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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.
Current Opinion In Infectious Diseases. 2008 Dec; 21(6):653-8.PURPOSE OF REVIEW: As antiretroviral therapy scale-up proceeds in developing countries, simple and inexpensive procedures are required to monitor the prevalence and transmission of drug-resistant HIV strains to ensure optimal use of antiviral therapy. This article reviews new surveillance methods and practices used to monitor drug resistance in the developing world. RECENT FINDINGS: Several recently published studies report the successful development of methods using dried blood spots, collected on filter paper, for HIV drug resistance genotyping tests. In concert to antiretroviral therapy rollout, the WHO has developed a laboratory network and sought to implement surveillance of transmitted drug resistance in developing countries. A small number of developing world prevalence studies have thus far been published using dried blood spots. These studies reveal low rates of transmitted drug resistance. Other studies indicate that the use of dried blood spots for HIV drug resistance surveillance may possibly lead to overestimates. SUMMARY: The use of dried blood spots as a method of specimen collection and storage is simple, inexpensive and is an appropriate technique for the surveillance of transmitted HIV drug resistance.
International Journal of Gynecology and Obstetrics. 2007 Feb; 96(2):147-150.The objective was to compare two World Health Organization (WHO) partographs -- a composite partograph including latent phase with a simplified one without the latent phase. Comparison of the two partographs in a crossover trial. Eighteen physicians participated in this trial. One or the other partograph was used in 658 parturients. The mean (S.D.) user-friendliness score was lower for the composite partograph (6.2 (0.9) vs. 8.6 (1.0); P = 0.002). Most participants (84%) experienced difficulty "sometimes" with the composite partograph, but no participant reported difficulty with the simplified partograph. While most maternal and perinatal outcomes were similar, labor values crossed the action line significantly more often when the composite partograph was used, and the women were more likely to undergo cesarean deliveries. The simplified WHO partograph was more user-friendly, was more to be completed than the composite partograph, and was associated with better labor outcomes. (author's)
Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach. Executive summary.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2002 Apr. 31 p.Currently, fewer than five per cent of those who require ARV treatment can access these medicines in resource limited settings. WHO believes that at least three million people needing care should be able to get medicines by 2005—a more than ten-fold increase. These guidelines are intended to support and facilitate the proper management and scale-up of ART in the years to come by proposing a public health approach to achieve these goals. The key tenets of this approach are: 1) Scaling up of antiretroviral treatment programmes to meet the needs of people living with HIV/AIDS in resource-limited settings; 2) Standardization and simplification of ARV regimens to support the efficient implementation of treatment programmes; 3) Ensuring that ARV treatment programmes are based on the best scientific evidence, in order to avoid the use of substandard treatment protocols which compromise the treatment outcome of individual clients and create the potential for emergence of drug resistant virus. (excerpt)
Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2002. 163 p.These guidelines are part of the World Health Organization’s commitment to the global scale-up of antiretroviral therapy. Their development involved international consultative meetings throughout 2001, in which more than 200 clinicians, scientists, government representatives, representatives of civil society and people living with HIV/AIDS from more than 60 countries participated. The recommendations included in this document are largely based on a review of evidence and reflect the best current practices. Where the body of evidence was not conclusive, expert consensus was used as a basis for recommendations. We hope that this guidance will help Member countries as they work towards meeting the global target of having three million people on antiretroviral therapy by 2005. (excerpt)