Provision Of Antiretroviral Drugs Research Articles

Biomedical Risk Factors for COVID-19 among People Living with HIV during the First Wave of the Pandemic

Objective: We assessed the associations between testing positive for COVID-19 and HIV viral load, and access to and adherence to antiretroviral therapy during the initial phase of the COVID-19 pandemic. Methods: We conducted a secondary analysis of data, where we extracted complete information for 904 participants self-identifying as HIV positive. The dataset encompassed the dependent variable (testing positive for COVID-19), independent variables (HIV viral load, access to a 90-day supply of antiretroviral drugs, adherence to antiretroviral therapy), and confounding variables (age, sex assigned at birth, living with HIV co-morbidities, and self-reported depression). Results: Adherence to antiretroviral therapy (AOR: 0.364; 95% CI: 0.231-0.574; p < .001) was significantly association with decreased odds of testing positive for COVID-19. We found no statistically significant associations between HIV viral load or access to a 90-day supply of antiretroviral drugs and testing positive for COVID-19. Conclusion: The results underscore the necessity for ongoing HIV treatment adherence counseling for individuals with HIV during the COVID-19 pandemic. Further research is warranted to elucidate the paradox wherein adherence to antiretroviral therapy was associated with testing positive for COVID-19, but HIV viral load was not.

HIV pre-exposure prophylaxis and incidence of sexually transmitted infections in Brazil, 2018 to 2022: An ecological study of PrEP administration, syphilis, and socioeconomic indicators.

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is one of the pillars of a combination prevention strategy for reducing the risk of new infections caused by HIV. The daily use of antiretroviral drugs by individuals who are not infected with HIV is required to prevent infection. Although its efficacy has been well established in the literature, in recent years, the decreased supply of antiretroviral drugs has been associated with an increase in the incidence of sexually transmitted infections (STI) and changes in the social determinants of health. An ecological study was conducted covering a five-year period (2018-2022), starting from the year of initiation of PrEP administration in Brazilian state capitals. Descriptive analysis was performed, and the spatial distribution of study data was taken into account. Correlation analysis was used to assess the association between PrEP administration, the incidence and detection rate of STI, and socioeconomic data. The southern region showed the highest incidence rates of STI, but the northern and northeastern regions demonstrated the worst socioeconomic indicators, especially those related to illiteracy and basic sanitation. PrEP administration was significantly correlated with illiteracy (ρ = -0.658), per capita income (ρ = 0.622), public garbage collection (ρ = 0.612), syphilis (ρ = 0.628) and viral hepatitis (ρ = 0.419) incidences. Further, all STI were significantly associated with illiteracy and per capita income. Our findings highlight the need to continue exploring PrEP use and rising syphilis rates. In terms of policy, PrEP administration appears to be inversely associated with regions of greater social vulnerability. Further efforts should focus on the social determinants and health needs of this population to improve access to PrEP and reduce social disparities.

HIV Situation in the Penitentiary System of the Russian Federation

The objective: to identify promising directions for prevention of HIV incidence mortality on the basis of analysis of changes in HIV situation assessing the effectiveness of interventions in penitentiary units.HIV infection has traditionally been a critical issue for the penitentiary system worldwide and in Russia particularly. Recently, Russia has managed to achieve positive changes in the epidemic situation: by 2020, HIV incidence reduced to 852.8 per 100,000 (including 2,433.6 in remand prisons and 122.8 in correctional institutions); HIV prevalence was 10,512.8 per 100,000; HIV mortality was 98.3 per 100,000; HIV lethality was 0.9 per 100,000 people living with HIV.The proportion of HIV infection as a cause of death decreased from 32.0 in 2016 to 20.5 in 2020. The positive changes developed faster compared to civilian health care and occurred during the growing coverage with antiretroviral therapy which increased from 21.7% in 2014 to 89.6% in 2020. The following problems persist: high prevalence of HIV infection among female inmates (19,275.0 versus 9,769.2 among male inmates per 100,000), the high proportion of HIV/hepatitis C co-infection (49.0%; 95% CI 48.6-49.5), and the low coverage with hepatitis C treatment (0.5% of the total number of persons with co-infection). Promising directions for the prevention of HIV incidence and mortality are related to stable supply of antiretroviral drugs, improved patient adherence to treatment, and expanding treatment for HIV/hepatitis C co-infection.

Optimal Scale‐Up of HIV Treatment Programs in Resource‐Limited Settings Under Supply Uncertainty

This study is motivated by the challenges faced by clinics in sub‐Saharan Africa in allocating scarce and unreliable supply of antiretroviral drugs (ARVs) among a large pool of eligible patients. Existing discussion of ARV allocation is focused on qualitative rules for prioritizing certain socioeconomic and demographic patient segments over others at the national level. However, such prioritization rules are of limited utility in providing quantitative guidance on scaling up of treatment programs at individual clinics. In this study, we take the perspective of a clinic administrator whose objective is to maximize the quality‐adjusted survival of the entire patient population in its service area by allocating scarce and unreliable supply of drugs among two activities: initiating treatment for untreated patients and continuing treatment for previously treated patients. The key trade‐off underlying this allocation decision is between the marginal health benefit obtained by initiating an untreated patient on treatment and that obtained by avoiding treatment interruption of a treated patient. This trade‐off has not been explicitly studied in the clinical literature, which focuses either on the incremental value obtained from initiating treatment (over no treatment) or on the value of providing continuous treatment (over interrupted treatment) but not on the difference of the two. We cast the clinic's problem as a stochastic dynamic program and provide a partial characterization of the optimal policy, which consists of dynamic prioritization of patient segments and is characterized by state‐dependent thresholds. We use this structure of the optimal policy to design a simpler Two‐Period heuristic and show that it substantially outperforms the Safety‐Stock heuristic, which is commonly used in practice. In our numerical experiments based on realistic parameter values, the performance of the Two‐Period heuristic is within 4% of the optimal policy whereas that of the Safety‐Stock heuristic can be as much as 20% lower than that of the optimal policy. Our model can serve as a basis for developing a decision support tool for clinics to design their ARV treatment program scale‐up plans.

Evaluation of epidemiological and economic consequences due to the delay in treatment of hiv-positive patients caused by the covid-19 pandemic

Objective: To assess, from an epidemiological and economic point of view, the consequences of the reduction in the supply of antiretroviral drugs due to the COVID-19 pandemic. Method: The analysis was conducted by adapting a Markov model previously published in literature. The simulations were conducted considering the possibility of continuous treatment for patients already diagnosed (no therapeutic interruptions are expected) and an immediate start of patients with new diagnosis during 2021. This analysis was compared with a scenario involving a therapeutic interruption or diagnostic delay caused by COVID-19. Results: The analysis showed that the scenario characterized by a treatment delay, compared to the scenario of early resumption of therapy, could generate an increase in the number of patients with CD4 < 200 equal to 1,719 subjects (+16%) and a reduction in the number of patients with CD4 500 equal to 6,751 (−9%). A timely resumption of treatment for HIV+ patients could prevent 296, 454 and 687 deaths in the third, fifth and tenth years of analysis respectively with a potential cost reduction equal to 78,9 million at a 10 year time horizon. Conclusions: These findings show that it is essential, especially in a pandemic situation such as the present one, to introduce technological, digital and organizational solutions, aimed at promoting timely diagnosis and at accelerating the therapeutic switch for patients who are no longer targeted.

HIV situation in Russia at the beginning of implementation of state strategy aimed to combat the spread of HIV infection

The objective of the study: to determine the objectivity of statistical data on HIV infection, to analyze HIV situation in Russia at the beginning of implementation of the State Strategy Aimed to Combat the Spread of HIV Infection in the Russian Federation until 2030.Subjects and methods. The data from federal statistical surveillance forms no. 4, 8, 30, 33, and 61 were studied. The number of those died is presented as per the Rosstat data. Epidemiological and statistical analysis, expert assessment, and content analysis of publications and regulations were applied.Results. In Russia, HIV epidemic situation has stabilized; in 2019-2020, HIV-associated incidence and mortality were decreasing, and the number of deaths in patients with TB/HIV co-infection is also going down. In Russia, COVID-19 will not contribute to an increase in HIV incidence and mortality in the near future. The negative effects of the pandemic are partially offset by a sharp reduction in contacts, the stable supply of antiretroviral drugs, and the expansion of hospital-replacement technologies in specialized medical units. It is necessary to set up a unified monitoring system for HIV infection in this country. Federal statistical surveillance form no. 61 on HIV infection requires improvement and revision.

Willingness to pay for community delivery of antiretroviral treatment in urban Tanzania: a cross-sectional survey.

Community health worker (CHW)-led community delivery of HIV antiretroviral therapy (ART) could increase ART coverage and decongest healthcare facilities. It is unknown how much patients would be willing to pay to receive ART at home and, thus, whether ART community delivery could be self-financing. Set in Dar es Salaam, this study aimed to determine patients’ willingness to pay (WTP) for CHW-led ART community delivery. We sampled ART patients living in the neighbourhoods surrounding each of 48 public-sector healthcare facilities in Dar es Salaam. We asked participants (N = 1799) whether they (1) preferred ART community delivery over standard facility-based care, (2) would be willing to pay for ART community delivery and (3) would be willing to pay each of an incrementally increasing range of prices for the service. 45.0% (810/1799; 95% CI: 42.7—47.3) of participants preferred ART community delivery over standard facility-based care and 51.5% (417/810; 95% CI: 48.1—55.0) of these respondents were willing to pay for ART community delivery. Among those willing to pay, the mean and median amount that participants were willing to pay for one ART community delivery that provides a 2-months’ supply of antiretroviral drugs was 3.61 purchasing-power-parity-adjusted dollars (PPP$) (95% CI: 2.96–4.26) and 1.27 PPP$ (IQR: 1.27–2.12), respectively. An important limitation of this study is that participants all resided in neighbourhoods within the catchment area of the healthcare facility at which they were interviewed and, thus, may incur less costs to attend standard facility-based ART care than other ART patients in Dar es Salaam. While there appears to be a substantial WTP, patient payments would only constitute a minority of the costs of implementing ART community delivery. Thus, major co-financing from governments or donors would likely be required.

Optimal Scale-Up of HIV Treatment Programs in Resource-Limited Settings Under Supply Uncertainty

HIV clinics in sub-Saharan Africa face an important challenge of allocating scarce and unreliable supply of antiretroviral drugs (ARVs) among new patients (treatment initiation) and patients already on treatment (treatment continuation). The key trade-off underlying this allocation is between the marginal health benefit obtained by initiating an untreated patient on treatment and that obtained by avoiding treatment interruption of a treated patient. Existing national level policies on ARV allocation, based on socioeconomic and demographic criteria, are qualitative and of limited utility in providing quantitative guidance on scaling up of treatment programs at individual clinics. Moreover, the trade-off involved in clinic level allocation decisions has not been studied in the clinical literature, which focuses either on the incremental value obtained from initiating treatment (over no treatment) or on the value of providing continuous treatment (over interrupted treatment) but not on the difference of the two. We cast the clinic’s problem as a stochastic dynamic program, derive the optimal policy structure for some special cases and use it to derive a practically relevant Two-Period heuristic. We conduct extensive numerical analysis to compare the performance of this heuristic with Safety-Stock heuristic widely used in practice. Not serving higher value patients (those already on treatment), to avoid interrupting their treatment in the future, might be optimal under some conditions. Performance of the Two-Period heuristic (within 5% of the upper bound) is significantly better than that of the Safety-Stock heuristic (as much as 20% lower than the upper bound) and is robust to misspecification of key problem parameters, which might be difficult to estimate. Our model can serve as a basis for developing a decision-support tool for clinics to design their ARV treatment program scale-up plans.

Attitude of infectious diseases physicians in Turkey about HIV pre-exposure prophylaxis: results of an online survey.

Pre-exposure prophylaxis (PrEP) is the provision of antiretroviral drugs before HIV exposure to prevent infection for those in whom it is indicated. We conducted an online survey about PrEP in a national sample of infectious diseases physicians in Turkey. They were surveyed from March to April 2019 and they were asked about their attitudes, knowledge and clinical practise about PrEP. Overall, 209 of 2100 (10%) completed the survey, of whom 66.3% were female, 69.5% were specialist and 41.1% were working at education and research hospitals. Most of the participants reported their PrEP knowledge as 'low'. Men who have sex with men was the most suitable group for PrEP according to participants. 27.9% of them were requested to prescribe PrEP which was to be paid by individuals themselves and 24.2% of the participants had recommended PrEP in their clinical practice. The primary concerns among those who would not recommend PrEP were the possible increase in sexually transmitted infections, the potential low cost-effectiveness of PrEP, the ineffectiveness of PrEP in HIV transmission and the time lost to following-up the individuals taking PrEP. Developing a national guideline would support clinicians in order to change their attitudes and to find answers to their concerns.

Invivo Impact of Malaria and HIV Co-Infection on CD4 Cell Count of Infected Patients of Niger Delta Extraction

The study evaluated the impact of co-infection of malaria parasitaemia, and HIV positive indices on the CD4 cell count of 120 HIV infected subjects, who were already diagnosed and visiting Braithwaite Memorial Specialist Hospital Port Harcourt for routine Medical check-up. Also, a control group of 40 HIV negative were included as part of the study control group. The subjects were between the age ranges of ≤10–79 years respectively. A double check laboratory assay was conducted to detect the presence of antibody to HIV as confirmed using immunocomb 11 and Determine for HIV status. A thick Blood film stained with field stain (A and B) was used to detect the presence of malaria parasite in the subject’s blood. Furthermore, CD4 cell count was assayed using Partec cyflow counter (Partec, Germany). Excel and Graphpad statistical software were used for analysis of the data generated. The result among the HIV positive subjects and control subjects revealed that the highest positive for malaria infection was observed among ≤10 years age group as 2 (100%) and 11 (84.61%) respectively. In the HIV positive subjects, the distribution of malaria infection among sex revealed a high rate in male 42(77.78%) than in female 44 (66.67%). Similarly, the control recorded a high rate of malaria infection in male 11 (57.89%) than in female 7 (33.33%). However, 86 (71.67%) had malaria and HIV co-infection while 34 (65%) had only HIV mono infection. The positive HIV subjects who had CD4 cells count below 200 cells/mm3 were 15%, above 200-499cells/mm3 were 58.3% while 500 cells/mm3 and above had normal CD4 cells counts for 26%. Nonetheless, for the control subjects, no CD4 cells count of below 200cells/ mm was observed, 2.5% fell within the moderate category while 75% had normal CD4 cells count. Statistical analysis using ANOVA and t-test showed that there is significant difference between CD4 of seropositive and seronegative subjects infected with or without malaria (p=0.00). In addition, a t-test further demonstrated Comparison of Mean CD4 Cell Count among HIV and Malaria Infected and Non-Infected Subjects. MP/HIV Co-Infection and Mono Infection with No Infection showed strong mean difference (p=0.00) in the various CD4 counts while HIV Mono-Infection and others only had a non significant (p=0.44) mean difference between HIV Mono-Infection and No HIV or Malaria Infection. A robust and effective malaria and HIV control management programme should be strongly underpinned; so as to improve the quality of life of patients and HIV patients should be encouraged to live a healthy life style, through the provision of antiretroviral drugs and regular health education engagement, even as the provision of antimalarial treated net would be helpful to the subjects.

HIV DRUG RESISTANCE EARLY WARNING INDICATORS AND THEIR ASSESSMENT IN SOME REGIONS OF RUSSIA

The article describes the first limited experience of early warning indicators (EWIs) of HIV drug resistance recommended by WHO; information on their content and order of use is given. The results of EWIs survey performed in 2016 in nine Russian cities: Blagoveshchensk, Vladivostok, Yekaterinburg, Izhevsk, Krasnodar, Perm, Saint-Petersburg, Khanty-Mansiysk, and the Moscow Region — are presented. The on-time pill pick up indicators were optimal, >90% in four centers (44,4%), all others showed intermediate resulеs (80–90%). The retention rate was over 85% in six of the nine regions (66,6%). Two of the nine regions (22,2%) reported the existence of stock-outs in the supply of antiretroviral drugs. Bi-and monotherapy with antiretroviral drugs was administered to patients in three regions (33,3%). Suppression of viral load to values less than 1000 copies RNA/ml in more than 85% of patients was achieved only in three regions (33,3%). The conclusion was made concerning the necessity to implement the monitoring of HIV drug resistance in Russia as soon as possible, including an analysis of the EWIs and other types of monitoring studies.

ACTUAL ISSUES IN HIV INFECTION AND PREVENTION OF PERINATAL HIV TRANSMISSION IN THE SOUTH OF RUSSIA

One of the serious negative consequences of the HIV infection epidemic is the involvement of women of reproductive age and children into the epidemic process. The problem of vertical HIV infection transmission does not lose its relevance and causes the need for continuous monitoring of measures to prevent the transmission of HIV from mother to child. The aim of the study is to evaluate the effectiveness of a set of measures to prevent the transmission of HIV infection from mother to child in the South of Russia.Materials and methods. The common methods of variation statistics were used in the work to analyze the data from the reporting forms of monitoring by Rospotrebnadzor «Imformation on measures for the prevention of HIV infection, hepatitis B and C, detection and treatment of HIV patients» and federal reporting forms N 61 «Information on contingents of patients with a disease caused by a human immunodeficiency virus (HIV)» for 2016 and 2017, presented by the territorial Centers for Prevention and Control of AIDS of 15 RF subjects of the Southern Federal District and the North Caucasus Federal District.Results. In 2017, compared to 2016, the decrease in the number of births in HIV-positive women was traced on the territory of the South of Russia. In 2017, target levels of mother-child coverage with chemoprevention of mother-to-child transmission of HIV during pregnancy (over 92%) and during childbirth (more than 93,5%) were achieved in the Southern Federal District and the North Caucasus Federal District. A high proportion of women with a detectable level of HIV replication before birth was revealed.Conclusion. The implementation of the recommended by standards preventive measures and the provision of antiretroviral drugs allowed to significantly increase the coverage of HIV infected pregnant women and their newborns with antiretroviral prophylactic treatment by 2018 which prevented HIV infection transmission from mothers to 8840 children. The problems that prevent the implementation of the full range of measures for the prevention of the vertical transmission of HIV in the South of Russia are identified and approaches for their solution are suggested.

Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial.

IntroductionIn urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence.MethodsFormative research at eight facilities in Lusaka revealed that only 46% of stable HIV treatment patients were receiving a three-month refill supply of antiretroviral drugs, despite it being national policy for stable adult patients. We designed a quality improvement intervention to improve the operationalization of this policy. We conducted a cluster-randomized controlled trial in sixteen facilities in Lusaka with the primary objective of examining the intervention’s impact on the proportion of stable patients receiving three-month refills. The secondary objective was examining whether the quality improvement intervention reduced facility congestion measured through two proxy indicators: daily volume of clinic visits and average clinic wait times for services.ResultsThe mean change in the proportion of three-month refills among control facilities from baseline to endline was 10% (from 38% to 48%), compared to a 25% mean change (an increase from 44% to 69%) among intervention facilities. This represents a significant 15% mean difference (95% CI: 2%-29%; P = 0.03) in the change in proportion of patients receiving three-month refills. On average, control facilities had 15 more visits per day in the endline than in the baseline, while intervention facilities had 20 fewer visits per day in endline than in baseline, a mean difference of 35 fewer visits per day (P = 0.1). The change in the mean facility total wait time for intervention facilities dropped 19 minutes between baseline and endline when compared to control facilities (95% CI: -10.2–48.5; P = 0.2).ConclusionA more patient-centred service delivery schedule of three-month prescription refills for stable patients is viable. We encourage the expansion of this sustainable intervention in Zambia’s urban clinics.

The possible contribution of civil society in the moral edification of South African society: The example of the ‘United Democratic Front’ and the ‘Treatment Action Campaign’ (1983–2014)

In spite of much candid protest and overt criticism against the service delivery record and corruption of the South African government, the governing party, the African National Congress (ANC), once again secured a persuasive victory in the 2014 national elections. This situation begs the question whether the ballot box is really the only efficient instrument for disgruntled voters to influence government policy and behaviour. This article examines the possibilities that the mobilisation of civil society offers in this regard. The central theoretical argument is that civil society can be an important instrument through which the citizenry can exercise their critical function with regard to the government in an effort to address poor service delivery and corruption and to influence government policy. Christian organisations can play a crucial role in this process. Two examples of past efficient action by civil society serve to illustrate this argument. With the assistance of churches and Christian organisations,these organisations profoundly influenced government policy and are consequently presented as models for action today. The first example is the ‘United Democratic Front’ (UDF) that forced the pre-1994 South African apartheid government to a negotiated settlement despite the strict security laws that the state utilised to keep the UDF in check. The second example is the ‘Treatment Action Campaign’ (TAC) that forced the post-1994 Thabo Mbeki government to adopt a policy of free provision of antiretroviral drugs to HIV-positive patients. These two influential civil organisations offer models of how civil society can act as critical watchdog. In future, these models can be used to mobilise civil society, including churches and Christian organisations, to act correctively in defining and enacting government policy, despite the ANC’s strong position in government and the large majority that the governing party can secure at the voting polls.

Use of Compassionate Supply of Antiretroviral Drugs to Avoid Treatment Interruptions or Delayed Treatment Initiation among HIV-Positive Patients Living in Ontario: A Retrospective Review

Without a national pharmacare plan in Canada, HIV-infected patients across the nation differ in their ability to obtain essential HIV therapy. Despite the fact there are public insurance programs in Ontario, patients are unable to access medication. The authors described how frequently patients in their urban clinic could not access medications and why they required a compassionate supply of HIV drugs, with the goals of minimizing treatment delays and avoiding interruptions.The authors conducted a retrospective review and collected information about demographic characteristics, current drug insurance and the challenges encountered.Over one year, the authors provided 2,886 days of free HIV drugs to 42 patients who were predominantly citizens or permanent residents of Canada (88%). The most common obstacles were associated with the Trillium Drug Program and the total value of all drugs supplied was $134,860.This study suggests that Ontario's catastrophic drug insurance plan leaves some patients with significant gaps in drug coverage.

PHP47 - ABC Analysis Of Pharmaceuticals In A Resource Limited Rural Hospital In India

The Pharmacy and Therapeutic Committee in the hospital planned to study the aggregate medicine use in the hospital. After implementation of the Essential Drug List (EDL) 2011, it was important to know the consumption and cost contributed by each pharmaceuticals in the list so that further revisions could be done on the list annually. The study was conducted for one year using Always Better Control (ABC) analysis of pharmaceuticals in the EDL. Pharmaceuticals from the EDL were categorized for A (70%) B (20%) C (10%) categories. The calculations were done from a period of January 11, 2011 to January 11, 2012 using the data from the hospital billing database. The total annual drug expenditure (ADE) was Rs. 2,61,78,251. Out of 311 pharmaceuticals in the list, 47 (15%) were in A group, 60 (19%) were in B group and the remaining 204 (66%) were in C group. In the A group 45% of the pharmaceuticals were belong to ATC category J (Antimicrobials). Out of the top 10 pharmaceuticals, the costlier one was Anti D Immunoglobulin costing Rs. 1995. But it came on sixth position as the consumption was lesser than the other ones in the top. The first one was Lopinavir-Ritonavir combination with an annual cost of 13, 76529. Insulin was on fourth position with an annual expenditure just short of one million Indian Rupees. The top 10 include 3 anti-virals and 2 anti-bacterial preparations showing the high consumption and costs of the anti-microbial agents. The least unit cost in the A category was Rs. 0.18 for ferrous sulphate – folic acid combination. Antimicrobilas consumed major resources of the charity hospital. Control on antimicrobial prescription with updated protocols and adoption of government free supply of anti-retroviral drugs will substantially reduce the hospital budget on medicines.

Potential Effect of Pharmacogenetics on Maternal, Fetal and Infant Antiretroviral Drug Exposure During Pregnancy and Breastfeeding

Mother-to-child-transmission rates of HIV in the absence of any intervention range between 20 and 45%. However, the provision of antiretroviral drugs (ARVs) during pregnancy, delivery and breastfeeding can reduce HIV transmission to less than 2%. Physiological changes during pregnancy can influence ARV disposition. Associations between SNPs in genes coding for metabolizing enzymes, and/or transporters, and ARVs disposition are well described; however, relatively little is known about the influence of these SNPs on ARV pharmacokinetics during pregnancy and lactation as well as their effect on distribution into the fetal compartment and breast milk excretion. Differences in maternal, fetal and infant ARV exposure due to SNPs may affect the efficacy and safety of ARVs used to prevent mother-to-child-transmission. The aim of this review is to provide an update on the effect of pregnancy-induced changes on the pharmacokinetics of ARVs and highlight the potential role of pharmacogenetics.

“What Took You So Long?” The Impact of PEPFAR on the Expansion of HIV Testing and Counseling Services in Africa

HIV testing and counseling services in Africa began in the early 1990s, with limited availability and coverage. Fears of stigma and discrimination, complex laboratory systems, and lack of available care and treatment services hampered expansion. Use of rapid point-of-care tests, introduction of services to prevent mother-to-child transmission, and increasing provision of antiretroviral drugs were key events in the late 1990s and early 2000s that facilitated the expansion of HIV testing and counseling services. Innovations in service delivery included providing HIV testing in both clinical and community sites, including mobile and home testing. Promotional campaigns were conducted in many countries, and evolutions in policies and guidance facilitated expansion and uptake. Support from President's Emergency Plan for AIDS Relief and national governments, other donors, and the Global Fund for AIDS, Tuberculosis, and Malaria contributed to significant increases in the numbers of persons tested in many countries. Quality of both testing and counseling, limited number of health care workers, uptake by couples, and effectiveness of linkages and referral systems remain challenges. Expansion of antiretroviral treatment, especially in light of the evidence that treatment contributes to prevention of transmission, will require greater yet strategic coverage of testing services, especially in clinical settings and in combination with other high-impact HIV prevention strategies. Continued support from President's Emergency Plan for AIDS Relief, governments, and other donors is required for the expansion of testing needed to achieve international targets for the scale-up of treatment and universal access to knowledge of HIV status.

The Treatment Action Campaign's Struggle for AIDS Treatment in South Africa: Coalition-building Through Networks

The Treatment Action Campaign (TAC), South Africa's – and probably the world's – most prominent AIDS activist movement, emerged in the context of state-supported AIDS denialism and government resistance to evidence-based responses such as antiretroviral treatment. TAC's forceful campaigns against denialism and in favour of the provision of antiretroviral drugs are widely lauded and even credited with the dramatic policy turnaround in South Africa. This study draws on extensive interviews with TAC leaders and members to provide a detailed historical narrative of the emergence and impact of TAC, while employing a range of theoretical approaches to help explain its influence. It describes how TAC's founders drew on their experiences and networks from the anti-apartheid struggle to build the movement and construct new local and international support networks in order to gain influence. It concludes that TAC succeeded in leveraging ‘networks of influence’ (which also included scientists, bureaucrats and politicians) to contribute to the formation of a moral consensus on treatment access and the construction of an inclusive coalition that pursued policy change.

Human immunodeficiency virus type 1 mother-to-child transmission and prevention: successes and controversies

The World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) estimated that an additional 370 000 new human immunodeficiency virus type 1 (HIV-1) infections occurred in children in 2009, mainly through mother-to-child transmission (MTCT). Intrapartum transmission contributes to approximately 20-25% of infections, in utero transmission to 5-10% and postnatal transmission to an additional 10-15% of cases. MTCT accounts for only a few hundred infected newborns in those countries in which services are established for voluntary counselling and testing of pregnant women, and a supply of antiretroviral drugs is available throughout pregnancy with recommendations for elective Caesarean section and avoidance of breastfeeding. The single-dose nevirapine regimen has provided the momentum to initiate MTCT programmes in many resource-limited countries; however, regimens using a combination of antiretroviral drugs are needed also to effectively reduce transmission via breastfeeding.