351
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Madec Y, Laureillard D, Pinoges L, Fernandez M, Prak N, Ngeth C, Moeung S, Song S, Balkan S, Ferradini L, Quillet C, Fontanet A. Response to highly active antiretroviral therapy among severely immuno-compromised HIV-infected patients in Cambodia. AIDS 2007; 21:351-9. [PMID: 17255742 DOI: 10.1097/qad.0b013e328012c54f] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HAART efficacy was evaluated in a real-life setting in Phnom Penh (Médecins Sans Frontières programme) among severely immuno-compromised patients. METHODS Factors associated with mortality and immune reconstitution were identified using Cox proportional hazards and logistic regression models, respectively. RESULTS From July 2001 to April 2005, 1735 patients initiated HAART, with median CD4 cell count of 20 (inter-quartile range, 6-78) cells/microl. Mortality at 2 years increased as the CD4 cell count at HAART initiation decreased, (4.4, 4.5, 7.5 and 24.7% in patients with CD4 cell count > 100, 51-100, 21-50 and < or = 20 cells/microl, respectively; P < 10). Cotrimoxazole and fluconazole prophylaxis were protective against mortality as long as CD4 cell counts remained < or = 200 and < or = 100 cells/microl, respectively. The proportion of patients with successful immune reconstitution (CD4 cell gain > 100 cells/microl at 6 months) was 46.3%; it was lower in patients with previous ART exposure [odds ratio (OR), 0.16; 95% confidence interval (CI), 0.05-0.45] and patients developing a new opportunistic infection/immune reconstitution infection syndromes (OR, 0.71; 95% CI, 0.52-0.98). Similar efficacy was found between the stavudine-lamivudine-nevirapine fixed dose combination and the combination stavudine-lamivudine-efavirenz in terms of mortality and successful immune reconstitution. No surrogate markers for CD4 cell change could be identified among total lymphocyte count, haemoglobin, weight and body mass index. CONCLUSION Although CD4 cell count-stratified mortality rates were similar to those observed in industrialized countries for patients with CD4 cell count > 50 cells/microl, patients with CD4 cell count < or = 20 cells/microl posed a real challenge to clinicians. Widespread voluntary HIV testing and counselling should be encouraged to allow HAART initiation before the development of severe immuno-suppression.
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Affiliation(s)
- Yoann Madec
- Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, 25-28 rue du Docteur Roux, 75015 Paris, France
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352
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Affiliation(s)
- Andrew Hill
- Pharmacology Research Laboratories, University of Liverpool, 70 Pembroke Place, Liverpool, UK.
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353
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Abstract
Non-nucleoside reverse transcriptase inhibitors form the backbone of antiretroviral treatment for many HIV-infected individuals. The tolerability, pill burden and efficacy associated with this class of agents make them a frequent choice for first-line therapy. Here we review nevirapine and efavirenz in terms of efficacy, resistance and toxicity, focusing particularly on the use of nevirapine to prevent mother-to-child transmission in developing countries.
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Affiliation(s)
- L Waters
- Department of HIV/GU Medicine, Chelsea & Westminster Hospital, London, UK
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354
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Bennett DE. The requirement for surveillance of HIV drug resistance within antiretroviral rollout in the developing world. Curr Opin Infect Dis 2006; 19:607-14. [PMID: 17075338 DOI: 10.1097/qco.0b013e3280109ff1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe surveillance measures to inform HIV drug-resistance prevention, as part of the public health approach to antiretroviral therapy in developing countries. RECENT FINDINGS Neither HIV drug-resistance transmission nor its emergence in treatment is routinely assessed in the developing world, but routine methods should be part of antiretroviral therapy scale-up. Mathematical modelling and experience in resource-rich countries suggest HIV drug-resistance transmission will increase as antiretroviral therapy coverage increases, but its rise will be limited initially. Transmission surveys should begin in geographic areas in each country where antiretroviral therapy coverage is widespread. Reports from resource-limited countries suggest that antiretroviral therapy programs are as effective as in resource-rich countries, which should limit HIV drug resistance if effectiveness is maintained with antiretroviral therapy expansion. Surveillance of HIV drug resistance emerging in treatment and other factors will support implementation of prevention measures on a population level. SUMMARY Standardized surveillance of transmitted and treatment-associated HIV drug resistance is critical to the success of antiretroviral therapy expansion in developing countries. Routine assessment of prescribing practices, availability of and access to appropriate regimens for adults and children, antiretroviral drug supply continuity, and measures to prevent HIV transmission will supply critical information for HIV drug-resistance prevention.
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Affiliation(s)
- Diane E Bennett
- Global AIDS Program, National Centre for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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355
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Abstract
Despite the clear benefits of antiretroviral therapy (ART), only three countries in sub-Saharan Africa have achieved the "3 by 5" goal of treating at least half of the persons living with HIV/AIDS who need it. A major obstacle faced by many lower income countries is the establishment of treatment programs in rural areas where there is a scarcity of trained health care providers and infrastructure. This paper reviews published data on rural ART programs in lower income countries to identify necessary components of such a program. No clearly superior model for rural ART delivery has emerged. All programs document the need for expanded physical infrastructure, laboratory development, recruitment/training of additional health care providers, and/or the introduction of new technologies in order to effectively support the needs of ART roll-out.
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Affiliation(s)
- Kara Wools-Kaloustian
- Division of Infectious Diseases, Indiana University School of Medicine,Wishard Memorial Hospital (Room OPW 430),1001 West 10th Street, Indianapolis, IN 46202, USA.
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356
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Calmy A, Ford N, Hirschel B, Reynolds SJ, Lynen L, Goemaere E, Garcia de la Vega F, Perrin L, Rodriguez W. HIV viral load monitoring in resource-limited regions: optional or necessary? Clin Infect Dis 2006; 44:128-34. [PMID: 17143828 DOI: 10.1086/510073] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 08/30/2006] [Indexed: 11/04/2022] Open
Abstract
Although it is a standard practice in high-income countries, determination of the human immunodeficiency virus (HIV) load is not recommended in developing countries because of the costs and technical constraints. As more and more countries establish capacity to provide second-line therapy, and as costs and technological constraints associated with viral load testing decrease, the question of whether determination of the viral load is necessary deserves attention. Viral load testing could increase in importance as a guide for clinical decisions on when to switch to second-line treatment and on how to optimize the duration of the first-line treatment regimen. In addition, the viral load is a particularly useful tool for monitoring adherence to treatment, performing sentinel surveillance, and diagnosing HIV infection in children aged <18 months. Rather than considering viral load data to be an unaffordable luxury, efforts should be made to ensure that viral load testing becomes affordable, simple, and easy to use in resource-limited settings.
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Affiliation(s)
- Alexandra Calmy
- Medecins sans Frontieres, Access to Medicines Campaign, Geneva, 1211, Switzerland.
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357
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Rosato M, Mwansambo CW, Kazembe PN, Phiri T, Soko QS, Lewycka S, Kunyenge BE, Vergnano S, Osrin D, Newell ML, Costello AMDL. Women's groups' perceptions of maternal health issues in rural Malawi. Lancet 2006; 368:1180-8. [PMID: 17011945 DOI: 10.1016/s0140-6736(06)69475-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Improvements in preventive and care-seeking behaviours to reduce maternal mortality in rural Africa depend on the knowledge and attitudes of women and communities. Surveys have indicated a poor awareness of maternal health problems by individual women. We report the perceptions of women's groups to such issues in the rural Mchinji district of Malawi. METHODS Participatory women's groups in the Mchinji district identified maternal health problems (172 groups, 3171 women) and prioritised problems they considered most important (171 groups, 2833 women). In-depth qualitative data was obtained through six focus-group discussions with the women's groups, three with women's group facilitators, and four interviews with facilitator supervisors. FINDINGS The maternal health problems most commonly identified by more than half the groups were anaemia (87%), malaria (80%), retained placenta (77%), obstructed labour (76%), malpresentation (71%), antepartum and postpartum haemorrhage (70% each), and pre-eclampsia (56%). The five problems prioritised as most important were anaemia (sum of rank score 304), malpresentation (295), retained placenta (277), obstructed labour (276). and postpartum haemorrhage (275). HIV/AIDS and sepsis were identified or prioritised much less because complexity and contextual factors hindered their consideration. INTERPRETATION Rural Malawian women meeting in participatory groups showed a developed awareness of maternal health problems and the concern and motivation to address them. Community mobilisation strategies, such as women's groups, might be effective at reducing maternal mortality because they can draw on the collective capacity in communities to solve problems and make women's voices heard by decision-makers.
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Affiliation(s)
- Mikey Rosato
- Centre for International Health and Development, Institute of Child Health, University College London, UK.
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358
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Abstract
The HIV-1 pandemic is a complex mix of diverse epidemics within and between countries and regions of the world, and is undoubtedly the defining public-health crisis of our time. Research has deepened our understanding of how the virus replicates, manipulates, and hides in an infected person. Although our understanding of pathogenesis and transmission dynamics has become more nuanced and prevention options have expanded, a cure or protective vaccine remains elusive. Antiretroviral treatment has transformed AIDS from an inevitably fatal condition to a chronic, manageable disease in some settings. This transformation has yet to be realised in those parts of the world that continue to bear a disproportionate burden of new HIV-1 infections and are most affected by increasing morbidity and mortality. This Seminar provides an update on epidemiology, pathogenesis, treatment, and prevention interventions pertinent to HIV-1.
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Affiliation(s)
- Viviana Simon
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, NY, USA.
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359
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Gilks CF, Crowley S, Ekpini R, Gove S, Perriens J, Souteyrand Y, Sutherland D, Vitoria M, Guerma T, De Cock K. The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings. Lancet 2006; 368:505-10. [PMID: 16890837 DOI: 10.1016/s0140-6736(06)69158-7] [Citation(s) in RCA: 491] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the "four Ss"--when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop--enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system.
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Affiliation(s)
- Charles F Gilks
- Department of HIV/AIDS, World Health Organization, Geneva 1211, Switzerland.
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360
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Bisson GP, Gross R, Strom JB, Rollins C, Bellamy S, Weinstein R, Friedman H, Dickinson D, Frank I, Strom BL, Gaolathe T, Ndwapi N. Diagnostic accuracy of CD4 cell count increase for virologic response after initiating highly active antiretroviral therapy. AIDS 2006; 20:1613-9. [PMID: 16868442 DOI: 10.1097/01.aids.0000238407.00874.dc] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To derive and internally validate a clinical prediction rule for virologic response based on CD4 cell count increase after initiation of HAART in a resource-limited setting. DESIGN AND METHODS A retrospective cohort study at two HIV care clinics in Gaborone, Botswana. The participants were previously treatment-naive HIV-1-infected individuals initiating HAART. The main outcome measure was a plasma HIV-1 RNA level (viral load) < or = 400 copies/ml (i.e. undetectable) 6 months after initiating HAART. RESULTS The ability of CD4 cell count increase to predict an undetectable viral load was significantly better in those with baseline CD4 cell counts < or = 100 cells/microl [area under the ROC curve (AUC), 0.78; 95% confidence interval (CI), 0.67-0.89; versus AUC, 0.60; 95% CI, 0.48-0.71; P = 0.018]. The sensitivity, specificity, and positive and negative predictive values of a CD4 cell count increase of > or = 50 cells/microl for an undetectable viral load in those with baseline CD4 cell counts < or = 100 cells/microl were 93.1, 61.3, 92.5 and 63.3%, respectively. Alternatively, these values were 47.8, 87.1, 95.0 and 24.5%, respectively, if a increase in CD4 cell count of > or = 150 cells/microl was used. CONCLUSIONS CD4 cell count increase after initiating HAART has only moderate discriminative ability in identifying patients with an undetectable viral load, and the predictive ability is higher [corrected] in patients with lower baseline CD4 cell counts. Although HIV treatment programs in resource-constrained settings could consider the use of CD4 cell count increases to triage viral load testing, more accurate approaches to monitoring virologic failure are urgently needed.
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Affiliation(s)
- Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania19104-6021, USA.
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