Antiretroviral Treatment In sub-Saharan Africa Research Articles

Mid-thigh circumference as an indicator of nutritional status to predict adverse pregnancy outcomes among HIV-infected and HIV-uninfected women in Malawi

BackgroundHigh rates of adverse pregnancy outcomes globally raise the need to understand risk factors and develop preventative interventions. The Pregnancy Outcomes in the Era of Universal Antiretroviral Treatment in Sub-Saharan Africa (POISE Study) was a prospective, observational cohort study conducted from 2016 to 2017 in Blantyre, Malawi. We examine the associations between indicators of nutritional status, specifically mid-thigh circumference (MTC) and body-mass index (BMI), and adverse pregnancy outcomes, low birth weight (LBW), preterm birth (PTB), and small-for-gestational age (SGA), in a cohort of HIV-infected and HIV-uninfected women.MethodsSociodemographic, clinical, laboratory, and maternal height, weight and MTC data were collected immediately before or after delivery at the Queen Elizabeth Central Hospital (QEHC) and 4 affiliated health centers in Blantyre, Malawi. LBW was defined as birth weight < 2.5 kg; PTB as gestational age < 37 weeks using Ballard score; and SGA as birth weight < 10th percentile for gestational age. Descriptive, stratified, and multivariable logistic regression were conducted using R.ResultsData from 1298 women were analyzed: 614 HIV-infected and 684 HIV-uninfected. MTC was inversely associated with LBW (adjusted odds ratio [aOR] = 0.95, p = 0.03) and PTB (aOR 0.92, p < 0.001), after controlling for HIV status, age, socioeconomic status and hemoglobin. The association between MTC and SGA was (aOR 0.99, p = 0.53). Similarly, higher BMI was significantly associated with lower odds of PTB (aOR 0.90, p < 0.001), LBW (aOR 0.93, p = 0.05), and SGA (aOR 0.95, p = 0.04).ConclusionsWe observed an inverse relationship between MTC and adverse pregnancy outcomes in Malawi irrespective of HIV infection. MTC performs comparably to BMI; the ease of measuring MTC could make it a practical tool in resource-constrained settings for identification of women at risk of adverse pregnancy outcomes.

Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub-Saharan Africa: a rapid systematic review.

IntroductionDifferentiated service delivery (DSD) models for antiretroviral treatment (ART) for HIV are being scaled up in the expectation that they will better meet the needs of patients, improve the quality and efficiency of treatment delivery and reduce costs while maintaining at least equivalent clinical outcomes. We reviewed the recent literature on DSD models to describe what is known about clinical outcomes.MethodsWe conducted a rapid systematic review of peer‐reviewed publications in PubMed, Embase and the Web of Science and major international conference abstracts that reported outcomes of DSD models for the provision of ART in sub‐Saharan Africa from January 1, 2016 to September 12, 2019. Sources reporting standard clinical HIV treatment metrics, primarily retention in care and viral load suppression, were reviewed and categorized by DSD model and source quality assessed.Results and discussionTwenty‐nine papers and abstracts describing 37 DSD models and reporting 52 discrete outcomes met search inclusion criteria. Of the 37 models, 7 (19%) were facility‐based individual models, 12 (32%) out‐of‐facility‐based individual models, 5 (14%) client‐led groups and 13 (35%) healthcare worker‐led groups. Retention was reported for 29 (78%) of the models and viral suppression for 22 (59%). Where a comparison with conventional care was provided, retention in most DSD models was within 5% of that for conventional care; where no comparison was provided, retention generally exceeded 80% (range 47% to 100%). For viral suppression, all those with a comparison to conventional care reported a small increase in suppression in the DSD model; reported suppression exceeded 90% (range 77% to 98%) in 11/21 models. Analysis was limited by the extensive heterogeneity of study designs, outcomes, models and populations. Most sources did not provide comparisons with conventional care, and metrics for assessing outcomes varied widely and were in many cases poorly defined.ConclusionsExisting evidence on the clinical outcomes of DSD models for HIV treatment in sub‐Saharan Africa is limited in both quantity and quality but suggests that retention in care and viral suppression are roughly equivalent to those in conventional models of care.

Pregnancy Outcomes in the Era of Universal Antiretroviral Treatment in Sub-Saharan Africa (POISE Study).

Adverse pregnancy outcomes such as preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA) remain major global problems. We compared pregnancy outcomes among HIV-infected women receiving antiretroviral treatment (ART) and with CD4 ≥350 cells, and HIV-uninfected women to assess whether disparities associated with HIV infection have been eliminated through use of ART. Observational study conducted at 5 health facilities in Blantyre, Malawi, during 2016-2017. HIV-infected women receiving the national ART regimen (efavirenz + lamivudine + tenofovir) and HIV-uninfected women were consented and enrolled at delivery. Data collected included sociodemographic and clinical; gestational age; BW; infant/maternal anthropometry; and laboratory results. We defined PTB as GA <37 weeks; LBW as BW <2·5 kg; and SGA as BW <10th percentile of GA. SGA infants were classified into proportionate and disproportionate based on ponderal index. Descriptive, stratified, and multivariate logistic and linear regression analyses were used. Of 5423 women approached, 614 HIV-infected and 685 HIV-uninfected women were enrolled. Rates of PTB, LBW, and SGA were 10.6%, 7.2%, and 17.1% among HIV-infected women on ART and 9.5%, 5.0%, and 18.4% among HIV-uninfected women, respectively. None of these differences were statistically significant in univariate- or multivariate-adjusted analyses (P > 0.05). Of 231 SGA infants, 78.8% were proportionate and 21% were disproportionate. Of the 614 HIV-infected women on ART, 75% had undetectable virus at delivery. ART use has reduced the high rates of adverse pregnancy outcomes among HIV-infected women. However, the rates remain high irrespective of HIV infection and require appropriate interventions.

Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review

ObjectiveThe rapid scale up of antiretroviral treatment (ART) in sub-Saharan Africa (SSA) has resulted in an increased focus on patient adherence. Non-adherence can lead to drug-resistant HIV caused by failure...

The Impact of the TRIPS Agreement on the Access to Antiretroviral Therapy in Sub-Saharan Africa

This dissertation analyses the impact that the current global intellectual property system is having on the access to antiretroviral treatment in Sub-Saharan Africa. HIV/AIDS is causing an unprecedented public health crisis in the region, where approximately 1.2 million die every year of AIDS-related diseases. Despite the fact that a life-saving treatment exists, the high prices on antiretroviral drugs make them inaccessible to a vast number of patients. This is the direct consequence of the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), which entered into force in 1994, by virtue of which signatory states agreed to implement standardized intellectual property protection within their domestic laws. Now, States are required to grant patents to any new invention by a pharmaceutical corporation, which give it the exclusive right to use, manufacture and market the pharmaceutical good for a period of 20 years, thus preventing generic competition. Consequently, patent holders are entitled to freely set the prices on their drugs, which tend to be excessively high. Notwithstanding, the TRIPS agreement establishes a set of opt-out clauses for those cases of national emergency caused by a public health crisis. Governments are given the option to grant compulsory licenses on patented drugs to national manufacturers and to allow for parallel import of patented drugs in order to make them available at affordable prices in the national territory, under the fulfillment of certain requirements. However, the U.S. and the E.U. have continuously opposed to the use of TRIPS-get out clauses under the menace of trade retaliations, and multinational pharmaceutical corporations have threaten to file law suits against those governments issuing compulsory licenses and allowing for parallel import of their drugs. Further, the U.S and the E.U. have celebrated free trade agreements with developing states containing obligations that hinder the use of TRIPS-get out clauses. Despite the attempts by the international community and the civil society to enhance the access to antiretroviral treatment in the developing world, at the present date many eligible patients cannot afford the high prices on antiretroviral drugs. Thus, it renders necessary that the TRIPS Agreement is amended in order to establish a more balanced system, which ensures that not only the interests of pharmaceutical corporations but also the interests of patients are met.

Pretreatment HIV-1 drug resistance in Africa

476 www.thelancet.com/infection Vol 13 June 2013 1 Hamers RL, Schuurman R, Sigaloff KCE, et al, for the PharmAccess African Studies to Evaluate Resistance (PASER) Investigators. Eff ect of pretreatment HIV-1 drug resistance on immunological, virological, and drugresistance outcomes of fi rst-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort study. Lancet Infect Dis 2012;12: 307–17. 2 Lynen L, Fransen K, Van Griensven J, Colebunders R. Pretreatment HIV-1 drug resistance testing in sub-Saharan Africa. Lancet Infect Dis 2012; 12: 911. 3 Roberts T, Bygrave H, Fajardo E, Ford N. Challenges and opportunities for the implementation of virological testing in resource-limited settings. J Int AIDS Soc; 15: 17324. 4 Hamers RL, Sawyer AW, Tuohy M, Stevens WS, Rinke de Wit TF, Hill AM. Cost-eff ectiveness of laboratory monitoring for management of HIV treatment in sub-Saharan Africa: a model-based analysis. AIDS 2012; 26: 1663–72. 5 Sigaloff KC, Hamers RL, Wallis CL, et al. Unnecessary antiretroviral treatment switches and accumulation of HIV resistance mutations; two arguments for viral load monitoring in Africa. J Acquir Immune Defi c Syndr 2011; 58: 23–31. 6 Nichols BE, Sigaloff KC, Kityo C, et al. Benefi ts of early antiretroviral treatment initiation outweigh risk of transmitted HIV drug resistance: a modelling study of two east African settings. 20th Conference on Retroviruses and Opportunistic Infections; March 3–6, 2013; Atlanta, GA. Abstr 1116. 7 Phillips AN, Pillay D, Garnett G, et al. Eff ect on transmission of HIV-1 resistance of timing of implementation of viral load monitoring to determine switches from fi rst to second-line antiretroviral regimens in resource-limited settings. AIDS 2011; 25: 843–50. 8 Gupta RK, Jordan MR, Sultan BJ, et al. Global trends in antiretroviral resistance in treatment-naive individuals with HIV after rollout of antiretroviral treatment in resource-limited settings: a global collaborative study and meta-regression analysis. Lancet 2012, 380: 1250–58. test ing and alternative fi rst-line regimens. Accurate ident ifi cation of virological failure will preserve drug options by avoiding the incremental cost of unnecessary switches and reducing drugresistance accumulation. Moreover, mathematical models predict that access to viral-load monitoring and second-line regimens might mitigate transmitted drug resistance. A shift to protease inhibitors in fi rst-line ART is regarded as a last resort by many experts, since this would have major programmatic implications, increase drug cost, and restrict options for constructing eff ective second-line regimens. Routine pretreatment drug-resistance testing is not feasible for most ART programmes because of restricted resources and laboratory capacity. As levels of transmitted drug resistance increase in east and southern Africa, we argue that improved functioning of national HIV treatment programmes will be crucial to preserve the longterm eff ectiveness of available ART regimens. Functioning would be improved by an uninterrupted drug supply, optimised patient adherence and retention, and access to viral-load monitoring.

Frequency of stavudine substitution due to toxicity in children receiving antiretroviral treatment in sub-Saharan Africa

Stavudine is a commonly used drug in paediatric antiretroviral treatment (ART) regimens. Due to toxicity concerns, however, the drug abacavir has replaced stavudine in first-line paediatric regimens in many countries. We describe the frequency of stavudine toxicity in children receiving ART at a treatment clinic in Soweto, South Africa. Data on patient characteristics and outcomes of ART were collected from a cohort of 2222 HIV-infected children initiating ART between 2004 and 2008 when stavudine-containing regimens were routinely recommended. At several time-points after treatment initiation, we estimate the proportion of children where an attending clinician discontinued stavudine due to lipodystrophy, pancreatitis, lactic acidosis or peripheral neuropathy. Factors associated with stavudine-related toxicities were identified. At ART initiation, most children had advanced disease. The majority initiated an efavirenz/lamivudine/stavudine regimen (n = 1422), and 76% of children remained on their initial ART regimen after a median 19.9 months of ART. Replacement of stavudine due to drug toxicity occurred at a rate of 28.8 per 1000 child years on treatment (95% confidence interval = 23.6-35.2). Rates of toxicity increased with treatment duration (in their first year of ART stavudine was replaced in 0.5% of children, but after 3 years stavudine had been changed to abacavir in 12.6% of children). Toxicity was more common in older children and in girls. Lipodystrophy accounted for 87 of 96 toxic events. Stavudine-associated toxicity resulting in single-drug substitution was uncommon in this cohort, though its frequency increased steadily with ART duration, especially with lipodystrophy. Where drug options are limited, stavudine remains a relatively well tolerated and effective option for children.

Predictors of mortality among HIV infected patients taking antiretroviral treatment in Ethiopia: a retrospective cohort study

BackgroundStudies indicate that there is high early mortality among patients starting antiretroviral treatment in sub-Saharan Africa. However, there is paucity of evidence on long term survival of patients on anti-retroviral treatment in the region. The objective of this study is to examine mortality and its predictors among a cohort of HIV infected patients on anti-retroviral treatment retrospectively followed for five years.MethodsA retrospective cohort study was conducted among HIV infected patients on ART in eastern Ethiopia. Cox regression and Kaplan-Meier analyses were performed to investigate factors that influence time to death and survival over time.ResultA total of 1540 study participants were included in the study. From the registered patients in the cohort, the outcome of patients as active, deceased, lost to follow up and transfer out was 1005 (67.2%), 86 (5.9%), 210 (14.0%) and 192 (12.8%) respectively. The overall mortality rate provides an incidence density of 2.03 deaths per 100 person years (95% CI 1.64 - 2.50). Out of a total of 86 deaths over 60 month period; 63 (73.3%) died during the first 12 months, 10 (11.6%) during the second year, and 10 (11.6%) in the third year of follow up. In multivariate analysis, the independent predictors for mortality were loss of more 10% weight loss, bedridden functional status at baseline, ≤ 200 CD4 cell count/ml, and advanced WHO stage patients.ConclusionA lower level of mortality was detected among the cohort of patients on antiretroviral treatment in eastern Ethiopia. Previous history of weight loss, bedridden functional status at baseline, low CD4 cell count and advanced WHO status patients had a higher risk of death. Early initiation of ART, provision of nutritional support and strengthening of the food by prescription initiative, and counseling of patients for early presentation to treatment is recommended.

Commentary on Greig et al, "Similar Mortality and Reduced Loss to Follow-Up in Integrated Compared With Vertical Programs Providing Antiretroviral Treatment in Sub-Saharan Africa"

Commentary on Greig et al, "Similar Mortality and Reduced Loss to Follow-Up in Integrated Compared With Vertical Programs Providing Antiretroviral Treatment in Sub-Saharan Africa"

Similar Mortality and Reduced Loss to Follow-Up in Integrated Compared With Vertical Programs Providing Antiretroviral Treatment in Sub-Saharan Africa

Vertical HIV programs have achieved good results but may not be feasible or appropriate in many resource-limited settings. Médecins sans Frontières has treated HIV in vertical programs since 2000 and over time integrated HIV treatment into general health care services using simplified protocols. We analyzed the survival probability among patients receiving antiretroviral therapy (ART) from 2003 to 2010 in integrated versus vertical programs in 9 countries in sub-Saharan Africa. Cox regression assessed mortality and program design association, adjusting for baseline age, body mass index, clinical WHO stage, tuberculosis, program age and setting. The analysis included 15,403 HIV-positive adults on ART in 7 vertical (14,124 patients) and 10 integrated (1279 patients) programs. Cox regression including 14,523 patients followed for up to 30 months ART showed similar outcomes for mortality (adjusted hazard ratio (aHR) 1.02; 95% confidence interval (CI): 0.83 to 1.24) and lower risk of loss to follow-up (aHR: 0.71; 95% CI: 0.61 to 0.83) in integrated compared with vertical programs. The greatest risk of death was from initiating ART at WHO stage 4 (aHR 1.99, 95% CI: 1.74 to 2.29), although greater program experience was protective (aHR: 0.77, 95% CI: 0.66 to 0.89). Risk of loss to follow-up was greater in experienced programs (aHR: 3.33; 95% CI: 2.92 to 3.79) and rural settings (aHR: 3.82; 95% CI: 3.49 to 4.20). ART delivery in integrated general health care programs results in good outcomes. Compared with vertical HIV programs, patients initiated ART in integrated programs at more advanced stages of clinical immunosuppression yet had similar risk of death and lower risk of loss to follow-up.

Prognostic Value of Virological and Immunological Responses After 6 Months of Antiretroviral Treatment in Adults With HIV-1 Infection in Sub-Saharan Africa

HIV RNA monitoring is not available in most antiretroviral treatment (ART) programs in sub-Saharan Africa; switch to second-line therapy is mostly guided by clinical/immunological criteria. This may lead to unnecessary disease progression and drug resistance accumulation. We investigated the prognostic value of virological and immunological status 6 months after ART initiation with respect to death, loss to follow-up, and treatment switch. We considered treatment-naive HIV-1-infected patients, starting ART with available 6-month visit and subsequent follow-up, enrolled in a prospective cohort comprising 5 ART sites in 3 sub-Saharan countries. Outcome measures included the time from 6-month visit to death for all causes, loss to follow-up, and switch to second line. Of 2539 patients, 62% were females, their median pre-ART CD4 count was 215 cells per microliter, median HIV RNA 4.6 Log10 copies per milliliter, 30% were on WHO stage 3/4. At 6 months, 85% had HIV RNA <1000 copies per milliliter. During 3112 person-years follow-up after the 6-month visit, 91 patients died. Death was predicted by 6-month HIV RNA ≥10,000 copies per milliliter, adherence, and 6-month CD4 <200 cells per microliter. The 2-year estimated probability of surviving ranged from 0.69 (with 6-month HIV RNA ≥10,000 and CD4 <200) to 0.95 (with HIV RNA <1000 and CD4 ≥200). Loss to follow-up (1.95 per 100 person-years follow-up) was predicted by the 6-month HIV RNA >10,000 copies per milliliter and adherence but not by CD4. Switch to second line (6.94 per 100 person-years follow-up) was predicted by 6-month HIV RNA and CD4. In patients starting ART in sub-Saharan Africa, 6-month HIV RNA independently predicts subsequent survival, retention to care, and switch to second-line therapy. This measure warrants further evaluation as specific time point monitoring option.

Scale-up of antiretroviral treatment in sub-Saharan Africa is accompanied by increasing HIV-1 drug resistance mutations in drug-naive patients

To evaluate the frequency and progression over time of the WHO-defined transmitted HIV-1 drug resistance mutations (DRMs) among antiretroviral treatment (ART)-naive HIV-1-infected patients in Cameroon. We analyzed HIV-1 DRM data generated from 369 ART-naive individuals consecutively recruited between 1996 and 2007 in urban and rural areas in Cameroon. HIV-1 drug resistance genotyping was performed in the pol gene using plasma samples and surveillance DRMs were identified using the 2009 WHO-DRM list. We observed in Yaounde, the capital city, an increasing prevalence of DRMs over time: 0.0% (none of 61 participants) in 1996-1999; 1.9% (one of 53 participants) in 2001; 4.1% (two of 49 participants) in 2002; and 12.3% (10 of 81 participants) in 2007. In the rural areas with more recently implemented ART programs, we found DRMs in six of 125 (4.8%) ART-naive individuals recruited in 2006-2007. DRMs identified in both areas included resistance mutations to protease inhibitors, nucleoside reverse transcriptase inhibitors (NRTIs) and non-NRTIs (NNRTIs) that might impair the efficacy of available first-line and second-line treatments. This report showed an increase in transmitted DRMs in areas where antiretroviral drugs were introduced earlier, although other factors such as natural viral polymorphisms and acquired DRMs through exposure to antiretroviral cannot be totally excluded. Further surveillances are needed to confirm this evolution and inform public health policies on adequate actions to help limit the selection and transmission of drug-resistant HIV, while scaling up access to ART in developing countries.

Effect of pretreatment HIV-1 drug resistance on immunological, virological, and drug-resistance outcomes of first-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort study

The effect of pretreatment HIV-1 drug resistance on the response to first-line combination antiretroviral therapy (ART) in sub-Saharan Africa has not been assessed. We studied pretreatment drug resistance and virological, immunological, and drug-resistance treatment outcomes in a large prospective cohort. HIV-1 infected patients in the PharmAccess African Studies to Evaluate Resistance Monitoring (PASER-M) cohort started non-nucleoside reverse transcriptase inhibitor-based ART at 13 clinical sites in six countries, from 2007 to 2009. We used the International Antiviral Society-USA drug resistance mutation list and the Stanford algorithm to classify participants into three pretreatment drug resistance categories: no pretreatment drug resistance, pretreatment drug resistance with fully active ART prescribed, or pretreatment drug resistance with reduced susceptibility to at least one prescribed drug. We assessed risk factors of virological failure (≥400 copies per mL) and acquired drug resistance after 12 months of ART by use of multilevel logistic regression with multiple imputations for missing data. CD4 cell count increase was estimated with linear mixed models. Pretreatment drug resistance results were available for 2579 (94%) of 2733 participants; 2404 (93%) had no pretreatment drug resistance, 123 (5%) had pretreatment drug resistance to at least one prescribed drug, and 52 (2%) had pretreatment drug resistance and received fully active ART. Compared with participants without pretreatment drug resistance, the odds ratio (OR) for virological failure (OR 2·13, 95% CI 1·44-3·14; p<0·0001) and acquired drug-resistance (2·30, 1·55-3·40; p<0·0001) was increased in participants with pretreatment drug resistance to at least one prescribed drug, but not in those with pretreatment drug resistance and fully active ART. CD4 count increased less in participants with pretreatment drug resistance than in those without (35 cells per μL difference after 12 months; 95% CI 13-58; p=0·002). At least three fully active antiretroviral drugs are needed to ensure an optimum response to first-line regimens and to prevent acquisition of drug resistance. Improved access to alternative combinations of antiretroviral drugs in sub-Saharan Africa is warranted. The Netherlands Ministry of Foreign Affairs.

Interventions to increase antiretroviral adherence in sub-Saharan Africa: a systematic review of evaluation studies

The success of potent antiretroviral treatment for HIV infection is primarily determined by adherence. We systematically review the evidence of effectiveness of interventions to increase adherence to antiretroviral treatment in sub-Saharan Africa. We identified 27 relevant reports from 26 studies of behavioural, cognitive, biological, structural, and combination interventions done between 2003 and 2010. Despite study diversity and limitations, evidence suggests that treatment supporters, directly observed therapy, mobile-phone text messages, diary cards, and food rations can effectively increase adherence in sub-Saharan Africa. However, some interventions are unlikely to have large or lasting effects, and others are effective only in specific settings. These findings emphasise the need for more research, particularly for randomised controlled trials, to examine the effect of context and specific features of intervention content on effectiveness. Future work should assess intervention targeting and selection of interventions based on behavioural theories relevant to sub-Saharan Africa.

Development and validation of systems for rational use of viral load testing in adults receiving first-line ART in sub-Saharan Africa.

World Health Organization (WHO) immunological and clinical criteria for monitoring first-line antiretroviral treatment (ART) offer low accuracy for predicting viral failure. Targeting viral load assays to those at high risk has been recommended and a system to do this has been developed in Cambodia. Systems for use in sub-Saharan African populations were evaluated. A new Ugandan-based scoring system for targeting viral load assays was developed from data from the first 4 years of a Ugandan cohort (N = 559) receiving first-line ART. The accuracy of this, the Cambodian system and the WHO criteria to predict viral failure, through targeting viral load assays, were compared in a separate population of 496 Ugandans. The new Ugandan scoring system included CD4 cell count, mean cell volume, adherence, and HIV-associated clinical events as predictors of viral failure. In the validation population, the Ugandan system undertook viral load assays in 61 (12.3%) cases offering 20.5% sensitivity and 100% positive predictive value (PPV) to predict viral failure. The Cambodian system undertook viral load assays in 33 (6.7%) cases producing 23.1% sensitivity and 90.0% PPV. WHO criteria recommended viral load assays in 72 (14.5%) cases offering 30.8% sensitivity and 100% PPV. Locally developed algorithms based on clinical and immunological criteria may offer little additional accuracy over WHO criteria for targeting viral load assays. When possible, confirming viral load before switching therapy is recommended. Scoring systems are more flexible than WHO criteria in allowing ART providers to choose the proportion of the population that undergo targeted viral load testing.

HIV-1 drug resistance in antiretroviral-naive individuals in sub-Saharan Africa after rollout of antiretroviral therapy: a multicentre observational study

There are few data on the epidemiology of primary HIV-1 drug resistance after the roll-out of antiretroviral treatment (ART) in sub-Saharan Africa. We aimed to assess the prevalence of primary resistance in six African countries after ART roll-out and if wider use of ART in sub-Saharan Africa is associated with rising prevalence of drug resistance. We did a cross-sectional study in antiretroviral-naive adults infected with HIV-1 who had not started first-line ART, recruited between 2007 and 2009 from 11 regions in Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe. We did population-based sequencing of the pol gene on plasma specimens with greater than 1000 copies per mL of HIV RNA. We identified drug-resistance mutations with the WHO list for transmitted resistance. The prevalence of sequences containing at least one drug-resistance mutation was calculated accounting for the sampling weights of the sites. We assessed the risk factors of resistance with multilevel logistic regression with random coefficients. 2436 (94.1%) of 2590 participants had a pretreatment genotypic resistance result. 1486 participants (57.4%) were women, 1575 (60.8%) had WHO clinical stage 3 or 4 disease, and the median CD4 count was 133 cells per μL (IQR 62-204). Overall sample-weighted drug-resistance prevalence was 5.6% (139 of 2436; 95% CI 4.6-6.7), ranging from 1.1% (two of 176; 0.0-2.7) in Pretoria, South Africa, to 12.3% (22 of 179; 7.5-17.1) in Kampala, Uganda. The pooled prevalence for all three Ugandan sites was 11.6% (66 of 570; 8.9-14.2), compared with 3.5% (73 of 1866; 2.5-4.5) for all other sites. Drug class-specific resistance prevalence was 2.5% (54 of 2436; 1.8-3.2) for nucleoside reverse-transcriptase inhibitors (NRTIs), 3.3% (83 of 2436; 2.5-4.2) for non-NRTIs (NNRTIs), 1.3% (31 of 2436; 0.8-1.8) for protease inhibitors, and 1.2% (25 of 2436; 0.7-1.7) for dual-class resistance to NRTIs and NNRTIs. The most common drug-resistance mutations were K103N (43 [1.8%] of 2436), thymidine analogue mutations (33 [1.6%] of 2436), M184V (25 [1.2%] of 2436), and Y181C/I (19 [0.7%] of 2436). The odds ratio for drug resistance associated with each additional year since the start of the ART roll-out in a region was 1.38 (95% CI 1.13-1.68; p=0.001). The higher prevalence of primary drug resistance in Uganda than in other African countries is probably related to the earlier start of ART roll-out in Uganda. Resistance surveillance and prevention should be prioritised in settings where ART programmes are scaled up. Ministry of Foreign Affairs of the Netherlands.

Sources of motivation and frustration among healthcare workers administering antiretroviral treatment for HIV in rural Zimbabwe

The roll-out of accessible and affordable antiretroviral (ARV) drugs for people living with HIV in low-income countries is drastically changing the nature of HIV-related healthcare. The Zimbabwean Ministry of Health has renewed efforts to make antiretroviral treatment (ART) for HIV free and publically available across the country. This paper describes the findings from a multi-method qualitative study including interviews and a focus group with healthcare workers (mostly nurses), totalling 25 participants, and field notes from over 100 hours of ethnographic observation in three rural Zimbabwean health centres. These health centres began providing free ARV drugs to HIV-positive people over one year prior to the research period. We examined sources of motivation and frustration among nurses administering ART in these resource-poor health centres. The findings suggest that healthcare workers administering ART in challenging circumstances are adept at drawing strength from the dramatic physical and emotional recoveries made possible by ART and from their personal memories of the suffering caused by HIV/AIDS among close friends or family. However, healthcare staff grappled with extreme resource shortages, which led to exhaustion and frustration. Surprisingly, only one year into ART provision, healthcare workers did not reference the professional challenges of their HIV work before ART became available, suggesting that medical breakthroughs such as ART rapidly come to be seen as a standard element of nursing. Our findings provide a basis for optimism that medical breakthroughs such as ART can reinvigorate healthcare workers in the short term. However, we caution that the daily challenges of nursing in poor environments, especially administering an ongoing and resource-intensive regime such as ART, must be addressed to enable nurses to continue delivering high-quality ART in sub-Saharan Africa.

Viral cartographies: Mapping the molecular politics of global HIV

This article uses fieldwork conducted among North American and Ugandan HIV researchers to track the evolution of molecular HIV science in the global context. The recent initiation of programs funding free antiretroviral treatment in sub-Saharan Africa has both forestalled the deaths of millions of patients and brought molecular medicine to the continent on a massive scale. However, in the years leading up to this development, scientists and policymakers engaged in heated debates over whether HIV treatment in Africa could succeed, with many arguing that economic and ‘cultural’ factors would lead to missed pills and the rapid development of drug-resistant HIV strains. This article describes how the molecular ‘maps’ upon which knowledge claims about HIV were made (including claims about treatment and drug resistance) are based on HIV strains found primarily in patients in North America and Europe, and raises questions about what this implies for patients and scientists in Africa and other regions in the global South. Borrowing from the insights of critical geographers, I argue that our genetic maps of HIV are partial and contingent and reflect a ‘molecular politics’ in which the global inequalities of the AIDS epidemic are manifest at the most minute scale, embedded within the very materials and tools scientists use to study HIV. The consequences of this fact are at once clinical, political and epistemological.

A Select List of Articles on Africa Appearing in Non-Africanist Periodicals: January to March 2009

General Anyu, J. N. and Ifredi, J-P. A. China's venture in Africa: patterns, prospects and implications for Africa's development. Mediterranean Quarterly19, 1 (2008), pp. 91–110. Bäringhausen, T. and Bloom, D. E. ‘Conditional scholarships’ for HIV/AIDS health workers: educating and retaining the workforce to provide antiretroviral treatment in sub-Saharan Africa. Social Science and Medicine68, 3 (2009), pp. 554–61. Bove, R. and Valeggia, C. Polygyny and women's health in sub-Saharan Africa. Social Science and Medicine68, 1 (2009), pp. 21–9. Dunn, K. ‘Sons of the soil’ and contemporary state making: autochthony, uncertainty and political violence in Africa. Third World Quarterly30, 1 (2009), pp. 113–27. Handler, J. S. The middle passage and the material culture of captive Africans. Slavery and Abolition, 30, 1 (2009), pp. 1–26. Kallaway, P. Education, health and social welfare in the late colonial context: the International Missionary Council and educational transition in interwar years, with specific reference to colonial Africa. History of Education38, 2 (2009), pp. 217–46.

A global partnership for development

At the UN Millennium Summit in 2000, the international community declared it would spare no effort to achieve the Millennium Development Goals (MDGs), which included halving global poverty, getting all the world’s children into school, reducing infant and maternal mortality, and providing clean water and sanitation. Seven years later, we have made some progress: 34 countries are now on track to meet the infant mortality goal, 44 countries are on their way to achieving the poverty goal, and 47 countries are on target with the education goal. Aid increases and debt cancellation have helped to put nearly 40 million more African children into school in the last seven years. Today, more than 1 million people are on antiretroviral treatment in sub-Saharan Africa, compared with 100,000 just three years ago.