Suchergebnisse

Abstract Background The South African Government has outlined detailed plans for antiretroviral (ART) rollout in KwaZulu-Natal Province, but has not created a plan to address treatment accessibility in rural areas in KwaZulu-Natal. Here, we calculate the distance that People Living With HIV/AIDS (PLWHA) in rural areas in KwaZulu-Natal would have to travel to receive ART. Specifically, we address the health policy question 'How far will we need to go to reach PLWHA in rural KwaZulu-Natal?'. Methods We developed a model to quantify treatment accessibility in rural areas; the model incorporates heterogeneity in spatial location of HCFs and patient population. We defined treatment accessibility in terms of the number of PLWHA that have access to an HCF. We modeled the treatment-accessibility region (i.e. catchment area) around an HCF by using a two-dimensional function, and assumed that treatment accessibility decreases as distance from an HCF increases. Specifically, we used a distance-discounting measure of ART accessibility based upon a modified form of a two-dimensional gravity-type model. We calculated the effect on treatment accessibility of: (1) distance from an HCF, and (2) the number of HCFs. Results In rural areas in KwaZulu-Natal even substantially increasing the size of a small catchment area (e.g. from 1 km to 20 km) around an HCF would have a negligible impact (~2%) on increasing treatment accessibility. The percentage of PLWHA who can receive ART in rural areas in this province could be as low as ~16%. Even if individuals were willing (and able) to travel 50 km to receive ART, only ~50% of those in need would be able to access treatment. Surprisingly, we show that increasing the number of available HCFs for ART distribution ~ threefold does not lead to a threefold increase in treatment accessibility in rural KwaZulu-Natal. Conclusion Our results show that many PLWHA in rural KwaZulu-Natal are unlikely to have access to ART, and that the impact of an additional 37 HCFs on treatment accessibility in rural areas would be less substantial than might be expected. There is a great length to go before we will be able to reach many PLWHA in rural areas in South Africa, and specifically in KwaZulu-Natal.

Abstract Background The state of the HIV epidemic in the Philippines has been described as "low and slow", which is in stark contrast to many other countries in the region. A review of the conditions for HIV spread in the Philippines is necessary. Methods We evaluated the current epidemiology, trends in behaviour and public health response in the Philippines to identify factors that could account for the current HIV epidemic, as well as to review conditions that may be of concern for facilitating an emerging epidemic. Results The past control of HIV in the Philippines cannot be attributed to any single factor, nor is it necessarily a result of the actions of the Filipino government or other stakeholders. Likely reasons for the epidemic's slow development include: the country's geography is complicated; injecting drug use is relatively uncommon; a culture of sexual conservatism exists; sex workers tend to have few clients; anal sex is relatively uncommon; and circumcision rates are relatively high. In contrast, there are numerous factors suggesting that HIV is increasing and ready to emerge at high rates, including: the lowest documented rates of condom use in Asia; increasing casual sexual activity; returning overseas Filipino workers from high-prevalence settings; widespread misconceptions about HIV/AIDS; and high needle-sharing rates among injecting drug users. There was a three-fold increase in the rate of HIV diagnoses in the Philippines between 2003 and 2008, and this has continued over the past year. HIV diagnoses rates have noticeably increased among men, particularly among bisexual and homosexual men (114% and 214% respective increases over 2003-2008). The average age of diagnosis has also significantly decreased, from approximately 36 to 29 years. Conclusions Young adults, men who have sex with men, commercial sex workers, injecting drug users, overseas Filipino workers, and the sexual partners of people in these groups are particularly vulnerable to HIV infection. There is no guarantee that a large HIV epidemic will be avoided in the near future. Indeed, an expanding HIV epidemic is likely to be only a matter of time as the components for such an epidemic are already present in the Philippines.

BackgroundThe state of the HIV epidemic in the Philippines has been described as "low and slow", which is in stark contrast to many other countries in the region. A review of the conditions for HIV spread in the Philippines is necessary.MethodsWe evaluated the current epidemiology, trends in behaviour and public health response in the Philippines to identify factors that could account for the current HIV epidemic, as well as to review conditions that may be of concern for facilitating an emerging epidemic.ResultsThe past control of HIV in the Philippines cannot be attributed to any single factor, nor is it necessarily a result of the actions of the Filipino government or other stakeholders. Likely reasons for the epidemic's slow development include: the country's geography is complicated; injecting drug use is relatively uncommon; a culture of sexual conservatism exists; sex workers tend to have few clients; anal sex is relatively uncommon; and circumcision rates are relatively high.In contrast, there are numerous factors suggesting that HIV is increasing and ready to emerge at high rates, including: the lowest documented rates of condom use in Asia; increasing casual sexual activity; returning overseas Filipino workers from high‐prevalence settings; widespread misconceptions about HIV/AIDS; and high needle‐sharing rates among injecting drug users.There was a three‐fold increase in the rate of HIV diagnoses in the Philippines between 2003 and 2008, and this has continued over the past year. HIV diagnoses rates have noticeably increased among men, particularly among bisexual and homosexual men (114% and 214% respective increases over 2003‐2008). The average age of diagnosis has also significantly decreased, from approximately 36 to 29 years.ConclusionsYoung adults, men who have sex with men, commercial sex workers, injecting drug users, overseas Filipino workers, and the sexual partners of people in these groups are particularly vulnerable to HIV infection. There is no guarantee that a large HIV epidemic will be avoided in the near future. Indeed, an expanding HIV epidemic is likely to be only a matter of time as the components for such an epidemic are already present in the Philippines.

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.

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, ...

Antiretroviral therapy (ART) is becoming available in South Africa. Demand will exceed supply; thus, difficult decisions will have to be made in allocating ART. The majority of those treated for HIV are likely to be in cities, because health infrastructure and personnel are concentrated in urban centers. We predict the epidemiological impact of drug allocation strategies (DAS) by using a spatially explicit model that links urban and rural epidemics. We parameterize our model by using data from the KwaZulu-Natal province in South Africa. We model the South African government's treatment plan from 2004–2008, and we predict the consequences of one DAS that allocates drugs only to Durban and of two DAS that allocate drugs to both urban and rural areas. All three strategies would treat 500,000 people by 2008. Not surprisingly, the Durban-only DAS would prevent the greatest number of infections (an additional 15,000 infections by 2008). However, it may have been expected that this DAS would generate the highest levels of transmitted resistance, because it concentrates ART in one location. Paradoxically, we found that this DAS would generate the lowest levels of transmitted resistance. Concentrating treatment in Durban would also avert the greatest number of AIDS-related deaths. We discuss the difference between using the principle of treatment equity versus using the principle of utilitarianism/efficiency to allocate ART. Decisions about allocating scarce drugs should consider treatment equity as well as epidemiological consequences. Notably, a Durban-only DAS would lead to new disparities in healthcare between urban and rural areas in KwaZulu-Natal.

Abstract Background As a harm reduction strategy in response to HIV epidemics needle and syringes programs (NSPs) were initiated throughout China in 2002. The effectiveness of NSPs in reducing the spread of infection in such an established epidemic is unknown. In this study we use data from Yunnan province, the province most affected by HIV in China, to (1) estimate the population benefits in terms of infections prevented due to the programs; (2) calculate the cost-effectiveness of NSPs. Methods We developed a mathematical transmission model, informed by detailed behavioral and program data, which accurately reflected the unique HIV epidemiology among Yunnan injecting drug users (IDUs) in the presence of NSPs. We then used the model to estimate the likely epidemiological and clinical outcomes without NSPs and conducted a health economics analysis to determine the cost-effectiveness of the program. Results It is estimated that NSPs in Yunnan have averted approximately 16-20% (5,200-7,500 infections) of the expected HIV cases since 2002 and led to gains of 1,300-1,900 DALYs. The total $1.04 million spending on NSPs from 2002 to 2008 has resulted in an estimated cost-saving over this period of $1.38-$1.97 million due to the prevention of HIV and the associated costs of care and management. Conclusion NSPs are not only cost-effective but cost-saving in Yunnan. Significant scale-up of NSPs interventions across China and removal of the societal and political barriers that compromise the effects of NSPs should be a health priority of the Chinese government.

Objective::Prices of antiretroviral (ARV) drugs in lower income countries have decreased substantially over the past two decades, helping to facilitate greatly expanded access to antiretroviral therapy (ART). However, ART coverage in many parts of the world remains low. We investigate the extent of epidemiological benefits that might be expected if ARV drug prices decline further.Design:A modeling study using data from seven countries in West and Central Africa (Cameroon, Democratic Republic of the Congo, Côte d'Ivoire, Niger, Nigeria, Senegal, and Togo).Methods:We investigated how the timing of ARV cost reductions could affect the impact and compared three different possible investment strategies: reinvesting in ART, reinvesting in the HIV response according to historical allocations, and reinvesting with the aim of minimizing HIV incidence and mortality.Results:If ARV drug prices fell by 37% relative to 2018 levels (i.e. following continued trend declines), we calculate ART unit costs could decrease by ∼20% (holding other cost components constant). If this could be achieved by 2020 and the savings were reinvested into ART, we estimate that an additional 8% of HIV infections and 11% of HIV-related deaths could be averted over 2020-2030 across the seven countries. Slightly greater gains could be attained if funds were reinvested in ART in combination with primary prevention. Delays in the year of introduction of ARV price reductions would reduce the impact by about 1% per year.Conclusion:ARV price reductions could free up funds that - if strategically invested - would help countries move closer toward the elimination of HIV.

NTRODUCTION Despite recent and robust economic growth across the Asia-Pacific region, the majority of low- and middle-income countries in the region remain dependent on some donor support for HIV programmes. We describe the availability of bilateral and multilateral official development assistance (ODA) for HIV programmes in the region. METHODS: The donor countries considered in this analysis are Australia, Canada, Denmark, France, Germany, Netherlands, Norway, Sweden, the United Kingdom and the United States. To estimate bilateral and multilateral ODA financing for HIV programmes in the Asia-Pacific region between 2004 and 2013, we obtained funding data from the Organisation for Economic Co-operation and Development Creditor Reporting System database. Where possible, we checked these amounts against the funding data available from government aid agencies. Estimates of multilateral ODA financing for HIV/AIDS were based on the country allocations announcement by the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) for the period 2014 to 2016. RESULTS: Countries in the Asia-Pacific region receive the largest share of aid for HIV from the Global Fund. Bilateral funding for HIV in the region has been relatively stable over the last decade and is projected to remain below 10% of the worldwide response to the epidemic. Bilateral donors continue to prioritize ODA for HIV to other regions, particularly sub-Saharan Africa; Australia is an exception in prioritizing the Asia-Pacific region, but the United States is the bilateral donor providing the greatest amount of assistance in the region. Funding from the Global Fund has increased consistently since 2005, reaching a total of US$1.2 billion for the Asia-Pacific region from 2014 to 2016. CONCLUSIONS: Even with Global Fund allocations, countries in the Asia-Pacific region will not have enough resources to meet their epidemiological targets. Prevention funding is particularly vulnerable and requires greater domestic leadership and coordination. Bilateral donors are still crucially important in the response to HIV throughout the Asia-Pacific region. KEYWORDS: Asia; HIV; Pacific; bilateral; funding; multilateral

IntroductionDespite recent and robust economic growth across the Asia‐Pacific region, the majority of low‐ and middle‐income countries in the region remain dependent on some donor support for HIV programmes. We describe the availability of bilateral and multilateral official development assistance (ODA) for HIV programmes in the region.MethodsThe donor countries considered in this analysis are Australia, Canada, Denmark, France, Germany, Netherlands, Norway, Sweden, the United Kingdom and the United States. To estimate bilateral and multilateral ODA financing for HIV programmes in the Asia‐Pacific region between 2004 and 2013, we obtained funding data from the Organisation for Economic Co‐operation and Development Creditor Reporting System database. Where possible, we checked these amounts against the funding data available from government aid agencies. Estimates of multilateral ODA financing for HIV/AIDS were based on the country allocations announcement by the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) for the period 2014 to 2016.ResultsCountries in the Asia‐Pacific region receive the largest share of aid for HIV from the Global Fund. Bilateral funding for HIV in the region has been relatively stable over the last decade and is projected to remain below 10% of the worldwide response to the epidemic. Bilateral donors continue to prioritize ODA for HIV to other regions, particularly sub‐Saharan Africa; Australia is an exception in prioritizing the Asia‐Pacific region, but the United States is the bilateral donor providing the greatest amount of assistance in the region. Funding from the Global Fund has increased consistently since 2005, reaching a total of US$1.2 billion for the Asia‐Pacific region from 2014 to 2016.ConclusionsEven with Global Fund allocations, countries in the Asia‐Pacific region will not have enough resources to meet their epidemiological targets. Prevention funding is particularly vulnerable and requires greater domestic leadership and coordination. Bilateral donors are still crucially important in the response to HIV throughout the Asia‐Pacific region.

IntroductionLeadership is a key factor in the success of HIV prevention and treatment. Positive HIV‐related outcomes are also affected by funding levels for HIV, health sector resources, disease burden and the socio‐economic environment. Leadership on HIV as well as these other factors are affected by the quality of political governance of the country, which may be an overarching factor that influences the making of effective responses to the HIV epidemic.AimThe aim of the study was to investigate the association between quality of political governance, on one hand, and coverage of antiretroviral therapy (ART) and prevention of mother‐to‐child transmission (PMTCT), on the other, in low‐ to middle‐income countries.MethodsThis investigation was carried out through a global review, online data sourcing and statistical analyses. We collected data on health burden and resources, the socio‐economic environment, HIV prevalence, ART and PMTCT coverage and indicators of political governance. Outcome variables were coverage of ART (from 2004) and PMTCT (from 2007) to 2009 as a percentage of persons needing it. Potential predictors of treatment coverage were fitted with a baseline multilevel model for univariable and multivariable analyses.ResultsCountries with higher levels of political voice and accountability, more political stability and better control of corruption have higher levels of ART coverage but not PMTCT coverage. Control of corruption (in standard deviation units) had a strong association with ART (AOR=1.82, p=0.002) and PMTCT (AOR=1.97, p=0.01) coverage. Indicators of economic development were not significant when control of corruption was included in the multivariable regression model. Many countries in all income groups had high ART but not PMTCT coverage (e.g. Mexico, Brazil and Romania in the upper‐middle‐income group; Papua New Guinea and Philippines in the lower‐middle‐income group; and Cambodia, Laos and Comoros in the low‐income group). Very few low‐income countries (notably, Haiti and Kenya) had high PMTCT coverage.ConclusionsOur research found a significant relationship between quality of political governance and treatment coverage. Measures and policies for improving the quality of political governance should be considered as a part of HIV programme implementation to more effectively improve the welfare of people living with HIV, particularly mothers living with HIV and their babies.

IntroductionAntiretroviral therapy (ART) substantially improves the health of people living with HIV and contributes to preventing new infections. While HIV incidence is decreasing in most regions, the epidemic in eastern Europe continues to rise, as new infections currently outnumber the rate of ART initiation. In this study, we assess ART use in Armenia and its impact on the number of AIDS diagnoses and mortality.MethodsNational surveillance data were obtained from the National Centre for AIDS Prevention, Armenia. Cox‐proportional hazard models were used to determine the effect of demographic and clinical risk factors, including access to ART, on AIDS and mortality.ResultsAmong people diagnosed with HIV since 2005, approximately 40% per year were diagnosed with CD4<200 cells per mL. Overall, 232 people (57.1%) with AIDS or a low CD4 count had not received ART by the end of 2010. Mortality was 34.1% among people living with HIV who did not initiate ART, and 0.3% among people who received ART. Among people diagnosed with HIV from 1996 to 2010, age at diagnosis, no use of ART, likely mode of transmission, likely place of transmission, low baseline CD4 count and no STI diagnosis at last contact are significantly associated with death.DiscussionIn Armenia, HIV is frequently diagnosed at a late stage of disease, indicating low testing rates. Of people diagnosed with HIV and in need of ART, a large proportion (approximately 60%) either do not provide consent for treatment, or are who migrants who cannot be located.ConclusionsGlobally, the scale‐up of ART has resulted in substantial reductions in mortality among individuals initiating therapy. However, in an era of momentum for treatment as prevention, treatment levels are not at adequate levels for preventing morbidities and mortality in some settings. Particular focus should be placed on key at‐risk subgroups.

AbstractIntroductionOutbreaks of hepatitis C virus (HCV) infections among HIV‐positive men who have sex with men (MSM) have been observed globally. Using a multi‐modelling approach we estimate the time and number of direct‐acting antiviral treatment courses required to achieve an 80% reduction in HCV prevalence among HIV‐positive MSM in the state of Victoria, Australia.MethodsThree models of HCV transmission, testing and treatment among MSM were compared: a dynamic compartmental model; an agent‐based model (ABM) parametrized to local surveillance and behavioural data ("ABM1"); and an ABM with a more heterogeneous population ("ABM2") to determine the influence of extreme variations in sexual risk behaviour.ResultsAmong approximately 5000 diagnosed HIV‐positive MSM in Victoria, 10% are co‐infected with HCV. ABM1 estimated that an 80% reduction in HCV prevalence could be achieved in 122 (inter‐quartile range (IQR) 112 to 133) weeks with 523 (IQR 479 to 553) treatments if the average time from HCV diagnosis to treatment was six months. This was reduced to 77 (IQR 69 to 81) weeks if the average time between HCV diagnosis and treatment commencement was decreased to 16 weeks. Estimates were consistent across modelling approaches; however ABM2 produced fewer incident HCV cases, suggesting that treatment‐as‐prevention may be more effective in behaviourally heterogeneous populations.ConclusionsMajor reductions in HCV prevalence can be achieved among HIV‐positive MSM within two years through routine HCV monitoring and prompt treatment as a part of HIV care. Compartmental models constructed with limited behavioural data are likely to produce conservative estimates compared to models of the same setting with more complex parametrizations.