• A biregional survey and review of first-line treatment failure and second-line paediatric antiretroviral access and use in Asia and southern Africa

      Van Cutsem, G; Saphonn, V; Saramony, S; Vibol, U; Zhang, FJ; Han, N; Saghayam, S; Kurniati, N; Muktiarti, D; Fong, SM; Thien, M; Nik Yusoff, NK; Hai, LC; Razali, K; TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand. annette.sohn@treatasia.org (BioMed Central, 2011-04-08)
      To better understand the need for paediatric second-line antiretroviral therapy (ART), an ART management survey and a cross-sectional analysis of second-line ART use were conducted in the TREAT Asia Paediatric HIV Observational Database and the IeDEA Southern Africa (International Epidemiologic Databases to Evaluate AIDS) regional cohorts.
    • Cascade of HIV Care and Population Biral Suppression in a High-Burden Region of Kenya

      Maman, D; Zeh, C; Mukui, I; Kirubi, B; Masson, S; Opolo, V; Szumilin, E; Riche, B; Etard, JF (Lippincott Williams & Wilkins, 2015-07-31)
      Direct measurement of antiretroviral treatment (ART) program indicators essential for evidence-based planning and evaluation - especially HIV incidence, population viral load, and ART eligibility - is rare in sub-Saharan Africa.
    • Challenge and co-operation: civil society activism for access to HIV treatment in Thailand.

      Ford, N; Wilson, D; Cawthorne, P; Kumphitak, A; Kasi-Sedapan, S; Kaetkaew, S; Teemanka, S; Donmon, B; Preuanbuapan, C; Médecins Sans Frontières, Bangkok, Thailand. david.wilson.thai@gmail.com (Published by Wiley-Blackwell, 2009-03)
      Civil society has been a driving force behind efforts to increase access to treatment in Thailand. A focus on HIV medicines brought civil society and non-governmental and government actors together to fight for a single cause, creating a platform for joint action on practical issues to improve care for people with HIV/AIDS (PHA) within the public health system. The Thai Network of People with HIV/AIDS, in partnership with other actors, has provided concrete support for patients and for the health system as a whole; its efforts have contributed significantly to the availability of affordable generic medicines, early treatment for opportunistic infections, and an informed and responsible approach towards antiretroviral treatment that is critical to good adherence and treatment success. This change in perception of PHA from 'passive receiver' to 'co-provider' of health care has led to improved acceptance and support within the healthcare system. Today, most PHA in Thailand can access treatment, and efforts have shifted to supporting care for excluded populations.
    • Crunch time for funding of universal access to antiretroviral treatment for people with HIV infection

      Maher, D; von Schoen-Angerer, T; Cohn, J; MRC⁄ UVRI Uganda Research Unit on AIDS, Entebbe, Uganda; London School of Hygiene and Tropical Medicine, London, UK; Medecins sans Frontieres, Geneva, Switzerland; Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, USA (Wiley-Blackwell, 2011-07-15)
    • Cytomegalovirus retinitis: the neglected disease of the AIDS pandemic.

      Heiden, D; Ford, N; Wilson, D; Rodriguez, W; Margolis, T; Janssens, B; Bedelu, M; Tun, N; Goemaere, E; Saranchuk, P; Sabapathy, K; Smithuis, F; Luyirika, E; Drew, W L; Department of Ophthalmology and Pacific Vision Foundation, California Pacific Medical Center, San Francisco, California, United States of America. dheidenpea@yahoo.com (PLoS, 2007-12)
    • Driving a decade of change: HIV/AIDS, patents and access to medicines for all

      Hoen, Ellen 't; Berger, Jonathan; Calmy, Alexandra; Moon, Suerie; Medicines Patent Pool Initiative, UNITAID Secretariat, Geneva, Switzerland; SECTION27, Braamfontein, Johannesburg, South Africa; HIV Unit, Division of Infectious Disease, Geneva University Hospital, Geneva, Switzerland; Médecins Sans Frontières Campaign for Access to Essential Medicines, Geneva, Switzerland; Sustainability Science Program, Center for International Development, Kennedy School of Government, Harvard University, Cambridge, MA, USA (BioMed Central, 2011-03-27)
      Since 2000, access to antiretroviral drugs to treat HIV infection has dramatically increased to reach more than five million people in developing countries. Essential to this achievement was the dramatic reduction in antiretroviral prices, a result of global political mobilization that cleared the way for competitive production of generic versions of widely patented medicines.Global trade rules agreed upon in 1994 required many developing countries to begin offering patents on medicines for the first time. Government and civil society reaction to expected increases in drug prices precipitated a series of events challenging these rules, culminating in the 2001 World Trade Organization's Doha Declaration on the Agreement on Trade-Related Aspects of Intellectual Property Rights and Public Health. The Declaration affirmed that patent rules should be interpreted and implemented to protect public health and to promote access to medicines for all. Since Doha, more than 60 low- and middle-income countries have procured generic versions of patented medicines on a large scale.Despite these changes, however, a "treatment timebomb" awaits. First, increasing numbers of people need access to newer antiretrovirals, but treatment costs are rising since new ARVs are likely to be more widely patented in developing countries. Second, policy space to produce or import generic versions of patented medicines is shrinking in some developing countries. Third, funding for medicines is falling far short of needs. Expanded use of the existing flexibilities in patent law and new models to address the second wave of the access to medicines crisis are required.One promising new mechanism is the UNITAID-supported Medicines Patent Pool, which seeks to facilitate access to patents to enable competitive generic medicines production and the development of improved products. Such innovative approaches are possible today due to the previous decade of AIDS activism. However, the Pool is just one of a broad set of policies needed to ensure access to medicines for all; other key measures include sufficient and reliable financing, research and development of new products targeted for use in resource-poor settings, and use of patent law flexibilities. Governments must live up to their obligations to protect access to medicines as a fundamental component of the human right to health.
    • Expanding HIV care in Africa: making men matter.

      Mills, E; Ford, N; Mugyenyi, P; Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada V5Z4B4. emills@cfenet.ubc.ca (2009-07-25)
    • Malawi's contribution to "3 by 5": achievements and challenges

      Libamba, Edwin; Makombe, Simon D; Harries, Anthony D; Schouten, Erik J; Yu, Joseph Kwong-Leung; Pasulani, Olesi; Mhango, Eustice; Aberle-Grasse, John; Hochgesang, Mindy; Limbambala, Eddie; Lungu, Douglas; Clinical HIV Unit, Ministry of Health, Lilongwe, Malawi; HIV Coordinator, Ministry of Health, Lilongwe, Malawi; Taiwan Medical Mission, Mzuzu Central Hospital, Mzuzu, Malawi; Médecins sans Frontières Belgium, Thyolo District Hospital, Malawi; Lighthouse Clinic, Lilongwe, Malawi; Centres for Disease Control, Lilongwe office, Malawi; WHO country office, Lilongwe, Malawi; Department of Clinical Services, Ministry of Health, Lilongwe, Malawi (2007-02-01)
      PROBLEM: Many resource-poor countries have started scaling up antiretroviral therapy (ART). While reports from individual clinics point to successful implementation, there is limited information about progress in government institutions at a national level. APPROACH: Malawi started national ART scale-up in 2004 using a structured approach. There is a focus on one generic, fixed-dose combination treatment with stavudine, lamivudine and nevirapine. Treatment is delivered free of charge to eligible patients with HIV and there is a standardized system for recruiting patients, monthly follow-up, registration, monitoring and reporting of cases and outcomes. All treatment sites receive quarterly supervision and evaluation. LOCAL SETTING: In January 2004, there were nine public sector facilities delivering ART to an estimated 4 000 patients. By December 2005, there were 60 public sector facilities providing free ART to 37,840 patients using national standardized systems. Analysis of quarterly cohort treatment outcomes at 12 months showed 80% of patients were alive, 10% dead, 9% lost to follow-up and 1% had stopped treatment. LESSONS LEARNED: Achievements were the result of clear national ART guidelines, implementing partners working together, an intensive training schedule focused on clinical officers and nurses, a structured system of accrediting facilities for ART delivery, quarterly supervision and monitoring, and no stock-outs of antiretroviral drugs. The main challenges are to increase the numbers of children, pregnant women and patients with tuberculosis being started on ART, and to avert high early mortality and losses to follow-up. The capacity of the health sector to cope with escalating case loads and to scale up prevention alongside treatment will determine the future success of ART delivery in Malawi.
    • The marriage of science and optimized HIV care in resource-limited settings

      Calmy, A; Pizzocolo, C; Pizarro, L; Brücker, G; Murphy, R; Katlama, C; Strategies in Resource-Limited Settings Working Group; Campaign for Access to Essential Medicines, Médecins Sans Frontières, Geneva; Geneva University, Geneva, Switzerland; Solidarité Théapeutique et Initiatives contre le Sida, Paris; Université Paris 11, Faculté de Médicine Paris-Sud, Le Kremlin-Bicêtre, Paris; Université Pierre et Marie Curie, Paris, France (2008-11-12)
    • Monitoring the South African National Antiretroviral Treatment Programme, 2003-2007: the IeDEA Southern Africa collaboration.

      Cornell, Morna; Technau, Karl; Fairall, Lara; Wood, Robin; Moultrie, Harry; van Cutsem, Gilles; Giddy, Janet; Mohapi, Lerato; Eley, Brian; MacPhail, Patrick; Prozesky, Hans; Rabie, Helena; Davies, Mary-Ann; Maxwell, Nicola; Boulle, Andrew; Infectious Disease Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town. morna@global.co.za (2009-09)
      OBJECTIVES: To introduce the combined South African cohorts of the International epidemiologic Databases to Evaluate AIDS Southern Africa (IeDEA-SA) collaboration as reflecting the South African national antiretroviral treatment (ART) programme; to characterise patients accessing these services; and to describe changes in services and patients from 2003 to 2007. DESIGN AND SETTING: Multi-cohort study of 11 ART programmes in Gauteng, Western Cape, Free State and KwaZulu-Natal. SUBJECTS: Adults and children (<16 years old) who initiated ART with > or =3 antiretroviral drugs before 2008. RESULTS: Most sites were offering free treatment to adults and children in the public sector, ranging from 264 to 17,835 patients per site. Among 45,383 adults and 6,198 children combined, median age (interquartile range) was 35.0 years (29.8-41.4) and 42.5 months (14.7-82.5), respectively. Of adults, 68% were female. The median CD4 cell count was 102 cells/microl (44-164) and was lower among males than females (86, 34-150 v. 110, 50-169, p<0.001). Median CD4% among children was 12% (7-17.7). Between 2003 and 2007, enrolment increased 11-fold in adults and 3-fold in children. Median CD4 count at enrolment increased for all adults (67-111 cells/microl, p<0.001) and for those in stage IV (39-89 cells/microl, p<0.001). Among children <5 years, baseline CD4% increased over time (11.5-16.0%, p<0.001). CONCLUSIONS: IeDEA-SA provides a unique opportunity to report on the national ART programme. The study describes dramatically increased enrolment over time. Late diagnosis and ART initiation, especially of men and children, need attention. Investment in sentinel sites will ensure good individual-level data while freeing most sites to continue with simplified reporting.
    • Providing antiretroviral care in conflict settings.

      Mills, Edward J; Ford, Nathan; Singh, Sonal; Eyawo, Oghenowede; BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada. emills@cfenet.ubc.ca (2009-11)
      There has been an historic expectation that delivering combination antiretroviral therapy (cART) to populations affected by violent conflict is untenable due to population movement and separation of drug supplies. There is now emerging evidence that cART provision can be successful in these populations. Using examples from Médecins Sans Frontières experience in a variety of African settings and also local nongovernmental organizations' experiences in northern Uganda, we examine novel approaches that have ensured retention in programs and adequate adherence. Emerging guidelines from United Nations bodies now support the expansion of cART in settings of conflict.
    • Public health. Getting HIV treatment to the most people.

      Lynch, Sharonann; Ford, Nathan; van Cutsem, Gilles; Bygrave, Helen; Janssens, Bart; Decroo, Tom; Andrieux-Meyer, Isabelle; Roberts, Teri; Balkan, Suna; Casas, Esther; Ferreyra, Cecilia; Bemelmans, Marielle; Cohn, Jen; Kahn, Patricia; Goemaere, Eric; Médecins Sans Frontières Access Campaign, New York, NY 10001, USA. (2012-07-20)
    • Sustaining Access to Antiretroviral Therapy in the Less-Developed World: Lessons from Brazil and Thailand.

      Ford, N; Wilson, D; Costa Chaves, G; Lotrowska, M; Kijtiwatchakul, K; Médecins Sans Frontières, 522 Mooban Nakorn Thai 14, Ladphrao Soi 101/1, Bangkok 10240, Thailand. nathan.ford@london.msf.org (2007-07)
      ANTIRETROVIRAL ROLLOUT IN BRAZIL AND THAILAND: Brazil and Thailand are among few developing countries to achieve universal access to antiretroviral therapy. Three factors were critical to this success: legislation for free access to treatment; public sector capacity to manufacture medicines; and strong civil society action to support government initiatives to improve access. LOCAL PRODUCTION OF AFFORDABLE, NON-PATENTED DRUGS: Many older antiretroviral drugs are not patented in either country and affordable generic versions are manufactured by local pharmaceutical institutes. EFFORTS TO ENSURE ACCESS TO EXPENSIVE, PATENTED DRUGS: Developing countries were not required to grant patents on medicines until 2005, but under US government threats of trade sanctions, Thailand and Brazil began doing so at least ten years prior to this date. Brazil has used price negotiations with multi-national pharmaceutical companies to lower the price of newer patented antiretrovirals. However, the prices obtained by this approach remain unaffordable. Thailand recently employed compulsory licensing for two antiretrovirals, obtaining substantial price reductions, both for generic and brand products. Following Thailand's example, Brazil has issued its first compulsory license. LESSONS LEARNED: Middle-income countries are unable to pay the high prices of multinational pharmaceutical companies. By relying on negotiations with companies, Brazil pays up to four times more for some drugs compared with prices available internationally. Compulsory licensing has brought treatment with newer antiretrovirals within reach in Thailand, but has resulted in pressure from industry and the US government. An informed and engaged civil society is essential to support governments in putting health before trade.
    • Treatment failure and mortality factors in patients receiving second-line HIV therapy in resource-limited countries.

      Pujades-Rodríguez, Mar; Balkan, Suna; Arnould, Line; Brinkhof, Martin A W; Calmy, Alexandra; Epicentre, Médecins Sans Frontières 42-bis, Bd, 8 rue Saint Sabin, 75011 Paris, France. mar.pujades@epicentre.msf.org (2010-07-21)
      CONTEXT: Long-term antiretroviral therapy (ART) use in resource-limited countries leads to increasing numbers of patients with HIV taking second-line therapy. Limited access to further therapeutic options makes essential the evaluation of second-line regimen efficacy in these settings. OBJECTIVES: To investigate failure rates in patients receiving second-line therapy and factors associated with failure and death. DESIGN, SETTING, AND PARTICIPANTS: Multicohort study of 632 patients > 14 years old receiving second-line therapy for more than 6 months in 27 ART programs in Africa and Asia between January 2001 and October 2008. MAIN OUTCOME MEASURES: Clinical, immunological, virological, and immunovirological failure (first diagnosed episode of immunological or virological failure) rates, and mortality after 6 months of second-line therapy use. Sensitivity analyses were performed using alternative CD4 cell count thresholds for immunological and immunovirological definitions of failure and for cohort attrition instead of death. RESULTS: The 632 patients provided 740.7 person-years of follow-up; 119 (18.8%) met World Health Organization failure criteria after a median 11.9 months following the start of second-line therapy (interquartile range [IQR], 8.7-17.0 months), and 34 (5.4%) died after a median 15.1 months (IQR, 11.9-25.7 months). Failure rates were lower in those who changed 2 nucleoside reverse transcriptase inhibitors (NRTIs) instead of 1 (179.2 vs 251.6 per 1000 person-years; incidence rate ratio [IRR], 0.64; 95% confidence interval [CI], 0.42-0.96), and higher in those with lowest adherence index (383.5 vs 176.0 per 1000 person-years; IRR, 3.14; 95% CI, 1.67-5.90 for < 80% vs > or = 95% [percentage adherent, as represented by percentage of appointments attended with no delay]). Failure rates increased with lower CD4 cell counts when second-line therapy was started, from 156.3 vs 96.2 per 1000 person-years; IRR, 1.59 (95% CI, 0.78-3.25) for 100 to 199/microL to 336.8 per 1000 person-years; IRR, 3.32 (95% CI, 1.81-6.08) for less than 50/microL vs 200/microL or higher; and decreased with time using second-line therapy, from 250.0 vs 123.2 per 1000 person-years; IRR, 1.90 (95% CI, 1.19-3.02) for 6 to 11 months to 212.0 per 1000 person-years; 1.71 (95% CI, 1.01-2.88) for 12 to 17 months vs 18 or more months. Mortality for those taking second-line therapy was lower in women (32.4 vs 68.3 per 1000 person-years; hazard ratio [HR], 0.45; 95% CI, 0.23-0.91); and higher in patients with treatment failure of any type (91.9 vs 28.1 per 1000 person-years; HR, 2.83; 95% CI, 1.38-5.80). Sensitivity analyses showed similar results. CONCLUSIONS: Among patients in Africa and Asia receiving second-line therapy for HIV, treatment failure was associated with low CD4 cell counts at second-line therapy start, use of suboptimal second-line regimens, and poor adherence. Mortality was associated with diagnosed treatment failure.
    • Universal access in the fight against HIV/AIDS

      Girard, Françoise; Ford, Nathan; Montaner, Julio; Cahn, Pedro; Katabira, Elly; Open Society Institute Public Health Program, New York, NY, USA; Médecins Sans Frontières, Cape Town, South Africa; Division of AIDS, University of British Columbia, Vancouver, BC, Canada; Fundacion Huesped, Buenos Aires, Argentina; Department of Research, Makerere Medical School, Kampala, Uganda. (2010-07-09)