Suchergebnisse

BackgroundRecently, a global commitment has been made to expand access to antiretrovirals (ARVs) in the developing world. However, in many resource-constrained countries the number of individuals infected with HIV in need of treatment will far exceed the supply of ARVs, and only a limited number of health-care facilities (HCFs) will be available for ARV distribution. Deciding how to allocate the limited supply of ARVs among HCFs will be extremely difficult. Resource allocation decisions can be made on the basis of many epidemiological, ethical, or preferential treatment priority criteria.Methods and findingsHere we use operations research techniques, and we show how to determine the optimal strategy for allocating ARVs among HCFs in order to satisfy the equitable criterion that each individual infected with HIV has an equal chance of receiving ARVs. We present a novel spatial mathematical model that includes heterogeneity in treatment accessibility. We show how to use our theoretical framework, in conjunction with an equity objective function, to determine an optimal equitable allocation strategy (OEAS) for ARVs in resource-constrained regions. Our equity objective function enables us to apply the egalitarian principle of equity with respect to access to health care. We use data from the detailed ARV rollout plan designed by the government of South Africa to determine an OEAS for the province of KwaZulu-Natal. We determine the OEAS for KwaZulu-Natal, and we then compare this OEAS with two other ARV allocation strategies: (i) allocating ARVs only to Durban (the largest urban city in KwaZulu-Natal province) and (ii) allocating ARVs equally to all available HCFs. In addition, we compare the OEAS to the current allocation plan of the South African government (which is based upon allocating ARVs to 17 HCFs). We show that our OEAS significantly improves equity in treatment accessibility in comparison with these three ARV allocation strategies. We also quantify how the size of the catchment region surrounding each HCF, and the number of HCFs utilized for ARV distribution, alters the OEAS and the probability of achieving equity in treatment accessibility. We calculate that in order to achieve the greatest degree of treatment equity for individuals with HIV in KwaZulu-Natal, the ARVs should be allocated to 54 HCFs and each HCF should serve a catchment region of 40 to 60 km.ConclusionOur OEAS would substantially improve equality in treatment accessibility in comparison with other allocation strategies. Furthermore, our OEAS is extremely different from the currently planned strategy. We suggest that our novel methodology be used to design optimal ARV allocation strategies for resource-constrained countries.

Objective: To analyze and list factors and monitoring techniques related to the adherence to antiretroviral treatment. Method: study of integrative review of the literature from the electronic bases LILACS and MEDLINE, conducted in April and May, 2013. Results: factors such as education level, complexity of treatment, psychological aggravating and the relationship between health professional and the user were highlighted in adherence to ART. In this context, to monitor and measure adherence to antiretroviral therapy with the use of appropriate techniques can contribute to a significant increase of these values. Conclusion: it is true that there is no gold standard to ensure ideal adhesion, however, the use of correct and combined monitoring techniques, can significantly decrease the impact of several factors that predispose the ineffective adherence to AIDS treatment.

In August 2003, the South African government announced its support for the provision of highly active antiretroviral therapy (HAART) in the public sector. This was a major break-through (antiretrovirals are now explicitly recognised as beneficial) but the Cabinet statement was very cautiously worded about actual implementation. The Ministry of Health has been instructed to develop a 'detailed operational plan' but it is increasingly clear that one of the major constraints on the scale and pace of the roll-out will be the amount of resources allocated to it. Given the discourse of 'unaffordability' which has dogged South African AIDS policy making over the past five years (Nattrass, 2004 forthcoming) it is likely that South Africa will opt for a limited intervention on the grounds that resources are best spent elsewhere.

IntroductionIn Brazil, the use of antiretrovirals is widespread: more than 260,000 individuals are currently undergoing treatment. We conducted a survey targeting antiretroviral‐naïve individuals who were initiating antiretroviral therapy (ART) according to local guidelines. This survey covered five Brazilian regions.MethodsThe HIV Threshold Survey methodology (HIV‐THS) of the World Health Organization was utilized, and subjects were selected from seven highly populated cities representative of all Brazilian macro‐regions. Dried blood spots (DBS) were collected on SS903 collection cards and were transported by regular mail at room temperature to a single central laboratory for genotyping.ResultsWe analysed samples from 329 individuals initiating highly active antiretroviral therapy (HAART), 39 (11.8%) of whom were harbouring transmitted drug resistance (TDR). The mean CD4+ T cell count was 253 cells/µL, and the mean viral load was 142,044 copies/mL. The regional prevalence of resistance was 17.0% in the Northeast, 12.8% in the Southeast, 10.6% in the Central region, 8.5% in the North and 8.5% in the South. The inhibitor‐specific TDR prevalence was 6.9% for nucleoside reverse transcriptase inhibitors, 4.9% for non‐nucleoside reverse transcriptase inhibitors and 3.9% for protease inhibitors; 3.6% of individuals presented resistance to more than one class of inhibitors. Overall, there were trends towards higher prevalences of subtype C towards the South and subtype F towards the North. Of the DBS samples collected, 9.3% failed to provide reliable results.DiscussionWe identified variable TDR prevalence, ranging from intermediate to high levels, among individuals in whom HIV disease progressed, thus implying that resistance testing before initiating ART could be effective in Brazil. Our results also indicate that the use of DBS might be especially valuable for providing access to testing in resource‐limited and remote settings.

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

The introduction of combination antiretroviral therapies in 1996 brought about a radical change in the temporality of HIV infection, moving us away from the event-time of the AIDS crisis to the expanded/expansive temporality of chronic 'undetectability'. That, and the later extension of antiretrovirals as Pre-Exposure Prophylaxis, has dramatically shifted the lived temporalities of both sex and subjectivity among gay men who were able to access the new medical protocols for testing, managing, and preventing HIV. In this essay, I draw from field work carried out in Berlin, Los Angeles, and San Francisco, and analysis of gay pornography, to map the new temporalities of sex and subjectivity that have been catalysed by the introduction of antiretroviral drugs, speculating on their limits and queer political potential, situated as they are at the intersection of neoliberal regimes of biomedical self-administration and sex understood as both an aesthetics and poetics of existence. If modernity developed through an incessant rationalisation of time, including of lived, embodied time, I argue that antiretroviral time has triggered the emergence of sexual behaviours and subjectivities that open up new avenues for thinking 21st-century triangulations of sex, subjectivity, and resistance being experimented with in bedrooms, sex clubs, and bathhouses across the developed world.

AbstractIntroductionAntiretroviral therapy (ART) has reduced morbidity and mortality in sub‐Saharan Africa, but the burden of coexistent cardiopulmonary disease in perinatally HIV‐positive adolescents on antiretroviral therapy (ART) has not been well described. The aim of this study was to investigate the prevalence and associations of cardiopulmonary dysfunction in adolescents with perinatally acquired HIV on ART.MethodsFor this cross‐sectional analysis, 515 perinatally HIV‐positive adolescents ages 9 to 14 years on ART for at least six months, and a comparator group of 110 age‐matched HIV‐uninfected adolescents were tested between August 2013 and April 2015 using echocardiography, six‐minute walk test (6MWT) and spirometry. Those with either abnormal spirometry or abnormal 6MWT and any right or left systolic or diastolic dysfunction or abnormal mean pulmonary arterial pressure were considered as having impaired cardiopulmonary function. Logistic regression was used to investigate determinants of impaired cardiopulmonary function.ResultsOverall, 474 adolescents with perinatally acquired HIV (mean [SD] age, 12 [1.6] years; median [IQR] ART duration, 7 [4.6 to 9.3] years; median [IQR] CD4 count, 712 [571 to 959] cell/mm3) and 109 HIV‐uninfected adolescents mean (SD) age 11.8 (1.8) years, had successful cardiac and lung function testing. Impaired cardiopulmonary function was detected in 13% of adolescents with perinatally acquired HIV and 8% of HIV‐uninfected adolescents, p = 0.136. Among adolescents with perinatally acquired HIV, those with low tricuspid annular plane systolic excursion (TAPSE) had significantly lower mean FEV1, 1.5 L versus 1.6 L, p = 0.011. Height (OR 0.7, 95%CI 0.5 to 0.9), body mass index (OR 0.7, 95%CI 0.5 to 0.9) and past pulmonary tuberculosis (OR 2.3, 95%CI 1.2 to 4.4) were significantly associated with a low cardiopulmonary function.ConclusionsDespite being on ART, cardiopulmonary dysfunction occurs in an appreciable proportion of perinatally HIV‐infected adolescents but no significant difference to uninfected controls. This finding requires further exploration. Factors associated with dysfunction may be amenable to public health interventions to reduce cardiopulmonary disease in this population.

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

BackgroundAfter rapid scaling up of antiretroviral therapy in HIV‐1‐infected patients, the data of primary HIV‐1 drug resistance in Thailand is still limited. This study aims to determine the prevalence and associated factors of primary HIV‐1 drug resistance in Thailand.MethodsA prospective observational study was conducted among antiretroviral‐naïve HIV‐1‐infected Thai patients from 2007 to 2010. HIV‐1 subtypes and mutations were assayed by sequencing a region of HIV‐1 pol gene. Surveillance drug resistance mutations recommended by the World Health Organization for surveillance of transmitted HIV‐1 drug resistance in 2009 were used in all analyses. Primary HIV‐1 drug resistance was defined as the presence of one or more surveillance drug resistance mutations.ResultsOf 466 patients with a mean age of 38.8 years, 58.6% were males. Risks of HIV‐1 infection included heterosexual (77.7%), homosexual (16.7%), and intravenous drug use (5.6%). Median (IQR) CD4 cell count and HIV‐1 RNA were 176 (42‐317) cells/mm3and 68,600 (19,515‐220,330) copies/mL, respectively. HIV‐1 subtypes were CRF01_AE (86.9%), B (8.6) and other recombinants (4.5%). The prevalence of primary HIV‐1 drug resistance was 4.9%; most of these (73.9%) had surveillance drug resistance mutations to only one class of antiretroviral drugs. The prevalence of patients with NRTI, NNRTI, and PI surveillance drug resistance mutations was 1.9%, 2.8% and 1.7%, respectively. From logistic regression analysis, there was no factor significantly associated with primary HIV‐1 drug resistance. There was a trend toward higher prevalence in females [odds ratio 2.18; 95% confidence interval 0.896‐5.304; p = 0.086].ConclusionsThere is a significant emergence of primary HIV‐1 drug resistance in Thailand after rapid scaling up of antiretroviral therapy. Although HIV‐1 genotyping prior to antiretroviral therapy initiation is not routinely recommended in Thailand, our results raise concerns about the risk of early treatment failure in patients with primary HIV‐1 drug resistance. Interventions to prevent the transmission of HIV‐1 drug resistance and continuation of surveillance for primary HIV‐1 drug resistance in Thailand are indicated.