Drug resistance and adherence to HIV/AIDS antiretroviral treatment: against a double standard between the north and the south

The Case for Resource Sensitivity: Why It Is Ethical to Provide Cheaper, Less Effective Treatments in Global Health

When Dr. Hortense screens her patients in Chicago for cervical dysplasia and cancer, she conducts a pelvic exam, takes a sample of cervical cells, and sends them for Pap cytology and human papilloma virus DNA co-testing. But when she conducts cervical cancer screening in Botswana, she employs a much simpler diagnostic strategy. She applies acetic acid to highlight precancerous lesions and visually inspects the cervix-a technique known as the VIA (visual inspection with acetic acid) method. She treats suspicious lesions with cryotherapy. There are multiple reasons that Dr. Hortense uses VIA in developing countries. It requires no specialized laboratory facilities or highly trained personnel. With immediate results, there is no delay in diagnosis and treatment, ensuring that patients are not lost to follow-up. Most importantly, VIA is considerably cheaper than Pap and HPV co-testing. This difference in care between Chicago and Botswana presents an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide. The provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the worst off.

Adherence to PI-based 2nd-line regimens in Cambodia is not simply a question of individual behaviour: the ANRS 12276 2PICAM study

OBJECTIVES

To investigate whether adherence to antiretroviral treatment (ART) can be explained not only by individual factors but also by health care facilities' characteristics, among a sample of people living with HIV (PLWH) treated with PI-based regimens in Cambodia.

METHODS

The ANRS 12276 2PICAM cross-sectional survey was conducted between February 2013 and April 2014 among PLWH followed up in 13 health care facilities. The 1316 patients in this analysis corresponded to 90% of the total number of adult patients treated with 2nd-line PI-based regimens in Cambodia in the study period. A variable indicating whether patients were non-adherent (=1) or completely adherent (=0) was constructed. Health care facilities and individual characteristics were included in a two-level logistic model to investigate their influence on patients' adherence to ART.

RESULTS

A total of 17% of participants did not adhere to ART. Patients in health care facilities outside the capital Phnom Penh were six times more likely to be non-adherent than those treated in health care facilities in the capital (OR: 6.15, 95% CI [1.47, 25.79]). Providing psychosocial care (provided by psychologist counsellors and/or full-time coaches) was found to be a structural facilitator of adherence, as the probability of non-adherence fell by 38.5% per each additional psychological worker present in health care facilities (OR: 0.62, 95% CI [0.43, 0.89]). Financial constraints were the main individual factor preventing adherence.

CONCLUSIONS

Our results suggest that inefficiencies in health care delivery are detrimental to PLWH health and to the exceptional progress currently being made by Cambodia in response to HIV. Policy makers should focus on increasing the number of psychosocial workers, especially in areas outside the capital.

Quality of life and adherence to antiretroviral therapy in Southern Brazil

The absence of or limited adherence to treatment is the main cause for the failure of Highly Active Antiretroviral Therapy (HAART). In Brazil, adherence to antiretroviral therapy has been lower than the recommended levels. Although HAART may produce adverse reactions, failure to comply with it may aggravate patients' health status and impair Quality of Life (QoL). The QoL of individuals living chronically with HIV and AIDS has been considered one of the main treatment outcomes. This study is part of a 225-day prospective trial in which participants were enrolled in two different modalities of follow-up: the usual model medical follow-up or an intervention based on the Medication Adherence Training Instrument (MATI). The WHOQOL-HIV BREF questionnaire was used to evaluate QoL of research participants in both groups on the 15th and 225th days of follow-up after the baseline assessment. The result of this study revealed no significant differences of WHOQOL-HIV BREF scores between participants allocated to MATI and non-MATI groups in the first assessment. However, there was a significant difference between the scores obtained on the 15th and 225th days in the domain related to spirituality and personal beliefs irrespective of the modality of follow-up. Other domains of the WHOQOL-HOV BREF remained unchanged. These results indicate that, in this sample, personal beliefs and spirituality may be relevant subjects to explain sustained levels of adherence to HAART.

Role of Education in HIV Clinical Outcomes in a Tuberculosis Endemic Setting

This study evaluated how educational attainment impacts clinical outcomes of HIV-positive patients in Durban, South Africa. The authors conducted a prospective study of 466 adult HIV-positive patients initiating antiretroviral therapy (ART) at an urban TB-HIV clinic from October 2004 to June 2007. The level of educational attainment (highest grade completed) was assessed at ART initiation. The authors measured tuberculosis treatment outcomes as well as death, lost to follow-up, viral suppression (HIV RNA <400 copies/mL), and immunologic response (CD4 ≥200 cells/mm(3)) at 6, 12, and 24 months after ART initiation. After 24 months of ART initiation, there were 43 deaths; viral suppression and immunologic response were observed in 88% and 83% of the remaining patients, respectively. The authors found no association between level of educational attainment and mortality (P = .12), loss to follow-up (P = .85), virologic response (P = .51), or immunologic response (P = .63). Similar findings were observed at 6 and 12 months post-ART initiation.

Retention in medical care and antiretroviral treatment according to skin color in southern Brazil

The aim of this study was to compare the retention in medical care and antiretroviral (ARV) treatment of individuals living with HIV and AIDS to antiretroviral therapy in southern Brazil according to their "race" or skin color. This study is part of a 225-day prospective trial, comprising 7 interviews, in which an intervention designed to improve adherence to treatment was tested. A convenience sample of 73 individuals living with HIV and/or AIDS enrolled in this follow-up procedure. The mean length of continuance in treatment was 161.5 (standard deviation [SD] = 18.6; 95% confidence interval [CI] = 125-198) and 138.4 (SD = 14.1; 95% C.I. = 111-166) days in the "nonwhite" and "white" categories, respectively. There was no significant difference between the 2 categories, χ(2)(1, n = 72) = 0.76, P = .38, which include similar levels of retention in medical care and treatment with ARV medications between groups of individuals categorized as white and nonwhite in this sample.

A randomized controlled trial of a protocol of interviews designed to improve adherence to antiretroviral medications in southern Brazil

The aim of this study was to evaluate the efficacy of the Portuguese version of the Medication Adherence Training Instrument (MATI) for improving adherence to antiretroviral therapy (ART) in southern Brazil. Two different follow-up modalities were compared in this 225 days randomized controlled study: one based on the MATI protocol and a conventional (non-MATI) clinical follow-up. There were no differences between the groups with the exception of socioeconomic class ( P < 0.005). The mean length of continuance in treatment was 111.4 (SD = 13.9) and 137.6 (SD = 17.3) days in the MATI and non-MATI groups, respectively. A Mantel–Cox log-rank test revealed no significant difference between the two interventions ( P = 0.34). Despite the sample size limitation, the results from this study indicate that the Portuguese version of the MATI was not more efficacious than the regular follow-up intervention for improving adherence of outpatients to ART.

Adherence to highly active antiretroviral therapy (HAART): a meta-analysis

This meta-analysis synthesizes eighty-four observational studies, conducted across twenty countries, to determine the mean proportion of people who reported ≥90% adherence to prescribed highly active antiretroviral therapy (HAART) and to identify the factors associated with high levels of adherence. Eight electronic databases were searched to locate all relevant studies available by January 2010, which were then coded for sample characteristics and adherence levels. The average rate of reporting ≥90% adherent HAART adherence is 62%. However, this proportion varies greatly across studies. In particular, a greater proportion of individuals maintaining ≥90% adherence to HAART is more likely in studies with higher proportions of men who have sex with men (MSM) and lower proportions of injection drug users (IDU), with participants in an earlier stage of infection, and in studies conducted in countries characterized by lower Human Development Index (HDI) scores.

The long road to universal antiretroviral treatment coverage in South Africa

In order to sustainably scale-up antiretroviral treatment (ART), South Africa needs to develop an efficient and effective implementation strategy, based on the best available scientific evidence. This article aims to bridge this knowledge gap first by describing the progress South Africa has made in the fight against HIV/AIDS in terms of virological efficacy, survival rates and retention in care, and second by identifying the potential remaining impediments to a durable and sustainable policy response to the epidemic. The study findings demonstrate that, despite favorable results in terms of virologic suppression, survival/mortality and retention in care, four challenges to a sustainable ART scale-up remain: first, the lack of integration of ART services into the general health system; second, the growing need for comprehensive HIV/AIDS care; third, the rising costs associated with the growing case load of people; and fourth, the crippling shortage in human resources for healthcare.

Surveying health professionals' satisfaction with the Integrated Management of Adult and Adolescent Illness Chronic HIV Care training programme: the Papua New Guinea experience

This study reports findings from a survey of Papua New Guinean registered nurse who completed the Integrated Management of Adult and Adolescent Illness (IMAI) Chronic HIV Care training conducted between November 2005 and December 2006. The survey conducted is one component of a mixed method evaluation of the IMAI program in Papua New Guinea. Data from the questionnaires were entered into version 16 of the Statistical Package for the Social Sciences (SPSS) software program. The responses on the effect of the IMAI training program had on various aspects of how care is provided, learning needs and other program outcomes were analysed with a chi-square test being applied to detect any difference in the response given by the different demographic subgroups in terms of gender, age, care status, current employer and past educational attainment. The survey revealed that all thirty-five respondents have a positive impression of the IMAI program and expressed the view that the IMAI program had a positive effect on various aspects of patient care and their learning and experience. Overall, the survey identified that registered nurses who participated in the IMAI Chronic HIV Care training program perceive the program to be beneficial for improving the way HIV care is provided.

Higher risk of unsafe sex and impaired quality of life among patients not receiving antiretroviral therapy in Cameroon: results from the EVAL survey (ANRS 12-116)

OBJECTIVE

Cameroon has initiated a national programme of HIV care decentralization providing access to antiretroviral therapy (ART) for patients with CD4 cell counts less than 200 cells/microl or AIDS stage. Current clinical research suggests these criteria may be too stringent. This study aimed at evaluating the effect of not receiving ART on patients' psychosocial outcomes.

DESIGN

The national cross-sectional survey EVAL (ANRS 12-116) collected psychosocial and clinical data for 3151 patients attending HIV services (September 2006 to March 2007).

METHODS

Propensity score matching was used to control for demographic/clinical-immunological differences between patients receiving ART and those who did not. Generalized linear models were used to assess the impact, for different CD4 cell levels, of "not receiving" ART on health-related quality of life (HRQoL) inconsistent condom use with a sexual partner either serodiscordant or of unknown HIV status, self-reported symptoms and disclosure of HIV status to relatives or friends.

RESULTS

Seventy-eight per cent of patients included in the survey were receiving ART. Non-treated patient breakdown was as follows: 8% (CD4<200 or AIDS stage), 5% (200<or=CD4<or=350) and 8% (CD4>350). In the multivariate matched-pairs analysis, impaired physical HRQoL, more frequent inconsistent condom use, more self-reported symptoms and less frequent disclosure of HIV status were all significantly associated (P < 0.0001) with not receiving ART, irrespective of the CD4 cell level.

CONCLUSION

In addition to increasing clinical effectiveness, earlier initiation of ART at less severe immune-depression levels than previously recommended by World Health Organization guidelines for low-resource settings may be justified for improving subjective health and positive prevention among people living with HIV.

Simplified Assessment of Antiretroviral Adherence and Prediction of Virological Efficacy in HIV-Infected Patients in Cambodia

Background. Adherence to antiviral therapy is important for HIV-infected people living in low- and middle-income countries, because of poor access to alternative regimens. Methods. We conducted a cross-sectional survey of adherence in Cambodian patients enrolled in the ESTHER program and treated with WHO first-line regimen for at least 6 months. The survey was based on a self-report questionnaire, drug assay, MCV measurement, visual analog scale, and viral load HIV RNA. Results. Two hundred fifty-nine patients treated for a median of 16 months participated in the survey. At inclusion in the program, 158 patients (61%) were ARV-naïve. The virological success rate was 71% overall and 81% in previously ARV-naive patients. Considered individually, the measures suggested perfect adherence in 71% to 93% of patients. In multivariate analysis adjusted for sex and therapeutic status before HAART initiation, only the biological markers were associated with virological efficacy. Self-funded treatment before entry to the program was highly predictive of virological failure. Conclusion. Adherence was excellent in these Cambodian patients. Biological markers were predictive of virological efficacy. MCV might thus serve as a simple alternative for assessing adherence and predicting virological efficacy among patients receiving AZT- or d4T-based regimens.

Financial barriers to HIV treatment in Yaoundé, Cameroon: first results of a national cross-sectional survey

OBJECTIVE

To assess the extent to which user fees for antiretroviral therapy (ART) represent a financial barrier to access to ART among HIV-positive patients in Yaoundé, Cameroon.

METHODS

Sociodemographic, economic and clinical data were collected from a random sample of 707 HIV-positive patients followed up in six public hospitals of the capital city (Yaoundé) and its surroundings through face-to-face interviews carried out by trained interviewers independently from medical staff and medical questionnaires filled out by prescribing physicians. Logistic regression models were used to identify factors associated with self-reported financial difficulties in purchasing ART during the previous 3 months.

FINDINGS

Of the 532 patients treated with ART at the time of the survey, 20% reported financial difficulty in purchasing their antiretroviral drugs during the previous 3 months. After adjustment for socioeconomic and clinical factors, reports of financial difficulties were significantly associated with lower adherence to ART (odds ratio, OR: 0.24; 95% confidence interval, CI: 0.15-0.40; P < 0.0001) and with lower CD4+ lymphocyte (CD4) counts after 6 months of treatment (OR: 2.14; 95% CI: 1.15-3.96 for CD4 counts < 200 cells/microl; P = 0.04).

CONCLUSION

Removing a financial barrier to treatment with ART by eliminating user fees at the point of care delivery, as recommended by WHO, could lead to increased adherence to ART and to improved clinical results. New health financing mechanisms based on the public resources of national governments and international donors are needed to attain universal access to drugs and treatment for HIV infection.

Public-sector ART in the Free State Province, South Africa: community support as an important determinant of outcome

The treatment outcomes for large-scale public antiretroviral therapy (ART) programs in developing countries, although promising, are still preliminary. The scaling-up of ART in resource-limited settings is inevitably hampered by human resource shortages. Therefore, community support for ART patients may play an important role in achieving favorable treatment outcomes. This study aimed to extend the current literature by investigating how immunological and virological responses to ART, measured at three points in time (after six, 12, and 24 months of ART), are influenced by patient characteristics (age, sex), health literacy (educational level and knowledge about HIV/AIDS), baseline CD4 cell count, baseline viral load, and three forms of community support (treatment buddy, community health worker [CHW], and HIV/AIDS support group). Cross-lagged regression analysis was used to test these relationships in a sample of 268 patients enrolled in the public-sector ART program of the Free State Province of South Africa (2004-2007). After 24 months of ART, 76.4% of patients were classified as treatment successes (viral load < 400 copies/mL, CD4 > or = 200 cells/microL), compared with 64.1% at 12 months and 46.1% at six months. When we examined the predictors of ART success, baseline health and all three community support initiatives had a positive effect on ART outcomes after six months, whereas patient characteristics had little effect. Six months later, patients with the support of a treatment buddy, CHW, or support group had better ART outcomes, whereas the impact of baseline health had diminished. After two years of treatment, community support again emerged as the most important predictor of treatment success. This study confirms that the ART provided by South African public-sector health services is effective. These results provide evidence from the field that communities can be mobilized to sustain these favorable outcomes under conditions of limited human resources for healthcare.

Community support and disclosure of HIV serostatus to family members by public-sector antiretroviral treatment patients in the Free State Province of South Africa

Recent studies have indicated that the support of close relatives is fundamental in coping with HIV/AIDS and in accessing the emotional and material support necessary for sustained adherence to treatment. Because disclosure to family members is imperative to ensure their support, identifying tools or resources that can minimize the possible risks and maximize the potential benefits of disclosure should be useful in improving the lives of people living with HIV/AIDS. Where health systems require strengthening, engaging the community in HIV/AIDS care could potentially create an environment that encourages disclosure to family members. This study investigated the impact of community support initiatives (community health workers and treatment support groups), patient characteristics (age, gender, and education), and time since first diagnosis on the disclosure of serostatus to family members by a sample of 268 public-sector antiretroviral treatment patients in a province of South Africa between August 2004 and July 2007. Whereas gender, age, and education only weakly influenced disclosure, there was a strong and stable positive association between community support and disclosure to family members. The immediate and long-term impact of community support on the disclosure by seropositive patients to family members indicates that initiatives such as community health workers and HIV support groups run by people living with HIV/AIDS should be strengthened, especially for those patients who cannot disclose their status to immediate family and close friends.

Adherence to first-line antiretroviral therapy affects non-virologic outcomes among patients on treatment for more than 12 months in Lusaka, Zambia

Background High-level adherence to antiretroviral therapy (ART) is associated with favourable patient outcomes. In resource-constrained settings, however, there are few validated measures. We examined the correlation between clinical outcomes and the medication possession ratio (MPR), a pharmacy-based measure of adherence.

Methods We analysed data from a large programmatic cohort across 18 primary care centres providing ART in Lusaka, Zambia. Patients were stratified into three categories based on MPR-calculated adherence over the first 12 months: optimal (≥95%), suboptimal (80–94%) and poor (<80%).

Results Overall, 27 115 treatment-naïve adults initiated and continued ART for ≥12 months: 17 060 (62.9%) demonstrated optimal adherence, 7682 (28.3%) had suboptimal adherence and 2373 (8.8%) had poor adherence. When compared with those with optimal adherence, post-12-month mortality risk was similar among patients with sub-optimal adherence [adjusted hazard ratio (AHR) = 1.0; 95% CI: 0.9–1.2] but higher in patients with poor adherence (AHR = 1.7; 95% CI: 1.4–2.2). Those <80% MPR also appeared to have an attenuated CD4 response at 18 months (185 cells/µl vs 217 cells/µl; P < 0.001), 24 months (213 cells/µl vs 246 cells/µl; P < 0.001), 30 months (226 cells/µl vs 261 cells/µl; P < 0.001) and 36 months (245 cells/µl vs 275 cells/µl; P < 0.01) when compared with those above this threshold.

Conclusions MPR was predictive of clinical outcomes and immunologic response in this large public sector antiretroviral treatment program. This marker may have a role in guiding programmatic monitoring and clinical care in resource-constrained settings.

Free care at the point of service delivery: a key component for reaching universal access to HIV/AIDS treatment in developing countries

BACKGROUND

User fees are a common feature of health system financing in low and middle-income countries. In the context of universal access to HIV/AIDS treatment and care, the advantages of user fees for funding at country and local level should be balanced with their clinical and public health impact.

METHODS

We reviewed the literature on user fees and the impact of user fees on HIV/AIDS service delivery.

RESULTS

Empirical evidence gathered since the 1980s shows that sustainability, efficiency and equity challenges faced by health systems have persisted with and have often been exacerbated by the introduction of user fees. The evidence on HIV/AIDS suggests that free care at the point of service fosters uptake and helps to extend access for the poorest users. User fees are currently the main barrier to adherence to antiretroviral therapy (ART). Their abolition is associated with better virological results and increased survival. Such abolition should be carried out in parallel with the implementation of financing mechanisms, such as prepayment and risk pooling, which are able to gather funds from the sectors of the population who are able to pay for healthcare and to promote equity towards the poorest.

CONCLUSION

WHO has included free access to HIV/AIDS treatment at the point of service delivery as a component of its public health approach for reaching universal access. Implementation of free HIV/AIDS care should, however, be linked to efforts to strengthen healthcare systems, ensure long-term sustainability of funding and monitor equity of access to care.

Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment

BACKGROUND

The recording of outcomes from large-scale, simplified HAART (highly active antiretroviral therapy) programmes in sub-Saharan Africa is critical. We aimed to assess the effectiveness of such a programme held by Médecins Sans Frontières (MSF) in the Chiradzulu district, Malawi.

METHODS

We scaled up and simplified HAART in this programme since August, 2002. We analysed survival indicators, CD4 count evolution, virological response, and adherence to treatment. We included adults who all started HAART 6 months or more before the analysis. HIV-1 RNA plasma viral load and self-reported adherence were assessed on a subsample of patients, and antiretroviral resistance mutations were analysed in plasma with viral loads greater than 1000 copies per mL. Analysis was by intention to treat.

FINDINGS

Of the 1308 patients who were eligible, 827 (64%) were female, the median age was 34.9 years (IQR 29.9-41.0), and 1023 (78%) received d4T/3TC/NVP (stavudine, lamivudine, and nevirapine) as a fixed-dose combination. At baseline, 1266 individuals (97%) were HAART-naive, 357 (27%) were at WHO stage IV, 311 (33%) had a body-mass index of less than 18.5 kg/m2, and 208 (21%) had a CD4 count lower than 50 cells per muL. At follow-up (median 8.3 months, IQR 5.5-13.1), 967 (74%) were still on HAART, 243 (19%) had died, 91 (7%) were lost to follow-up, and seven (0.5%) discontinued treatment. Low body-mass index, WHO stage IV, male sex, and baseline CD4 count lower than 50 cells per muL were independent determinants of death in the first 6 months. At 12 months, the probability of individuals still in care was 0.76 (95% CI 0.73-0.78) and the median CD4 gain was 165 (IQR 67-259) cells per muL. In the cross-sectional survey (n=398), 334 (84%) had a viral load of less than 400 copies per mL. Of several indicators measuring adherence, self-reported poor adherence (<80%) in the past 4 days was the best predictor of detectable viral load (odds ratio 5.4, 95% CI 1.9-15.6).

INTERPRETATION

These data show that large numbers of people can rapidly benefit from antiretroviral therapy in rural resource-poor settings and strongly supports the implementation of such large-scale simplified programmes in Africa.

Critical public health ethics and Canada's role in global health

This commentary introduces critical public health ethics as an innovative lens for considering Canada's role in global health. Arising from the relatively young field of public health ethics, this analytic perspective sheds light on questions regarding public health policy, research and practice that often remain shaded from view because of traditional ways of thinking about public health. The advantage of a critical public health ethics lens is illustrated through the example of Canada's role in scaling up access to HIV treatments in developing countries.

Adherence to antiretroviral therapy: merging the clinical and social course of AIDS

Compliance with HIV treatment is affected by many issues and social factors are as important as biological ones.

Cost effectiveness and delivery study for future HIV vaccines

Research teams from five countries, Brazil, China, Kenya, Peru and Thailand, have initiated a policy-maker survey on vaccine delivery, cost studies for future HIV vaccination programmes, and associated simulation modeling exercises analysing the relative cost-effectiveness of potential HIV vaccination strategies. The survey assesses challenges and opportunities for future country-level HIV vaccination strategies, providing data on the vaccine characteristics (e.g. vaccine efficacies for susceptibility, infectiousness and disease progression) and vaccination programme strategies to be considered in the cost-effectiveness modeling analyses. The study will provide decision-makers with modeling data on vaccination policy considerations that will assist in developing country-level capacities for future HIV vaccine policy adoption and effective delivery systems, and will help delineate the long-term financial requirements for sustainable HIV vaccination programmes. The WHO-UNAIDS HIV Vaccine Initiative and the collaborating researchers welcome comments or questions from policy makers, health professionals and other stakeholders in the public and private sectors about this effort to help advance policy and capacity related to future potential HIV vaccines.