Community-Based Accompaniment with Supervised Antiretrovirals for HIV-Positive Adults in Peru: A Cluster-Randomized Trial.

We conducted a cluster-randomized trial to estimate effects of directly observed combination antiretroviral therapy (DOT-cART) on retention with viral suppression among HIV-positive adults in Peru. We randomly allocated facilities to receive the 12-month intervention plus the standard of care, including adherence support provided through accompaniment. In the intervention arm, health workers supervised doses, twice daily, and accompanied patients to appointments. Among 356 patients, intention-to-treat analyses showed no statistically significant benefit of DOT, relative to no-DOT, at 12 or 24 months (adjusted probability of primary outcome: 0.81 vs. 0.73 and 0.76 vs. 0.68, respectively). A statistically significant benefit of DOT was found in per-protocol and as-treated analyses at 12 months (0.83 for DOT vs. 0.73 for no DOT, p value: 0.02 per-protocol, 0.01 as-treated), but not 24 months. Rates of retention with viral suppression were high in both arms. Among adults receiving robust adherence support, the added effect of time-limited DOT, if any, is small-to-moderate.

Community-based rapid oral human immunodeficiency virus testing for tuberculosis patients in Lima, Peru.

Among tuberculosis patients, timely diagnosis of human immunodeficiency virus (HIV) co-infection and early antiretroviral treatment are crucial, but are hampered by a myriad of individual and structural barriers. Community-based models to provide counseling and rapid HIV testing are few but offer promise. During November 2009-April 2010, community health workers offered and performed HIV counseling and testing by using the OraQuick Rapid HIV-1/2 Antibody Test to new tuberculosis cases in 22 Ministry of Health establishments and their household contacts (n = 130) in Lima, Peru. Refusal of HIV testing or study participation was low (4.7%). Intervention strengths included community-based approach with participant preference for testing site, use of a rapid, non-invasive test, and accompaniment to facilitate HIV care and family disclosure. We will expand the intervention under programmatic auspices for rapid community-based testing for new tuberculosis cases in high incidence establishments. Other potential target populations include contacts of HIV-positive persons and pregnant women.

[Bibliometric analysis of scientific production about HIV/AIDS in Peru 1985-2010]. / Análisis bibliométrico de la producción científica sobre VIH/SIDA en el Perú 1985-2010.

OBJECTIVE: To analyze the evolution of published scientific articles on HIV/AIDS in Peru. METHODS: A bibliometric analysis of papers on HIV/AIDS published in journals indexed in MEDLINE, SciELO and LILACS until October 2010. We selected research papers fully developed in Peru, and multicenter studies with participating Peruvian sites. RESULTS: We identified 257 publications on HIV/AIDS, showing an increase since 2003. The average publication delay was 2.8±1.8 years. Only 94 (36.6 %) articles were published in Spanish. The most studied areas were epidemiology (36.6 %) and clinical topics (35.8 %). The cross-sectional design was the most frequent (56.8 %) followed by case series. According to the WHO classification, studies to learn more about the disease and risk factors predominated (85.6 %) and according to the intervention areas, 46.7 % focused on diagnosis and treatment. Most studies were conducted in Lima (65.9 %). 48.2 % of studies focused on people living with HIV/AIDS. Finally, Revista Peruana de Medicina Experimental y Salud Pública was the journal that published most articles on HIV/AIDS (9.7 %). CONCLUSIONS: We found a growth in scientific production on HIV/AIDS in Peru; however, we believe that the research undertaken was not based on an agreed national agenda or national research priorities, which might have limitted its dissemination and application.

Análisis bibliométrico de la producción científica sobre VIH/SIDA en el Perú 1985 - 2010 / Bibliometric analysis of scientific production about HIV/AIDS in Perú 1985 - 2010

Objetivos. Analizar la evolución de la publicación de artículos de investigación sobre VIH/SIDA en Perú. Métodos. Estudio bibliométrico de los artículos sobre VIH/SIDA publicados en revistas indizadas en Medline, SciELO y LILACS hasta octubre de 2010. Se seleccionaron investigaciones desarrolladas completamente en Perú, o estudios multicéntricos con participación de sedes peruanas. Resultados. Se identificó 257 artículos sobre VIH/SIDA, observando un incremento desde el 2003. El promedio de demora de publicación fue de 2,8 ±1,8 años. Solo 94 (36,6 por ciento) artículos fueron publicados en español. Las áreas más estudiadas fueron epidemiología (36,6 por ciento) y clínica (35,8 por ciento). El diseño transversal fue el más frecuente (56,8 por ciento), seguido por las series de casos. Según la clasificación de OMS predominaron los estudios destinados a conocer más la enfermedad y los factores de riesgo (85,6 por ciento) y según las áreas de intervención el 46,7 por ciento se enfocó en el diagnóstico y tratamiento. La mayoría de estudios se realizaron en Lima (65,9 por ciento). El 48,2 por ciento de estudios se enfocaron en las personas afectadas por el VIH/SIDA. Finalmente, la Revista Peruana de Medicina Experimental y Salud Pública fue la que publicó más artículos sobre VIH/SIDA (9,7 por ciento). Conclusiones. Se evidencia un crecimiento en la producción científica sobre VIH/SIDA en el Perú, sin embargo, consideramos que las investigaciones no se han basado en una agenda nacional consensuada y basada en prioridades de investigación, lo que ha podido limitar su diseminación y aplicación.

Objective. To analyze the evolution of published scientific articles on HIV/AIDS in Peru. Methods. A bibliometric analysis of papers on HIV/AIDS published in journals indexed in MEDLINE, SciELO and LILACS until October 2010. We selected research papers fully developed in Peru, and multicenter studies with participating Peruvian sites. Results. We identified 257 publications on HIV/AIDS, showing an increase since 2003. The average publication delay was 2.8±1.8 years. Only 94 (36.6 percent) articles were published in Spanish. The most studied areas were epidemiology (36.6 percent) and clinical topics (35.8 percent). The cross-sectional design was the most frequent (56.8 percent) followed by case series. According to the WHO classification, studies to learn more about the disease and risk factors predominated (85.6 percent) and according to the intervention areas, 46.7 percent focused on diagnosis and treatment. Most studies were conducted in Lima (65.9 percent). 48.2 percent of studies focused on people living with HIV/AIDS. Finally, Revista Peruana de Medicina Experimental y Salud Pública was the journal that published most articles on HIV/AIDS (9.7 percent). Conclusions. We found a growth in scientific production on HIV / AIDS in Peru; however, we believe that the research undertaken was not based on an agreed national agenda or national research priorities, which might have limitted its dissemination and application.

Electromechanical effects on multilayered cells in nonuniform rotating fields.

We use the Maxwell stress tensor to calculate the dielectrophoretic force and electrorotational torque acting on a realistic four-shelled model of the yeast Saccharomyces cerevisiae in a nonuniform rotating electric field generated by four coplanar square electrodes. The comparison of these results with numerical calculations of the dipolar and quadrupolar contributions obtained from an integral equation for the polarization charge density shows the effect of the quadrupole contribution in the proximity of the electrode plane. We also show that under typical experimental conditions the substitution of the multilayered cell by an equivalent cell with homogeneous permittivity underestimates the quadrupole contribution to the force and torque by 1 order of magnitude.

Mental Health Burden Among Impoverished HIV-Positive Patients in Peru.

HIV and poor mental health are intricately related. In settings of poverty, both are often rooted in structural factors related to material and social deprivation. We performed a qualitative analysis to understand factors contributing to poor emotional health and its impact among impoverished Peruvian HIV-infected individuals. We conducted focus group discussions with patients and providers consisting of semistructured, open-ended questions. Qualitative analysis provided insight into the profound impact of depression, isolation, stigma, and lack of social support among these patients. Living with HIV contributed significantly to mental health problems experienced by HIV-positive individuals; furthermore, long-standing stressors-such as economic hardship, fragmented family relationships, and substance use-shaped patients' outlooks, and may have contributed not only to current emotional hardship but to risk factors for contracting HIV as well. Once diagnosed with HIV/AIDS, many patients experienced hopelessness, stigma, and socioeconomic marginalization. Patients tended to rely on informal sources of support, including peers and community health workers, and rarely used formal mental health services. In resource-poor settings, the context of mental health problems among HIV-positive individuals must be framed within the larger structural context of poverty and social exclusion. Optimal strategies to address the mental health problems of these individuals should include integrating mental health services into HIV care, task shifting to utilize community health workers where human resources are scarce, and interventions aimed at poverty alleviation.

Food insufficiency is a risk factor for suboptimal antiretroviral therapy adherence among HIV-infected adults in urban Peru.

We examined the relationship between food insufficiency and antiretroviral therapy (ART) adherence. A cohort of HIV-infected adults in urban Peru was followed for a two-year period after ART initiation. ART adherence was measured using a 30-day self-report tool and classified as suboptimal if <95% adherence was reported. We conducted a repeated measures cohort analysis to examine whether food insufficiency was more common during months of suboptimal adherence relative to months with optimal adherence. 1,264 adherence interviews were conducted for 134 individuals. Participants who reported food insufficiency in the month prior to interview were more likely to experience suboptimal adherence than those who did not (odds ratio [O.R.]:2.4; 95% confidence interval [C.I.]:1.4, 4.1), even after adjusting for baseline social support score (O.R. per 5 point increase:0.91; C.I.:[0.85, 0.98]) and good baseline adherence self-efficacy (O.R.:0.25; C.I.:[0.09, 0.69]). Interventions that ensure food security for HIV-infected individuals may help sustain high levels of adherence.

Matching social support to individual needs: a community-based intervention to improve HIV treatment adherence in a resource-poor setting.

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in Lima, Peru to receive community-based accompaniment with supervised antiretrovirals (CASA), consisting of 12 months of DOT-HAART, as well as microfinance assistance and/or psychosocial support group according to individuals' need. We matched 60 controls from a neighboring district, and assessed final clinical and psychosocial outcomes at 24 months. CASA support was associated with higher rates of virologic suppression and lower mortality. A comprehensive, tailored adherence intervention in the form of community-based DOT-HAART and matched economic and psychosocial support is both feasible and effective for certain individuals in resource-poor settings.

How does directly observed therapy work? The mechanisms and impact of a comprehensive directly observed therapy intervention of highly active antiretroviral therapy in Peru.

From December 2005 through August 2008, we provided community-based accompaniment with supervised antiretroviral therapy (CASA) to impoverished individuals starting highly active antiretroviral therapy. Adherence support was provided for 18 months by a community-based team comprised of several nurses and two types of community health workers: field supervisors and directly observed therapy (DOT) volunteers. To complement our quantitative data collection in 2008 using purposive sampling, we conducted two gender-mixed focus group discussions with 13 CASA patient participants and 13 DOT volunteers from Lima, Peru to identify the mediating mechanisms by which CASA improved well-being, and to understand the benefits of the intervention, as perceived by these individuals. Using standard qualitative methods for the review and analysis of transcripts and interview notes, we identified central themes and developed a coding scheme for categorising participants' statements. Two individuals blinded to each other's coding, coded interview transcripts for theme and content from which a third reviewer compared their coding to arbitrate discrepancies. Additional domains were added if necessary and all domains were integrated into a theoretical scheme. Among the forms of support delivered by the CASA team, DOT volunteers reported emotional support, instrumental support, directly observed therapy, building trust, education, advocacy, exercise of moral authority and preparation for transition off CASA support. CASA participants described outcomes of improved adherence, ability to resume social roles, increased self-efficacy, hopefulness, changes in non-HIV-related behaviour, reduced internalised and externalised stigma, as well as ability to disclose. Both sets of focus group participants highlighted remaining challenges after completion of CASA support: stigma in the community, difficulties achieving economic recovery and persistent barriers to health services. Based on our prior quantitative and qualitative outcomes reported here, we argue that DOT of highly active antiretroviral therapy could be designed to optimise psychosocial recovery during the period of DOT.

Polarizability of red blood cells with an anisotropic membrane.

We predict the complex polarizability of a realistic model of a red blood cell (RBC), with an inhomogeneous dispersive and anisotropic membrane. In this model, the frequency-dependent complex electrical parameters of the individual cell layers are described by the Debye equation while the dielectric anisotropy of the cell membrane is taken into account by the different permittivities along directions normal and tangential to the membrane surface. The realistic shape of the RBC is described in terms of the Jacobi elliptic functions. To calculate the polarizability, we evoke the effective dipole moment method to determine the cell internal electric field distribution, employing an adaptive finite-element numerical approach. We have furthermore investigated the influence of the anisotropic membrane and dispersive electrical parameters of each individual cell layer on the total complex polarizability. Our findings suggest that the individual layer contribution depends on two factors: the volume of the layer and the associated induced electric field, which in turn is influenced by other layers of the cell. These results further show that the average polarizability spectra of the cell are significantly impacted by the anisotropy and associated dispersion of the cellular compartments.

Analysis of radiofrequency energy stored in the altered shapes: Stomatocyte-echinocyte of human erythrocytes.

The aim of this study is to analyze the electromagnetic energy stored in stomatocyte, erythrocyte and echinocyte cells exposed to a linearly polarized electromagnetic plane wave at 900, 1800 and 2450MHz radiofrequency signals. This analysis can provide a better understanding of the order of appearance of altered shapes of erythrocytes (RBC) in the stomatocyte-echinocyte transition under radiofrequency exposure in terms of the deposited electromagnetic energy. For this purpose we use a realistic geometrical cell model based on parametric equations that allow for continuous transformations between normal erythrocytes and three stomatocyte subclasses with different degree of invagination and also between normal erythrocytes and echinocytes with an arbitrary number of spicules. We use a finite element technique with adaptive meshing for calculating the electromagnetic energy deposited on the different regions of the cell models. It is found that the echinocyte cell stores the minimum electromagnetic energy and therefore from an energetic point of view it would be the most stable and preferred cell state when this electromagnetic energy is the predominant energy component.

Community-based DOT-HAART accompaniment in an urban resource-poor setting.

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in a health district of Lima, Peru to receive community-based accompaniment with supervised antiretroviral (CASA). Paid community health workers performed twice-daily home visits to directly observe ART and offered additional medical, social and economic support to CASA participants. We matched 60 controls from a neighboring district by age, CD4 and primary referral criteria (TB status, female, neither). Using validated instruments at baseline and 12 months (time of DOT-HAART completion) we measured depression, social support, quality of life, HIV-related stigma and self-efficacy. We compared 12 month clinical and psychosocial outcomes among CASA versus control groups. CASA participants experienced better clinical and psychosocial outcomes at 12 months, including proportion with virologic suppression, increase in social support and reduction in HIV-associated stigma.

Validation and abbreviation of an HIV stigma scale in an adult spanish-speaking population in urban Peru.

The purpose of this study was to validate the Spanish version of the Berger HIV Stigma Scale in an urban Spanish-speaking population in Peru and create a valid and reliable abridged version of the scale. Participants were HIV-infected adults enrolled in an observational study to examine the effectiveness of a community-based antiretroviral therapy adherence intervention. Approximately half of participants were female, and the median age at enrollment was 30.5 years. The Spanish version of the full HIV Stigma Scale was internally reliable, demonstrated good construct validity, and was sensitive to change over time. The full HIV Stigma Scale was abbreviated by removing items that impaired subscale internal reliability, did not correlate with other subscale items, or demonstrated low factor correlations. The resulting abridged scale contained 21 of the 40 original items and revealed properties similar to the full Spanish version.

Fortalecimiento de la prevención y control del VIH y SIDA en el Perú: Evaluación final del componente VIH y SIDA del programa de segunda ronda financiado por el Fondo Mundial / Strengthening the prevention and control of HIV and AIDS in Peru: Final evaluation of HIV and AIDS component of the second round program funded by the Global Fund

El presente documento plantea el análisis de resultados y de impacto de los tres objetivos del programa, y expone un diagnóstico de estrategias de la gestión administrativa, de los sistemas de información, comunicación y de monitoreo y evaluación para la prevención del VIH y SIDA en el Perú(AU)

Fortalecimiento de la prevención y control del VIH y SIDA en el Perú: Evaluación final del componente VIH y SIDA del programa de segunda ronda financiado por el Fondo Mundial / Strengthening the prevention and control of HIV and AIDS in Peru: Final evaluation of HIV and AIDS component of the second round program funded by the Global Fund

El presente documento plantea el análisis de resultados y de impacto de los tres objetivos del programa, y expone un diagnóstico de estrategias de la gestión administrativa, de los sistemas de información, comunicación y de monitoreo y evaluación para la prevención del VIH y SIDA en el Perú

Polarizability of shelled particles of arbitrary shape in lossy media with an application to hematic cells.

We show that within the dipole approximation the complex polarizability of shelled particles of arbitrary shape can be written as the volume of the particle times a weighted average of the electric field in the particle, with weights determined by the differences in permittivities between the shells and the external, possibly lossy media. To calculate the electric field we use an adaptive-mesh finite-element method which is very effective in handling the irregular domains, material inhomogeneities, and complex boundary conditions usually found in biophysical applications. After extensive tests with exactly solvable models, we apply the method to four types of hematic cells: platelets, T-lymphocytes, erythrocytes, and stomatocytes. Realistic shapes of erythrocytes and stomatocytes are generated by a parametrization in terms of Jacobi elliptic functions. Our results show, for example, that if the average polarizability is the main concern, a confocal ellipsoid may be used as a model for a normal erythrocyte, but not for a stomatocyte. A comparison with experimental electrorotation data shows quantitatively the effect of an accurate geometry in the derivation of electrical cell parameters from fittings of theoretical models to the experimental data.

Psychosocial impact of poverty on antiretroviral nonadherence among HIV-TB coinfected patients in Lima, Peru.

OBJECTIVE: Tuberculosis and HIV coinfection poses unique clinical and psychosocial complexities that can impact nonadherence to highly active antiretroviral treatment (HAART). METHODS: This was a prospective case series to identify risk factors for HAART nonadherence among 43 patients with HIV and tuberculosis (TB) in Lima, Peru. Nonadherence was defined by patient self-report. RESULTS: The median initial CD4 and HIV viral load were 63 and 159,000, respectively. Patients had received a median of 6.1 months of ART. Univariable analysis found low social support, substance use, and depression to be associated with nonadherence. In multivariable analysis, low social support was associated with nonadherence. CONCLUSIONS: In the authors' urban cohort of HIV-TB coinfected individuals in Lima, Peru, substance use, depression, and lack of social support were key barriers to adherence. These findings suggest that adherence interventions may be unsuccessful unless they target the underlying psychosocial challenges faced by patients living with TB and AIDS.

Scaling up HIV treatment in Peru: applying lessons from DOTS-Plus.

Many countries with financial support for HIV treatment experience delays in scale-up because of bureaucratic, operational, and technical obstacles. The authors describe the Peruvian National HIV Program's response to such challenges. A team of consultants experienced in the scale-up of the Peruvian national program to treat multidrug-resistant tuberculosis worked with the national HIV program to identify and address key factors contributing to slow enrollment of HIV patients into the antiretroviral treatment program. The rate of enrollment into the antiretroviral treatment program increased from 124 patients/month in the first 9 months of the program to 226 patients/month in the last 7 months, an increase of 83%. This strategy achieved 38.5% coverage of the population in need. Effective programmatic expansion of the Peruvian National HIV Program was facilitated by a multidisciplinary collaboration in a systematized effort to overcome barriers to scale-up.

Erythrocyte rouleau formation under polarized electromagnetic fields.

We study the influence of an external electromagnetic field of 1.8 GHz in the formation or disaggregation of long rouleau of identical erythrocyte cells. In particular we calculate the variation of the transmembrane potential of an individual erythrocyte illuminated by the external field due to the presence of the neighboring erythrocytes in the rouleau, and compare the total electric energy of isolated cells with the total electric energy of the rouleau. We show that the polarization of the external electromagnetic field plays a fundamental role in the total energy variation of the cell system, and consequently in the formation or disaggregation of rouleau.