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Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives?
Journal of the International AIDS Society. 2011; 14:38.BACKGROUND: Updated World Health Organization guidelines have amplified debate about how resource constraints should impact monitoring strategies for HIV-infected persons on combination antiretroviral therapy (cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east Africans with known HIV infection. METHODS: Using a validated HIV computer simulation based on resource-limited data (USAID and AMPATH) and circumstances (east Africa), we compared alternative monitoring strategies for HIV-infected persons newly started on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and conditional logic (e.g., only perform virologic testing if immunologic testing is positive). We calculated incremental cost-effectiveness ratios (ICER) in units of cost per quality-adjusted life year (QALY), using a societal perspective and a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We compared the ICER of monitoring strategies with those of other resource-constrained decisions, in particular earlier cART initiation (at CD4 counts of 350 cells/mm3 rather than 200 cells/mm3). RESULTS: Monitoring strategies employing routine CD4 testing without virologic testing never maximized health benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness-to-pay levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing routine virologic testing alone only maximized health benefits at willingness-to-pay levels (> $4400/QALY) that greatly exceeded the ICER of earlier cART initiation. CONCLUSIONS: CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating monitoring resources towards earlier cART initiation.
The impact of the new WHO antiretroviral treatment guidelines on HIV epidemic dynamics and cost in South Africa.
PloS One. 2011; 6(7):e21919.BACKGROUND: Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of =350 cells/microl rather than =200 cells/microl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs. METHODS AND FINDING: We used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at =200 cells/microl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years. CONCLUSIONS: Our study strengthens the WHO recommendation of starting ART at =350 cells/microl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.
Implications of the new WHO guidelines on HIV and infant feeding for child survival in South Africa.
Bulletin of the World Health Organization. 2011 Jan 1; 89(1):62-7.The World Health Organization released revised principles and recommendations for HIV and infant feeding in November 2009. The recommendations are based on programmatic evidence and research studies that have accumulated over the past few years within African countries. This document urges national or subnational health authorities to decide whether health services should mainly counsel and support HIV-infected mothers to breastfeed and receive antiretroviral interventions, or to avoid all breastfeeding, based on estimations of which strategy is likely to give infants in those communities the greatest chance of HIV-free survival. South Africa has recently revised its clinical guidelines for prevention of mother-to-child HIV transmission, adopting many of the recommendations in the November 2009 World Health Organization's rapid advice on use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. However, one aspect of the new South African guidelines gives cause for concern: the continued provision of free formula milk to HIV-infected women through public health facilities. This paper presents the latest evidence regarding mortality and morbidity associated with feeding practices in the context of HIV and suggests a modification of current policy to prioritize child survival for all South African children.
Ten targets: 2011 United Nations General Assembly Political Declaration on HIV / AIDS: Targets and elimination commitments.
Geneva, Switzerland, UNAIDS, 2011.  p.Ten targets in the campaign to achieve universal access to HIV prevention, treatment, care and support by 2015 are listed. Targets include: Reduce sexual transmission of HIV by 50% by 2015; Reduce transmission of HIV among people who inject drugs by 50% by 2015; Eliminate new HIV infections among children by 2015 and substantially reduce AIDS-related maternal deaths; Reach 15 million people living with HIV with lifesaving antiretroviral treatment by 2015; Reduce tuberculosis deaths in people living with HIV by 50 percent by 2015; Close the global AIDS resource gap by 2015 and reach annual global investment of US$22-24 billion in low- and middle-income countries; Eliminate gender inequalities and gender-based abuse and violence and increase the capacity of women and girls to protect themselves from HIV; Eliminate stigma and discrimination against people living with and affected by HIV through promotion of laws and policies that ensure the full realization of all human rights and fundamental freedoms; Eliminate HIV-related restrictions on entry, stay and residence; Eliminate parallel systems for HIV-related services to strengthen integration of the AIDS response in global health and development efforts.
Geneva, Switzerland, UNAIDS, 2011.  p.A new report by the Joint United Nations Programme on HIV / AIDS (UNAIDS), released on 21 November, shows that 2011 was a game changing year for the AIDS response with unprecedented progress in science, political leadership and results. The report also shows that new HIV infections and AIDS-related deaths have fallen to the lowest levels since the peak of the epidemic.
Geneva, Switzerland, UNAIDS, 2011.  p.The data tables describe in greater detail the progress being made against the HIV epidemic and the main challenges to achieving zero HIV infections and zero AIDS deaths. The data are drawn from country progress reports and will be updated regularly. This document reflects information found in the publication “Global HIV / AIDS response: epidemic update and health sector progress towards universal access: progress report 2011", by UNAIDS, UNICEF and WHO.
Geneva, Switzerland, UNAIDS, 2011.  p.30 years into the AIDS epidemic, 30 milestones, thoughts, images, words, artworks, breakthroughs, inspirations, and ideas in response.
Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive. 2011-2015.
Geneva, Switzerland, UNAIDS, 2011.  p. (UNAIDS/ JC2137E)This Global Plan provides the foundation for country-led movement towards the elimination of new HIV infections among children and keeping their mothers alive. The Global Plan was developed through a consultative process by a high level Global Task Team convened by UNAIDS. It brought together 25 countries and 30 civil society, private sector, networks of people living with HIV and international organizations to chart a roadmap to achieving this goal by 2015.
Geneva, Switzerland, WHO, 2011.  p.In June 2010, the UNAIDS Secretariat and WHO launched Treatment 2.0, an initiative designed to achieve and sustain universal access and maximize the preventive benefits of antiretroviral therapy (ART). Treatment 2.0 builds on '3 by 5' and the programmatic and clinical evidence and experience over the last 10 years to expand access to HIV diagnosis, treatment and care through a series of innovations in five priority work areas: drugs, diagnostics, costs, service delivery and community mobilization. The principles and priorities of Treatment 2.0 address the need for innovation and efficiency gains in HIV programmes, in greater effectiveness, intervention coverage and impact in terms of both HIV-specific and broader health outcomes. Since the launch of Treatment 2.0, the UNAIDS Secretariat and WHO have worked with other UNAIDS co-sponsoring organizations, technical experts and global partners to further elaborate and begin implementing Treatment 2.0. The Treatment 2.0 Framework for Action outlines the five priority work areas which comprise the core elements of the initiative and establishes a strategic framework to guide action within each of them over the next decade. The Framework for Action reflects commitments outlined in Getting to Zero: 2011 - 2015 Strategy, UNAIDS and the WHO Global Health-Sector Strategy on HIV, 2011 - 2015, the guiding strategies for the multi-sectoral and health-sector responses to the HIV pandemic. (Excerpt)
Bangkok, Thailand, UNAIDS, Regional Support for Asia and the Pacific, 2011.  p. (UNAIDS / 11.05E)This report provides the most up to date information on the HIV epidemic in the region in 2011. While the region has seen impressive gains -- including a 20% drop in new HIV infections since 2001 and a three-fold increase in access to antiretroviral therapy since 2006 -- progress is threatened by an inadequate focus on key populations at higher risk of HIV infection and insufficient funding from both domestic and international sources.
From paper to practice. Implementing the World Health Organization’s 2010 Antiretroviral Therapy Recommendations for Adults and Adolescents in Zambia.
Arlington, Virginia, John Snow [JSI], AIDS Support and Technical Assistance Resources [AIDSTAR-One], 2011 May.  p. (USAID Contract No. GHH-I-00-07-00059-00; AIDSTAR-One Case Study Series)After the 2009 release of WHO’s Rapid Advice for HIV treatment in adults and adolescents, Zambia launched a broad-based effort to update its national treatment protocols. The Ministry of Health succeeded in creating an efficient and inclusive review and revision process for the guidelines, which they began implementing in 2011.