledge about medications, motivation, and proximal cues to action. Barriers to adherence were related to stigma and fear of discrimination; the medications themselves (including side effects and complicated dosing regimens); and other economic issues (i.e., costs of transportation, lab tests, and hospitalizations). Facilitators included participants' strong will to live, use of electronic reminders, and family support. These results support the conceptual model and suggest that successful interventions must minimize stigma as it negatively affects all components of the model for adherence.

Anti-retroviral drugs (ARVs) are the only medications capable of extending the lives of those with AIDS. How they are distributed is, therefore, an important concern for both normative and positive reasons. The paper tests various potential theories about the distribution of scarce resources and provision of public goods from political science and economics against new data on the distribution of ARVs under the South African national rollout plan. Strong evidence is found in support of theories that predict that voter interests and knowledge drive the distribution of resources in democracies.

Antiretroviral medications are known inhibitors and inducers of cytochrome p450 enzymes and can affect levels of non‐HIV medications. Finasteride 1 mg (Propecia), which prevents the conversion of testosterone (T) to dihydrotestosterone (DHT) is commonly prescribed for prevention of hair loss. This medication is a substrate of p450 3A4. Its efficacy may therefore be affected by HIV medications which induce or inhibit this enzyme. Levels of DHT to prevent hair loss are not well established, but likely need to be<15–20 ng/dl, or a DHT/T ratio of<0.02. Observational analysis in a private practice, measuring DHT and T levels in patients on finasteride and various antiretrovirals 21 patients were identified. 7 patients were taking protease inhibitors and had DHT levels<12 ng/dL; DHT/T<0.20. Three of these patients decreased their finasteride dose to 1 mg every‐other‐day and still have DHT <10. 8 patients were taking potent p450 inducers (efavirenz or etravirine) and had DHT levels between >20; DHT/T>0.025. Two of these patients increased the dose of finasteride to 2 mg/day and subsequently decreased DHT to 14 and 17. Two additional patients on efavirenz, however, had DHT levels of<15 without dose adjustment. Four patients taking nevirapine, a less potent inducer of p450 had DHT levels of<15, as did one patient on raltegravir, which does not affect CYP450. Antiretrovirals that affect CYP 3A4 may interact with finasteride. While it is unlikely that this interaction is dangerous, it may affect its efficacy of the finasteride. Evaluation of DHT/T levels, and/or dose adjustment of finasteride may be appropriate in men being treated for HIV.

BackgroundThe peculiarity of Romanian HIV epidemic is the high number of long‐time survivors, nosocomially infected with F subtype during early childhood. Although ART is provided for free, patients from certain regions are difficult to attain viral load (VL) and HIV resistance tests.ObjectivesTo assess the durability of first‐line antiretroviral therapy (1st ART) in Romanian HIV patients.MethodsRetrospective assessment of new HIV diagnosed patients during 2005–2010, monitored every 24 weeks (wk) in HIV clinic from Galati ‐ Romania, considering demographic data, HIV transmission pattern, immunity, HIV‐RNA blood levels, co‐morbidities, 1st ART regimen and adherence according to the national protocol. The endpoint was term on loss to follow‐up, death or 96 wk of ART.Results100 new diagnosed HIV patients since 2005 received 1st ART. Characteristics of naïve patients: median age on HIV diagnostic=22.5 years old; sex ratio M/F=53/47; living area rural/urban=55/45; low literacy 26%; HIV infection pattern paediatric/ sexual/ unknown=29/61/10; advanced late presenters 51%; TB as HIV indicator 22%; VHB co‐infection 22%; baseline av. CD4Ly=171/mm3. Experience of 1st ART: 2 NRTI+EFV 38% or LPV 27% or other protease inhibitor 35%. The reasons for 58% interrupting 1st ART: 9% dead, 17% abandoned, 18% failed, 12% developed adverse events and 2% drug‐drug interactions. While 53% patients were adherent previous to endpoint, no more than 42% kept on 1st ART>96 wk and recovered immunity with av. CD4Ly=213/mm3. Poor recovery of CD4Ly<100/mm3 was acquired by 13/48 patients with available HIV‐RNA<50 c/ml in 48 wk. The main risks below 24 weeks of 1st ART are the death (p=0.005; OR=36) and the adverse events (p=0.018; OR=24). Abandon rate (p=0.016; OR=5.14) is higher over 48 weeks. Regardless of 1st ARV regimen, adherence behaviour, immunologic benefits and ART durability were comparable. Viral failure is related to non‐adherence (p=0.03; OR=4.5) and low literacy situation (p<0.001; OR=7.5). Mortality is 4.6 times higher in TB and 2 times in HBV co‐morbidities.ConclusionsOver a half of naïve HIV patients continued 1st ART less than 96 wk. 26% patients with low literacy are a vulnerable group and require individualised educational and adherence programmes. To improve the sustainability of the 1st ART in HIV patients from Galati needs to intensify the support for earlier HIV diagnostic and current virology follow‐up.

Uganda faces major challenges to ensure the continuity and sustainability of treatment programmes for IDPs returning home. Adapted from the source document.