Plasma efavirenz concentration inversely correlates with increased risk of cytomegalovirus infection in HIV-infected pregnant women.

BACKGROUND: Effective combination antiretroviral therapy (cART) has tremendously reduced HIV-associated morbidity, mortality and mother-to-child transmission. However, the benefits of cART are threatened by comorbidities, adverse drug reactions and virus resistance to existing treatment regimens. One of the most occurring comorbidities is cytomegalovirus (CMV) infection. OBJECTIVES: To investigate the effects of cART on the occurrence of CMV infection among pregnant women. METHODS: Using a cross-sectional study design, 175 HIV-infected pregnant women were recruited, and data were obtained from their clinical records. Blood samples were collected for host DNA, CMV DNA and plasma efavirenz (EFV) measurement. CMV DNA was measured using real-time polymerase chain reaction (PCR). CYP2B6 c.516G>T and CYP2B6 c.983T>C single nucleotide polymorphisms were characterised using PCR/restriction fragment length polymorphism and TaqMan assays, respectively. Plasma EFV concentrations were determined using high-performance liquid chromatography. RESULTS: There was an inverse association between plasma EFV concentration and CMV DNA. Participants with lower plasma EFV concentrations were significantly (p<0.001) more likely to be CMV DNA positive than those with higher plasma concentrations. This result is also supported by the observation that carriers of CYP2B6 poor-metaboliser genotypes (CYP2B6 c.516T/T and CYP2B6 c.983T/C) were less likely to be positive for CMV DNA. Furthermore, poor metabolism as denoted by CYP2B6 c.516T/T and CYP2B6 c.983T/C genotypes was significantly associated with lower CMV viral load. CONCLUSIONS: HIV treatment disrupts the balance between host and co-infecting microbes. Reduced or subtherapeutic levels of antiretroviral drugs, which could be exacerbated by genetic polymorphisms in drug metabolism genes and non-adherence, predispose infected individuals to an increased risk of CMV infection in pregnancy.

The prices people pay for medicines in Zimbabwe.

OBJECTIVES: To collect, analyse and compare prices of medicines in different sectors and parts of the country and to compare them with the medicine prices in other countries. DESIGN: A prospective cross sectional study. SETTING: Pharmacy outlets in Zimbabwe comprising 27 retail pharmacies, 23 dispensing doctors, eight public hospital pharmacies and seven municipal clinics. MAIN OUTCOME MEASURES: Median price ratios, 25th percentiles and 75th percentiles. RESULTS: Innovator brands in the private sector were priced 10 times the International References Prices (IRP) and more than three times the price of generic medicines. Dispensing doctors were charging the highest prices for medicines and the public sector had the least prices. The national procurement agency, NatPharm, procured medicines at prices slightly below the Management Sciences for Health (MSH) prices. Prices of medicines in the public sector were higher than average prices for medicines from seven other African countries. CONCLUSION: Medicine prices in Zimbabwe are high, a scenario that may compromise affordability and accessibility to medicines especially by the poor. Urgent steps are needed to reduce the level and effect of the high prices on the population, especially the poor.

An investigation of the factors influencing the choice of infant feeding methods among urban Zimbabwean women in the context of HIV transmission.

OBJECTIVE: To determine the socio-economic and cultural factors influencing the choice of infant feeding methods in urban Zimbabwe women in the context of HIV transmission. STUDY DESIGN: A prospective survey. SETTING: Clinics in Harare and Chitungwiza, Zimbabwe. SUBJECTS: A total of 200 women attending eight baby clinics, with babies aged up to two years. MAIN OUTCOME MEASURES: Infant feeding methods used by mothers, number of women who had undergone HIV testing, those who knew the link between HIV and breast feeding, and those who were afraid to breast feed. The most common reasons for breast feeding and formula feeding. RESULTS: Husbands had a greater influence on feeding practices than nurses, implying that social influences have a higher influence than the advice of medical personnel when choosing a method of feeding (58% and 42% respectively). Thirty three percent and 77% of women in Harare and Chitungwiza respectively knew the link between HIV and breast milk. Thirteen percent and 36% of the women were afraid to breast feed in Harare and Chitungwiza respectively. CONCLUSION: The level of education and employment status as well as the opinions of family members and health care personnel are the major factors that influence the choice of method of infant feeding. The multiplicity of factors complicate the decision making process, considering the benefits of breast feeding, which have to be weighed against the risk of transmitting HIV to the infant.

Developing a computer database for registering and monitoring patients on chronic drug therapy to determine drug consumption: a pilot study.

OBJECTIVES: To develop a computerised database for monitoring actual drug consumption by a group of patients on chronic drug therapy and pilot the database to assess its effectiveness. SETTING: Community based in Chitungwiza, Zimbabwe. SUBJECTS: 434 patients with asthma, hypertension, epilepsy, Diabetes mellitus or multiple conditions whose medical information was entered into the database. MAIN OUTCOME MEASURE: Accessibility of information on the exact amount of drugs being utilised by patients. RESULTS: It was possible to determine the amount of drugs being consumed by the patients on chronic drug therapy from the database. Additional information on patient demographic data as well as adverse drug reactions could be compiled from that basic data. The database could also be used to follow up patients and record any changes in their treatment regimens and other relevant clinical information. CONCLUSION: It is feasible to create a database for monitoring actual drug consumption by patients on chronic drug therapy as a way of forecasting drug requirements accurately. Such a database has more advantages over the current methods used to estimate drug requirements. It could also be very useful as an information resource centre for nation-wide use.

A community-based clinical pharmacy teaching, research, and service program in Zimbabwe.

In an effort to optimize limited resources, a community-based clinical pharmacy program was initiated to promote service, teaching, and research. This program sponsored the recruitment of pharmacy personnel to carry out distributive and clinical functions. This service enabled the development of new clinical attachment sites for pharmacy students. Students on these attachments carried out supervised projects that enhanced their learning while providing essential services to the community. This program resulted in the enhancement of stock levels of drugs and medical equipment, improvement in the drug budget through on-site manufacturing and proper stock management, and the creation of a favorable working partnership with other health professionals as well as the community. A number of research projects were initiated and completed, and a teaching program was established. This program demonstrated that integration of the triple functions of clinical pharmacy service, teaching, and research is feasible in a rural setting and can achieve goals that are mutually beneficial to all facets of the pharmacy profession.

User fees and drug pricing policies: a study at Harare Central Hospital, Zimbabwe.

In 1991, Zimbabwe introduced cost recovery measures as part of its programme of economic reforms, following a course taken by many developing countries. The system of user fees in public health care, aimed to 'protect and support the vulnerable groups' by exemption or incremental fees based on 4 income brackets. Drugs were charged at a percentage of the recommended retail price in the private sector. This study of 488 outpatients at a referral hospital in Harare examined how the new fee system functioned 6 months after its introduction. Patients were interviewed and their prescription records examined. Mean charges were determined for each fee category and revenue from drug charges was analyzed in relation to purchase cost to determine the gross profit. 31% of patients were exempted from all fees upon proof of monthly earnings of less than Z$150 (Z$5 = US$1). The remainder were classified into three fee-paying categories. The mean purchase cost for drug items was Z$3.89 per outpatient prescription. Outpatients paid a mean drug charge of Z$9.75 after exemption or discount. This was 2.5 times the cost price. The number of drug items obtained differed according to fee status: the fee-exempt category received a mean of 2.9 drug items compared with 1.9 drug items in the fee-paying categories. This difference originated at the point of prescribing. A number of practical problems in fee collection were noted. The drug pricing system generated high profit even after re-distribution to low-income users. This was attributed to economical and rationalized public sector drug procurement. Observation indicated that a proportion of the vulnerable were not effectively protected due to stringent requirements for proof of income. Appraisal of the fee policy indicated the need for more effective cross-subsidy and better administrative procedures; fee revenue should be directed towards improvement in quality of service.

Lack of effect of piroxicam on theophylline clearance in healthy volunteers.

This study was conducted to determine if piroxicam alters the clearance or metabolism of theophylline in healthy adults. Six male volunteers were given aminophylline 6 mg/kg iv before and after piroxicam treatment. Piroxicam 20 mg/d po was administered for seven days. Serum samples were collected before and for 24 hours after each aminophylline dose. Theophylline serum concentrations were determined using the Abbott TDx automated immunoassay system. Theophylline and its 1,3-dimethyluric acid metabolite were measured in 24-hour urine collections. Serum theophylline concentration versus time curves were plotted and pharmacokinetic parameters determined for each subject. None of the derived parameters differed as a result of piroxicam exposure. Theophylline metabolites, clearance, half-life, and volume of distribution were compared during the baseline and piroxicam phases and were found to be similar. It was concluded that piroxicam does not alter the clearance, distribution, volume, or metabolism of theophylline in healthy adult volunteers.