Getting the balance right: Scaling-up treatment and prevention.

The goals of the international response to control the HIV epidemic include high antiretroviral therapy (ART) coverage with HIV viral suppression, as well as reduction of new infections. ART use at individual and population levels reduces HIV morbidity and mortality and likely reduces HIV incidence. HIV viral suppression requires high levels of ART adherence, which necessitates support through behavioural and structural interventions to optimise effectiveness of the use of ART for prevention. Many people living with HIV remain unaware that they are HIV-infected, and HIV transmission risk is high during early infection, therefore ART expansion should be accompanied by other interventions in order to achieve the promise of treatment for prevention. Biomedical and behavioural prevention efforts focused on HIV-uninfected individuals at substantial risk of HIV acquisition are also needed to control the epidemic. Maintaining prevention programming is essential during the scale up of ART to reduce HIV transmission.

HIV Prevention 2020: a framework for delivery and a call for action.

Although effective programmes are available and several countries have seen substantial declines in new HIV infections, progress in the reduction of adult HIV incidence has been slower than expected worldwide and many countries have not had large decreases in new infections in adults despite large reductions in paediatric infections. Reasons for slow progress include inadequate commitment, investment, focus, scale, and quality of implementation of prevention and treatment interventions. The UNAIDS-Lancet Commission on Defeating AIDS-Advancing Global Health reported that the provision of large-scale, effective HIV prevention programmes has failed and called on stakeholders to "get serious about HIV prevention". An ambitious worldwide target has been set by UNAIDS to reduce new infections below 500 000 by 2020-a 75% reduction from 2010. Models show that such a reduction requires a combination of primary prevention interventions and preventative effects of treatment. Achievement of the target will require more effective delivery of HIV prevention for sufficient coverage in populations at greatest risk of infection ensuring that interventions that have proved effective are made available, barriers to their uptake are overcome, demand is created, and use is consistent and occurs at the right scale with high coverage. This paper discusses how programmatic targets for prevention in a worldwide plan could be used to re-energise the HIV prevention approach. A management framework is proposed outlining global, regional, national, and subnational actions and is summarised in a call for action on HIV prevention for 2020.

An action agenda for HIV and sex workers.

The women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change to realise the benefits of advances in HIV prevention and treatment and to achieve global control of the HIV pandemic. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV in sex workers will need sustained community engagement and empowerment, continued research, political will, structural and policy reform, and innovative programmes. But such actions can and must be achieved for sex worker communities everywhere.

Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries.

OBJECTIVE: To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. METHODS: The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. FINDINGS: Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. CONCLUSION: HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model.

Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis.

OBJECTIVE: To determine whether integrating antiretroviral therapy (ART) into antenatal care (ANC) and maternal and child health (MCH) clinics could improve programmatic and patient outcomes. METHODS: The authors systematically searched PubMed, Embase, African Index Medicus and LiLACS for randomized controlled trials, prospective cohort studies, or retrospective cohort studies comparing outcomes in ANC or MCH clinics that had and had not integrated ART. The outcomes of interest were ART coverage, ART enrolment, ART retention, mortality and transmission of human immunodeficiency virus (HIV). FINDINGS: Four studies met the inclusion criteria. All were conducted in ANC clinics. Increased enrolment of pregnant women in ART was observed in ANC clinics that had integrated ART (relative risk, RR: 2.09; 95% confidence interval, CI; 1.78-2.46; I(2): 15%). Increased ART coverage was also noted in such clinics (RR: 1.37; 95% CI: 1.05-1.79; I(2): 83%). Sensitivity analyses revealed a trend for the national prevalence of HIV infection to explain the heterogeneity in the size of the effect of ART integration on ART coverage (P = 0.13). Retention in ART was similar in ANC clinics with and without ART integration. CONCLUSION: Although few data were available, ART integration in ANC clinics appears to lead to higher rates of ART enrolment and ART coverage. Rates of retention in ART remain similar to those observed in referral-based models.

Résumé OBJECTIF: Déterminer si l'intégration de la thérapie antirétrovirale (TAR) dans les établissements de soins prénataux (ESP) et de santé maternelle et infantile (SMI) pourrait améliorer les résultats du programme et la santé du patient. MÉTHODES: Les auteurs ont systématiquement recherché via PubMed, Embase, African Index Medicus et LILACS des essais contrôlés randomisés, des études de cohorte prospectives et des études de cohorte rétrospectives comparant les résultats des cliniques ESP ou SMI ayant ou n'ayant pas intégré la TAR. Les résultats pris en compte comprenaient la couverture, la participation et la rétention de la TAR, ainsi que la mortalité et la transmission du virus d'immunodéficience humaine (VIH). RÉSULTATS: Quatre études répondaient aux critères d'inclusion. Toutes ont été menées dans des cliniques ESP. Une participation accrue des femmes enceintes à la TAR a été observée dans les cliniques ESP qui l'avaient intégrée (risque relatif, RR: 2,09; intervalle de confiance IC à 95%: 1,78 à 2,46; I: 15%). Une couverture plus importante de la TAR a également été notée dans ces cliniques (RR: 1,37; IC à 95%: 1,05 à 1,79; I: 83%). Les analyses de sensibilité ont révélé une tendance à la prévalence nationale de l'infection par le VIH pour expliquer l'hétérogénéité de la taille de l'effet de l'intégration de la TAR sur sa couverture (P = 0,13). La rétention de la TAR était similaire dans les cliniques ESP avec ou sans intégration de la TAR. CONCLUSION: Bien que peu de données aient été disponibles, l'intégration de la TAR dans les cliniques ESP semblait entraîner une augmentation des taux de participation et de couverture de la TAR. Les taux de rétention de la TAR restent semblables à ceux qui sont observés dans les modèles de référence.

Resumen OBJETIVO: Determinar si la integración del tratamiento antirretroviral (TAR) en la atención prenatal (APN) y la salud materno-infantil (SMI) podría mejorar los resultados programáticos y del paciente. MÉTODOS: Partiendo de las bases de datos PubMed, Embase, Index Medicus de la Región de África y LiLACS, los autores realizaron búsquedas sistemáticas de ensayos controlados aleatorizados, estudios de cohortes prospectivos o estudios de cohortes retrospectivos en los que se compararon los resultados en clínicas de APN o SMI que habían y que no habían integrado el TAR. Los resultados de interés fueron la cobertura del TAR, la inclusión en el TAR, la retención en el TAR, la mortalidad y la transmisión del virus de la inmunodeficiencia humana (VIH). RESULTADOS: Cuatro estudios cumplieron los criterios de inclusión. Todos ellos se realizaron en clínicas de APN. Se observó un aumento de la inclusión de mujeres embarazadas en el TAR en aquellas clínicas de APN que se habían integrado el TAR (riesgo relativo, RR: 2,09, intervalo de confianza del 95%, IC; 1,78-2,46; I: 15%). En estas clínicas también se observó un aumento de la cobertura del TAR (RR: 1,37; IC del 95%: 1,05­1,79; I: 83%). Los análisis de sensibilidad revelaron una tendencia en la prevalencia nacional de la infección por el VIH para explicar la heterogeneidad en la magnitud del efecto de la integración del TAR sobre la cobertura del TAR (P=0,13). La retención en el TAR fue similar en las clínicas de APN con y sin integración del TAR. CONCLUSIÓN: A pesar de la escasez de los datos disponibles, la integración del TAR en las clínicas de APN parece traducirse en mayores tasas de inclusión en el TAR y de cobertura del TAR. Las tasas de retención en el TAR siguen siendo similares a las observadas en los modelos basados en derivaciones médicas.

Understanding methods for estimating HIV-associated maternal mortality.

The impact of HIV on maternal mortality and more broadly on the health of women, remains poorly documented and understood. Two recent reports attempt to address the conceptual and methodological challenges that arise in estimating HIV-related maternal mortality and trends. This paper presents and compares the methods and discusses how they affect estimates at global and regional levels. Country examples of likely patterns of mortality among women of reproductive age are provided to illustrate the critical interactions between HIV and complications of pregnancy in high-HIV-burden countries. The implications for collaboration between HIV and reproductive health programmes are discussed, in support of accelerated action to reach the Millennium Development Goals and improve the health of women.

Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience.

OBJECTIVES: To review the literature on the potential efficiency gains of integrating HIV services with other health services. DESIGN: Systematic literature review. Search of electronic databases, manual searching and snowball sampling. Studies that presented results on cost, efficiency or cost-effectiveness of integrated HIV services were included, focusing on low- and middle-income countries. Evidence was analysed and synthesised through a narrative approach and the quality of studies assessed. RESULTS: Of 666 citations retrieved, 46 were included (35 peer reviewed and 11 from grey literature). A range of integrated HIV services were found to be cost-effective compared with 'do-nothing' alternatives, including HIV services integrated into sexual and reproductive health services, integrated tuberculosis/HIV services and HIV services integrated into primary healthcare. The cost of integrated HIV counselling and testing is likely to be lower than that of stand-alone counselling and testing provision; however, evidence is limited on the comparative costs of other services, particularly HIV care and treatment. There is also little known about the most efficient model of integration, the efficiency gain from integration beyond the service level and any economic benefit to HIV service users. CONCLUSIONS: In the context of increasing political commitment and previous reviews suggesting a strong public health argument for the integration of HIV services, the authors found the evidence on efficiency broadly supports further efforts to integrate HIV services. However, key evidence gaps remain, and there is an urgent need for further research in this area.

Local perceptions of the forms, timing and causes of behavior change in response to the AIDS epidemic in Zimbabwe.

Quantitative studies indicate that HIV incidence in Zimbabwe declined since the late 1990s, due in part to behavior change. This qualitative study, involving focus group discussions with 200 women and men, two dozen key informant interviews, and historical mapping of HIV prevention programs, found that exposure to relatives and close friends dying of AIDS, leading to increased perceived HIV risk, was the principal explanation for behavior change. Growing poverty, which reduced men's ability to afford multiple partners, was also commonly cited as contributing to reductions in casual, commercial and extra-marital sex. HIV prevention programs and services were secondarily mentioned as having contributed but no specific activities were consistently indicated, although some popular culture influences appear pivotal. This qualitative study found that behavior change resulted primarily from increased interpersonal communication about HIV due to high personal exposure to AIDS mortality and a correct understanding of sexual HIV transmission, due to relatively high education levels and probably also to information provided by HIV programs.

HIV decline in Zimbabwe due to reductions in risky sex? Evidence from a comprehensive epidemiological review.

BACKGROUND: Recent data from antenatal clinic (ANC) surveillance and general population surveys suggest substantial declines in human immunodeficiency virus (HIV) prevalence in Zimbabwe. We assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence. METHODS: Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985-2007. RESULTS: HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000. Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15-24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007. CONCLUSIONS: These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis level.

Knowledge of, attitudes towards, and practices relating to child-spacing methods in northern Burkina Faso.

This study was carried out to document current trends in knowledge of, attitudes towards, and practices relating to traditional and modern child-spacing methods in a remote area in northern Burkina Faso. Information on sexual abstention, weaning, and contraception was elicited from 296 women of reproductive age, involving 413 postpartum intervals. A number of older women and key informants were also interviewed. The findings depicted significant diversity in that durations of individual postpartum sexual abstinence varied between 40 days and 3 years, with shorter durations associated with stricter adherence to Islamic beliefs and, possibly, a trend towards a less collective and, for the family unit, more labour intensive, agro-pastoral subsistence economy. Although durations of amenorrhoea were relatively short at between (median) 9 and 11 months, they determined the length of non-susceptible periods in almost 90% of cases. The median timing of weaning was stable at 24 months across all three main ethnic groups. However, changes in the frequency and type of complementary feeds may have impacted on the duration of amenorrhoea. Both demand for modem contraception and contraceptive prevalence (< 1%) were very low. The creation of new child-spacing norms and the promotion of modern contraceptive methods are likely to be successful in areas like this one only, if the population can be sensitized to the idea that Islam does not necessarily discourage contraception.

Long-term monitoring of renal function in poly-traumatized intensive care patients.

INTRODUCTION: For the long-term monitoring of kidney function, polytraumatized patients were examined and routine as well as specialized parameters were compared. MATERIALS AND METHODS: 30 patients of the Surgical Intensive Care Unit (ICU) were examined daily over the entire period they stayed in the ICU. The patients were retrospectively classified as either survivors or deceased patients. Group 1 consisted of 20 patients who resided in the ICU for 11-15 (Median 14) days before they could be transferred to a normal hospital unit. Group 2 consisted of 10 patients who had passed away after 13-18 (Median 16) days in the ICU. In addition to the routine parameters diuresis, serum creatinine and serum urea, specialized parameters for kidney function including the excretion rates of alpha1-microglobulin (alpha1-MG), N-Acetyl-beta-D-glucosaminidase (NAG), angiotensinase A (ATA) and immunoglobulin G (IgG) were determined. RESULTS: Similar biometric data were shown by all patients at admission into the ICU, but differences did exist regarding the Revised Trauma Score, Injury Severity Score and the APACHE-II-Score. In the period between the 5th and 8th day of intensive treatment almost all patients showed pathological excretion rates of tubular and glomerular parameters whereby no increased frequency of unusual events could be determined at these time-points. CONCLUSION: During treatment in the ICU, all examined patients showed at times pathological excretion rates of specialized kidney function parameters. Such transient damage was only apparent in a few of the patients when the standard parameters serum creatinine and serum urea were employed. In 90% of the surviving patients the kidney parameters had normalized until the time they were transferred, indicating that such parameters reflected the general state of health of these patients.

Renal effects of cardiopulmonary bypass in the elderly.

Cardiopulmonary bypass is widely believed to be injurious to renal function. The unknown consequences of renal dysfunction with modern techniques of bypass in the elderly caused us to examine creatinine clearance and the excretion of sensitive marker proteins in older adult patients undergoing CABG. Thirty male patients were divided into three groups: group I with an age up to 60 years, group II with an age between 61 and 70 years, inclusive and group III 71 years and over. Serum creatinine and urea, creatinine clearance, and alpha1-microglobulin (alpha1-MG), N-acetyl-beta-D-glucosaminidase (NAG), Tamm-Horsfall protein (TH) and immunoglobulin G (IgG) were all measured daily, pre- and postoperatively. Creatinine clearance remained lower in the older patients without significant differences. Raised excretion rates of alpha1-MG, and IgG were seen after CPB. The increase in alpha1-MG and NAG during the postoperative period revealed tubular damage in all elderly patients. Measurements of alpha1-MG, NAG and IgG represent useful supplements to standard clinical tests for recognizing early and differentiated changes in renal function.