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Antiretroviral therapy for HIV infection in infants and children: towards universal access. Recommendations for a public health approach.
Geneva, Switzerland, WHO, 2007.  p.These stand-alone treatment guidelines serve as a framework for selecting the most potent and feasible first-line and second-line ARV regimens as components of expanded national responses for the care of HIV-infected infants and children. Recommendations are provided on: diagnosing HIV infection in infants and children; when to start ART, including situations where severe HIV disease in children less than 18 months of age has been presumptively diagnosed; clinical and laboratory monitoring of ART; substitution of ARVs for toxicities. The guidelines consider ART in different situations, e.g. where infants and children are coinfected with HIV and TB or have been exposed to ARVs either for the prevention of MTCT (PMTCT) or because of breastfeeding from an HIV-infected mother on ART. They address the importance of nutrition in the HIV-infected child and of severe malnutrition in relation to the provision of ART. Adherence to therapy and viral resistance to ARVs are both discussed with reference to infants and children. A section on ART in adolescents briefly outlines key issues related to treatment in this age group. (excerpt)
Low sensitivity of total lymphocyte count as a surrogate marker to identify antepartum and postpartum Indian women who require antiretroviral therapy.
Journal of Acquired Immune Deficiency Syndromes. 2007 Nov; 46(3):338-342.Some studies support the use of total lymphocyte count (TLC) as a surrogate marker for CD4 cell count to guide antiretroviral therapy (ART) initiation. However, most of these studies have focused on nonpregnant adults. In light of expanding ART access through prevention of mother-to-child transmission (PMTCT)-plus programs in resource-limited settings, we assessed the sensitivity, specificity, and positive predictive value (PPV) of TLC for predicting low CD4 counts in antepartum and postpartum women in Pune, India. CD4, TLC, and hemoglobin were measured at third trimester, delivery, and 6, 9, and 12 months postpartum (PP) in a cohort of 779 HIV-infected women. Optimal TLC cutoff for predicting CD4 < 200 cells/mm3 was determined via logistic regression where sensitivity, specificity, PPV, and an area under the receiver operating characteristic (ROC) curve were calculated. Among the 779 women enrolled, 16% had WHO clinical stage 2 or higher and 7.9% had CD4 < 200 cells/mm3. Using 2689 TLC-CD4 pairs,the sensitivity, specificity, and PPV of TLC < 1200 cells/mm3 for predicting CD4 < 200 cells/mm3 was 59%, 94%, and 47%, respectively. The sensitivity of TLC < 1200 cells/mm3 cutoff ranged between 57% and 62% for time points evaluated. Addition of hemoglobin < 12 g/dL or < 11 g/dL increased the sensitivity of TLC to 74% to 92% for predicting CD4 < 200 cells/mm3 but decreased the specificity to 33% to 69% compared to TLC alone. A combination of TLC, hemoglobin, and WHO clinical staging had the highest sensitivity but lowest specificity compared to other possible combinations or use of TLC alone. The sensitivity and specificity of TLC < 1200 cells/mm3 to predict a CD4 < 350 cells/mm3 was 31% and 99%, respectively. Our data suggest that antepartum and PP women with TLC < 1200 cells/mm3 are likely to have CD4 < 200 cells/mm3. However, the sensitivity of this TLC cutoff was low. Between 45% and 64% of antepartum and PP women requiring initiation of ART may not be identified by using TLC alone as a surrogate markerfor CD4 < 200 cells/mm3. The WHO-recommended TLC cutoff of < 1200 cells/mm3 is not optimal for identifying antepartum and PP Indian women who require ART. (author's)
Towards universal access: scaling up priority HIV / AIDS interventions in the health sector. Progress report, April 2007.
Geneva, Switzerland, WHO, 2007 Apr. 88 p.Drawing on lessons from the scale-up of HIV interventions over the last few years, WHO, as the UNAIDS cosponsor responsible for the health sector response to HIV/AIDS, has established priorities for its technical work and support to countries on the basis of the following five Strategic Directions, each of which represents a critical area where the health sector must invest if significant progress is to be made towards achieving universal access. Enabling people to know their HIV status; Maximizing the health sector's contribution to HIV prevention; Accelerating the scale-up of HIV/AIDS treatment and care; Strengthening and expanding health systems; Investing in strategic information to guide a more effective response. In this context, WHO undertook at the World Health Assembly in May 2006 to monitor and evaluate the global health sector response in scaling up towards universal access and to produce annual reports. This first report addresses progress in scaling up the following health sector interventions. Antiretroviral therapy; Prevention of mother-to-child transmission of HIV (PMTCT); HIV testing and counseling; Interventions for injecting drug users (IDUs); Control of sexually transmitted infections (STIs) to prevent HIV transmission; Surveillance of the HIV/AIDS epidemic. (excerpt)
Global progress in PMTCT and paediatric HIV care and treatment in low- and middle-income countries in 2004 -- 2005.
Reproductive Health Matters. 2007 Sep; 15(30):179-189.A growing number of countries are moving to scale up interventions for prevention of mother-to-child transmission (PMTCT) of HIV in maternal and child health services. Similarly, many are working to improve access to paediatric HIV treatment. This paper reviews national programme data for 2004-2005 from low- and middle-income countries to track progress in these programmes. The attainment of the UNGASS target of reducing HIV infections by 50% by 2010 necessitates that 80% of all pregnant women accessing antenatal care receive PMTCT services. In 2005, only seven of the 71 countries were on track to meet this target. However PMTCT coverage increased from 7% in 2004 (58 countries) to 11% in 2005 (71 countries). In 2005, 8% of all infants born to HIV positive mothers received antiretroviral prophylaxis for PMTCT, up from 5% in 2004, though only 4% received cotrimoxazole. 11% of HIV positive children in need received antiretroviral treatment in 2005. In 31 countries that had data, 28% of women who received an antiretroviral for PMTCT also reported receiving antiretroviral treatment for their own health. Achieving the UNGASS target is possible but will require substantial investments and commitment to strengthen maternal and child health services, the health workforce and health systems to move from pilot projects to a decentralised, integrated approach. (author's)
Geneva, Switzerland, WHO, 2005. 64 p.In an effort to keep abreast of rapid changes in the landscape of the HIV pandemic, WHO and UNAIDS report semiannually on progress toward "3 by 5". The first update was presented at the XV International AIDS Conference in Bangkok, Thailand, in July 2004. This second report measures progress made by countries and describes how international partners are supporting their efforts. In addition, it summarizes how the building blocks of antiretroviral (ARV) therapy programmes are being put into place and how issues beyond treatment are being addressed. It provides examples of country progress and a global estimate of the number of people receiving ARV therapy, and it assesses how well the therapy is working. It also identifies some of the challenges faced in resource-constrained settings and how these are being met by improving health care systems, links between prevention and treatment and providing equal access to quality care. This report is based on reports and updates provided by dozens of international, national and community organizations involved in scaling up ARV therapy. We thank everyone who has contributed to this progress report. WHO departments at the headquarters, regional and country levels worked with national governments and nongovernmental organizations to gather the latest information on the scaling up of ARV therapy. The UNAIDS Secretariat and the UNAIDS Cosponsors gathered information on how United Nations agencies and international nongovernmental organizations are translating the rapidly expanding commitment to "3 by 5" into action. (excerpt)
Global Fund-supported programmes' contribution to international targets and the Millennium Development Goals: An initial analysis.
Bulletin of the World Health Organization. 2007 Oct; 85(10):805-811.The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of the largest funders to fight these diseases. This paper discusses the programmatic contribution of Global Fund-supported programmes towards achieving international targets and Millennium Development Goals, using data from Global Fund grants. Results until June 2006 of 333 grants supported by the Global Fund in 127 countries were aggregated and compared against international targets for HIV/AIDS, tuberculosis and malaria. Progress reports to the Global Fund secretariat were used as a basis to calculate results. Service delivery indicators for antiretrovirals (ARV) for HIV/AIDS, case detection under the DOTS strategy for tuberculosis (DOTS) and insecticide-treated nets (ITNs) for malaria prevention were selected to estimate programmatic contributions to international targets for the three diseases. Targets of Global Fund-supported programmes were projected based on proposals for Rounds 1 to 4 and compared to international targets for 2009. Results for Global Fund-supported programmes total 544 000 people on ARV, 1.4 million on DOTS and 11.3 million for ITNs by June 2006. Global Fund-supported programmes contributed 18% of international ARV targets, 29% of DOTS targets and 9% of ITNs in sub-Saharan Africa by mid-2006. Existing Global Fund-supported programmes have agreed targets that are projected to account for 19% of the international target for ARV delivery expected for 2009, 28% of the international target for DOTS and 84% of ITN targets in sub-Saharan Africa. Global Fund-supported programmes have already contributed substantially to international targets by mid-2006, but there is a still significant gap. Considerably greater financial support is needed, particularly for HIV, in order to achieve international targets for 2009. (author's)
Safety of switching to nevirapine-based highly active antiretroviral therapy at elevated CD4 cell counts in a resource-constrained setting [letter]
Journal of Acquired Immune Deficiency Syndromes. 2007 Aug 15; 45(5):598-600.The World Health Organization recommends the use of generic nevirapine (NVP)/efavirenz (EFV)-based highly active antiretroviral therapy (HAART) regimens as first-line therapy in the management of HIV in resource-limited settings. Initiating NVP-based HAART at elevated CD4 cell counts can lead to liver toxicity. Short-term risk of liver toxicity has been reported in men with CD4 counts greater than 400 cells/mL and in women with CD4 counts greater than 250 cells/mL. Hence, clinicians are advised to monitor the results of liver chemistry tests closely in the first 18 weeks of therapy because of the potential to develop life-threatening hepatic events. Mocroft et al showed that initiating NVP therapy at elevated CD4 levels may be safe for use in antiretroviral-experienced patients. Little is known about short-term adverse consequences and clinical outcome at elevated CD4 cell counts in a resource-limited setting. (author's)
UNAIDS and WHO Consultation on Progress in Prevention and Care in the Context of the "3 By 5 Initiative" and the Perspective of Universal Access in the Western Pacific Region, 12-16 December 2005, Manila, Philippines. Report.
Manila, Philippines. WHO, Regional Office for the Western Pacific, .  p. ((WP)HSI/ICP/HSI/3.5/001; Report Series No. RS/2005/GE/45(PHL))The WHO Western Pacific Regional Office, in collaboration with the Joint United Programme on HIV/AIDS (UNAIDS), organized the four-day UNAIDS and WHO Consultation on Progress in Prevention and Care in the Context of the "3 by 5" Initiative and the Perspective of Universal Access in the Western Pacific Region with the general objective that, by the end of the consultation, the participants would have: (1) reviewed progress made on prevention and care scale-up in the context of the "3 by 5" Initiative; (2) shared experiences among countries on the current performance of monitoring and evaluation systems related to HIV/AIDS care, treatment and support: (3) identified ways to strengthen the integration of HIV/AIDS prevention and care: and (4) defined the conditions and terms of reference of a partners technical working group on HIV/AIDS prevention and care scale-up in the Western Pacific Region. (excerpt)
Washington, D.C., World Bank, Knowledge and Learning Center, 2005 Nov.  p. (Findings Infobriefs No. 118; Good Practice Infobrief)The Mali Multi-sectoral AIDS Project (MAP) began implementation in late 2004 and is in the preliminary phases of the project cycle. This project has been commended by the World Bank's Board for its innovation and the involvement of the private sector to address HIV/AIDS. Mali is one of the poorest countries in the world due to factors such as its limited resource base, land-locked status and poor infrastructure. According to the 2001 Demographic and Health Survey (DHS) published by the Ministry of Health, Mali's HIV/AIDS prevalence rate is estimated at 1.7% in 2001. The project objective is to support the Government of Malis efforts to control the spread of the HIV/AIDS epidemic and provide sustainable access to treatment and care to those infected with or affected by HIV/AIDS. While Mali currently has a low HIV prevalence rate by Sub-Saharan African standards, it runs a high risk of experiencing an increase in prevalence rates. (excerpt)
Antiretroviral treatment and prevention of peripartum and postnatal HIV transmission in West Africa: Evaluation of a two-tiered approach.
PLoS Medicine. 2007 Aug; 4(8):e257.Highly active antiretroviral treatment (HAART) has only been recently recommended for HIV-infected pregnant women requiring treatment for their own health in resource-limited settings. However, there are few documented experiences from African countries. We evaluated the short-term (4 wk) and long-term (12 mo) effectiveness of a two-tiered strategy of prevention of mother-to-child transmission of HIV (PMTCT) in Africa: women meeting the eligibility criteria of the World Health Organization (WHO) received HAART, and women with less advanced HIV disease received short-course antiretroviral (scARV) PMTCT regimens. The MTCT-Plus Initiative is a multi-country, family-centred HIV care and treatment program for pregnant and postpartum women and their families. Pregnant women enrolled in Abidjan, Cote d'Ivoire received either HAART for their own health or short-course antiretroviral (scARV) PMTCT regimens according to their clinical and immunological status. Plasma HIV-RNA viral load (VL) was measured to diagnose peripartum infection when infants were 4 wk of age, and HIV final status was documented either by rapid antibody testing when infants were aged >/= 12 mo or by plasma VL earlier. The Kaplan-Meier method was used to estimate the rate of HIV transmission and HIV-free survival. Between August 2003 and June 2005, 107 women began HAART at a median of 30 wk of gestation, 102 of them with zidovudine (ZDV), lamivudine (3TC), and nevirapine (NVP) and they continued treatment postpartum; 143 other women received scARV for PMTCT, 103 of them with sc(ZDV+3TC) with single-dose NVP during labour. Most (75%) of the infants were breast-fed for a median of 5 mo. Overall, the rate of peripartum HIV transmission was 2.2% (95% confidence interval [CI] 0.3%-4.2%) and the cumulative rate at 12 mo was 5.7% (95% CI 2.5%-9.0%). The overall probability of infant death or infection with HIV was 4.3% (95% CI 1.7%-7.0%) at age week 4 wk and 11.7% (95% CI 7.5%-15.9%) at 12 mo. This two-tiered strategy appears to be safe and highly effective for short- and long-term PMTCT in resource-constrained settings. These results indicate a further benefit of access to HAART for pregnant women who need treatment for their own health. (author's)
Treatment strategies for HIV-infected patients with tuberculosis: Ongoing and planned clinical trials.
Journal of Infectious Diseases. 2007 Aug 15; 196 Suppl 1:S46-S51.Currently, there are limited data to guide the management of highly active antiretroviral therapy (HAART) for human immunodeficiency virus type 1 (HIV-1)-infected patients with active tuberculosis (TB), the leading cause of death among individuals with acquired immunodeficiency syndrome (AIDS) in resource-limited areas. Four trials to take place in Southeast Asian, African, and South American countries will address the unresolved question of the optimal timing for initiation of HAART in patients with AIDS and TB: (1) Cambodian Early versus Late Introduction of Antiretrovirals (CAMELIA [ANRS 1295/NIH-CIPRA KH001]), (2) Adult AIDS Clinical Trials Group A5221, (3) START, and (4) a trial sponsored by the World Health Organization/Special Programme for Research and Training in Tropical Diseases. Two other clinical questions regarding patients with TB and HIV-1 coinfection are also undergoing evaluation: (1) the benefits of short-term HAART when CD4 cell counts are > 350 cells/mm3 (PART [NIH 1 R01 AI051219-01A2]) and (2) the efficacy of a once-daily HAART regimen in treatment-naive patients (BKVIR [ANRS 129]). Here, we present an overview of these ongoing or planned clinical studies, which are supported by international agencies. (author's)
The evolving cost of HIV in South Africa: Changes in health care cost with duration on antiretroviral therapy for public sector patients.
Journal of Acquired Immune Deficiency Syndromes. 2007 Jul; 45(3):348-354.A retrospective costing study of 212 patients enrolled in a nongovernmental organization-supported public sector antiretroviral treatment (ART) program near Cape Town, South Africa was performed from a health care system perspective. t-Regression was used to analyze total costs in 3 periods: Pre-ART (median length = 30 days), first 48 weeks on ART (Year One), and 49 to 112 weeks on ART (Year Two). Average cost per patient Pre-ART was $404. Average cost per patient-year of observation was $2502 in Year One and $1372 in Year Two. The proportion of costs attributable to hospital care fell from 70% Pre-ART to 24% by Year Two; the proportion attributable to ART rose from 31% in Year One to 55% in Year Two. In multivariate analysis, Pre-ART and Year One costs were significantly lower for asymptomatic patients compared with those with AIDS. Costs were significantly higher for those who died Pre-ART or in Year One. In Year Two, only week 48 CD4 cell count and being male were significantly associated with lower costs. This analysis suggests that the total cost of treatment for patients on ART falls by almost half after 1 year, largely attributable to a reduction in hospital costs. (author's)
Lancet. 2007 Jul 7; 370(9581):15-16.A new spirit of cooperation and coordination between the key global players in the fight against HIV/AIDS was cemented at a meeting for programme implementers in Kigali, Rwanda, in mid-June. The partnership comes amidst concerns about rising infection rates in some countries where infections had slowed, as well as worries about the unpredictability of funding for HIV/AIDS activities. The collaboration is expected to curb duplication of efforts and wastage of resources, and to ultimately scale-up AIDS prevention and treatment. The meeting-usually an annual gathering for the US President's Emergency Plan for AIDS Relief (PEPFAR) and its grantees-opened up for the first time to include the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNAIDS, the World Bank, UNICEF, WHO, and the Global Network of People Living with HIV/AIDS (GNP+), who were all co-sponsors of the conference. (excerpt)
London, England, International Community of Women Living with HIV / AIDS, 2006.  p.WHO supported ICW to map positive women's experiences of access to care and treatment in three countries - Namibia, Kenya and Tanzania. The findings will contribute to advocacy for increased political support and resources to address gendered barriers to care, treatment and support. The project complements a mapping and database of civil society organizations (CSOs) providing treatment by the French consortium - SIDACTION. This mapping presents results from three focus group discussions with HIV positive women conducted in two districts of Tanzania - Arusha and Moshi (2006). Women who participated in these focus group discussions were aged between 30 to 45. Most of them came from villages Munduli (Arusha) and Seliani (Moshi). Three focus groups were also conducted with men only in Arusha. A mixed-sex focus group was conducted in Chalinze in the Bagamoyo district (Dar es Salaam coastal area) with men and women aged between 35 and 42. There were between 12 - 15 participants in each group in Arusha and Mosh. However, in Chalinze there were only 8 people. Results from the mixed sex and men only focus groups are presented here but the main emphasis is on the results from the women only focus groups. Medical personnel were also interviewed and their experiences are included. (excerpt)
London, England, International Community of Women Living with HIV / AIDS, 2006.  p.Namibia, Kenya and Tanzania. The findings will contribute to advocacy for increased political support and resources to address gendered barriers to care, treatment and support. The project complements a mapping and database of civil society organizations (CSOs) providing treatment by the French consortium - SIDACTION. The research was carried out in Homabay (rural) and Kibera community (urban) involving women and men living with HIV and AIDS (13th December 2005 - 31st January 2006). Data was gathered through questionnaires and focus group discussions (FGDs). Women who participated in the focus group discussions were aged between 22 - 45 years old and in total 100 people took part in the project, including questionnaire respondents. The service providers in both sites were of varied age group (28-45 years) and both female and male service providers participated in the focus group discussions. Results from the mixed sex and service provider focus groups are presented here but the main emphasis is onthe results from the women only focus groups. (excerpt)
WHO HIV clinical staging or CD4 cell counts for antiretroviral therapy eligibility assessment? An evaluation in rural Rakai district, Uganda [letter]
AIDS. 2007 May 31; 21(9):1208-1210.The ability of WHO clinical staging to predict CD4 cell counts of 200 cells/µl or less was evaluated among 1221 patients screened for antiretroviral therapy (ART). Sensitivity was 51% and specificity was 88%. The positive predictive value was 64% and the negative predictive value was 81%. Clinical criteria missed half the patients with CD4 cell counts of 200 cells/µl or less, highlighting the importance of CD4 cell measurements for the scale-up of ART provision in resource-limited settings. (author's)
AIDS. 2007 May; 21(9):1205-1209.Thanks to the leadership of the World Health Organisation (WHO), and massive financial support from programmes such as the Global Fund and the US President's Emergency Plan for AIDS Relief (PEPFAR), the number of HIV-infected individuals accessing antiretroviral therapy (ART) in resource-limited settings has tripled from 2001 to 2005. An estimated 1.3 million HIV-infected individuals were on ART in 2005, representing 20% of those in need of treatment. Contrary to initial fears, numerous reports have now been published describing successful early outcomes in many ART patient populations. This is as a result of a number of factors including the fact that the majority of patients are treatment naive, that a low prevalence of primary drug resistance still prevails, and that adherence is better than expected, particularly in patients receiving treatment free of charge. (excerpt)
Bulletin of the World Health Organization. 2007 May; 85(5):325-420.In 1991, the 44th World Health Assembly set two key targets for global tuberculosis (TB) control to be reached by 2000: 70% case detection of acid-fast bacilli smear-positive TB patients under the DOTS strategy recommended by WHO and 85% treatment success of those detected. This paper describes how TB control was scaled up to achieve these targets; it also considers the barriers encountered in reaching the targets, with a particular focus on how HIV infection affects TB control. Strong TB control will be facilitated by scaling-up WHO-recommended TB/HIV collaborative activities and by improving coordination between HIV and TB control programmes; in particular, to ensure control of drug-resistant TB. Required activities include more HIV counselling and testing of TB patients, greater use and acceptance of isoniazid as a preventive treatment in HIV-infected individuals, screening for active TB in HIV-care settings, and provision of universal access to antiretroviral treatment for all HIV-infected individuals eligible for such treatment. Integration of TB and HIV services in all facilities (i.e. in HIV-care settings and in TB clinics), especially at the periphery, is needed to effectively treat those infected with both diseases, to prolong their survival and to maximize limited human resources. Global TB targets can be met, particularly if there is renewed attention to TB/HIV collaborative activities combined with tremendous political commitment and will. (author's)
Lancet Infectious Diseases. 2007 May; 7(5):313.In Zambia, widespread promotion of claims that herbal remedies can cure HIV/AIDS have been making individuals with HIV/AIDS abandon their antiretroviral therapy for ineffective drugs, the Network of Zambian People Living with HIV and AIDS has warned. Miriam Banda of the Network told journalists that both print and electronic media in the country have been persistently carrying advertisements and news stories that bring false hope to people living with HIV/AIDS. It is unclear how many people have been leaving antiretroviral programmes in the country as a result of these claims. At least 1.1 million people of Zambia's 11.6 million population have HIV/AIDS, which has devastated the economy and decreased life expectancy at birth to less than 40 years. (excerpt)
Lancet. 2007 Apr 21; 369(9570):1320.In June, 2006, UN member states at the High Level Meeting on AIDS committed themselves to provide universal access to comprehensive prevention pro grammes, treatment, care, and support by 2010. This week WHO, UNAIDS, and UNICEF publish the first report about progress towards this goal. Sadly, there is little for the international community to be pleased about. Although 2 million people had access to antiretroviral therapy at the end of 2006, 5 million were still in need of treatment. Some progress has been made in reducing the costs of first-line antiretrovirals. In low-income and middle-income countries the prices of most first-line drugs decreased by between 37% and 53% from 2003 to 2006, contributing substantially to the wider availability of treatment. But more patients put on treatment will inevitably be accompanied by increasing HIV-drug resistance. Second-line drugs, and new types of antiretroviral drugs in the future, such as the integrase inhibitors, have the potential to offer new treatment options for patients whose disease no longer responds to first-line drugs. But unless prices for second-line regimens fall substantially, budgetary constraints mean treatment programmes will be put at risk. (excerpt)
The global AIDS crisis, "3 by 5", and a renewed commitment to primary health care. WHO, World Social Forum, 2004.
Contact. 2004 Jan; (177-178):20.On September 2003 at the United Nations General Assembly, the new Director General of the World Health Organization, Dr. Lee, stated: "The AIDS treatment gap is a global public health emergency. We must change the way we think and change the way we act. Business as usual means watching thousands of people die every single day." To address this AIDS treatment crisis, WHO and UNAIDS have committed to leading the "3 by 5" initiative, which targets delivering antiretroviral treatment (ART) to 3 million people in developing countries by the end of 2005. As evident from the experience in industrialized countries since 1996, access to ART has turned HIV/AIDS into a manageable condition, dramatically reducing mortality and morbidity, and allowing people living with HIV/AIDS to live productive, healthy lives. However, in developing countries, these drugs are currently available to only a fraction of those in need. WHO launched the "3 by 5" strategy in December 2003, basing the key elements of the strategy on information gained from numerous pilot programmes that show that it is feasible to provide ARTs in even the very poorest of settings. (excerpt)
BMJ. British Medical Journal. 2007 Mar 10; 334(7592):487-488.Recently, the World Health Organization updated its recommendations of 2000 on infant feeding in the context of HIV. At that time, data had just been published quantifying the risk of infection through breast feeding so avoiding breast feeding was acknowledged as the only effective way of avoiding transmission. WHO had also just published a meta-analysis of the mortality risks of not breast feeding, but in non-HIV infected populations. Considerations of these data resulted in the statement that, "When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended." Since the 2000 recommendations, the main emphasis of most national programmes aimed at preventing mother to child transmission of HIV has been to avert transmission of HIV in young infants. The most difficult challenge has been how to make breast feeding safer in communities with a high prevalence of HIV where breast feeding is the traditional mode of feeding. Remarkably, the dilemma of infant feeding and HIV has split scientific communities and programme managers into opposing camps. Even with the risk of HIV transmission, some maintain that breast feeding may still be the best option for many mothers infected with HIV because of its anti-infective and nutritional advantages. Others promote commercial infant formula, arguing that the risks of diarrhoea and malnutrition associated with formula feeding are lower in most urban communities, or that the risks of not breast feeding may not be as great for infants born to mothers infected with HIV who, to prevent transmission, choose to give formula milk from birth; it has been suggested that this active decision making and motivation may result in safer preparation and use of formula milk. (excerpt)
Progression to WHO criteria for antiretroviral therapy in a 7-year cohort of adult HIV-1 seroconverters in Abidjan, Côte d'Ivoire.
Bulletin of the World Health Organization. 2007 Feb; 85(2):116-123.The objective was to estimate the probability of reaching the criteria for starting highly active antiretroviral therapy (HAART) in a prospective cohort of adult HIV-1 seroconverters in Abidjan, Côte d'Ivoire. We recruited participants from HIV-positive donors at the blood bank of Abidjan for whom the delay since the estimated date of seroconversion (midpoint between last negative and first positive HIV-1 test) was = 36 months. Participants were offered early trimethoprim-sulfamethoxazole (cotrimoxazole) prophylaxis, twice-yearly measurement of CD4 count and we made standardized records of morbidity. We used the Kaplan-Meier method to estimate the probability of reaching the criteria for starting HAART according to WHO 2006 guidelines. 217 adults (77 women (35%)) were followed up during 668 person-years (PY). The most frequent diseases recorded were mild bacterial diseases (6.0 per 100 PY), malaria (3.6/100 PY), herpes zoster (3.4/100 PY), severe bacterial diseases (3.1/100 PY) and tuberculosis (2.1/100 PY). The probability of reaching the WHO 2006 criteria for HAART initiation was estimated at 0.09, 0.16, 0.24, 0.36 and 0.44 at 1, 2, 3, 4 and 5 years, respectively. Our data underline the incidence of the early HIV morbidity in an Ivorian adult population and provide support for HIV testing to be made more readily available and for early follow-up of HIV-infected adults in West Africa. (author's)
Revista de Saude Publica / Journal of Public Health. 2006 Apr; 40 Suppl:52-59.This study evaluates the targets of the United Nations Declaration on HIV/AIDS Resource Targets, the attainment of which are premised on promoting three fronts: reduction of material and services costs, increased efficiency in access to and management of funds, and the channeling of new funds. Data were derived from studies of National Accounts of HIV/AIDS in Latin America and the Caribbean and from the recent available literature on the global dynamics of HIV/AIDS resources. The economic concept of global public good occurs throughout the text. The article discusses factors that constrain funding, and thus compel the adoption of new strategies in Brazil. The issues addressed include: difficulties in maintaining the downward tendency in the cost of items related to the HIV/AIDS epidemic, the incorporation each year of thousands of persons needing antiviral therapy, the rise in patient survival and increased diagnosis for the control of HIV/AIDS transmission. It is concluded that, in order to guarantee additional resources to combat the epidemic, the discussion on funding must necessarily focus on both the share of AIDS support for the Brazilian Ministry of Health, and, more importantly, on an increase in health funding as a whole. The recognition that HIV/AIDS control contributes to the global public good should facilitate increases in development assistance from international funding sources. (author's)
Geneva, Switzerland, World Health Organization [WHO], 2006 Mar 30.  p.This independent formative evaluation was conducted by a team of six international consultants between August 2005 and January 2006 to appraise WHO's contributions and roles in implementing the "3 by 5" Initiative. Funded by the Canadian Government, and as a requirement for its grant to WHO, the evaluation investigated all three levels at which WHO operates (headquarters, regional offices and country offices), placing particular emphasis on Africa. This included seven country assessments and an extensive consultation of international and country-level partners and stakeholders. A number of focused technical studies were also commissioned. The evaluation reviewed how effectively WHO provided technical, managerial and administrative guidance and support pursuant to the "3 by 5" goals and target. An assessment was also made of the extent to which WHO has mobilized, sustained and contributed to this major global partnership through improving harmonization between United Nations agencies and working with other stakeholders and partners. Key lessons from "3 by 5" have been documented, including those on how the initiative contributed to health systems strengthening and HIV prevention, as well as the ways with which equity and gender concerns were dealt. Potential opportunities for future collaboration between WHO, main donors and partners were identified and recommendations have been provided for future plans and the way forward for WHO and its partners. (excerpt)