Achieving Access: Professional Movements and the Politics of Health Universalism

[Excerpt] This book examines efforts to expand access to health care and AIDS medicine in Thailand, Brazil, and South Africa. Although these countries are geographi­cally far apart, they share many similarities as newly industrializing countries engaged in processes of democratic opening. Scholars have often suggested that expansionary social policy is the product of left-wing parties and labor unions or bottom-up people’s movements. From a strictly rational perspective, that these groups would be at the forefront of such change makes perfect sense. After all, expanding access to health care and medicine would seem to be in their interest, and they would appear to have a lot to gain. While this book recognizes the role they often play, it focuses on a different, more puzzling set of actors whose actions are sometimes even more decisive in expanding access to health care and medicine: elites from esteemed professions who, rationally speaking, aren’t in need of health care or medicine themselves and who would otherwise seem to have little to gain from such policies. This group includes doctors like Sanguan Nitayarumphong and Paulo Teixeira, whose work with the poor and needy informed their advocacy for universal health care in Thailand and Brazil while also putting them into conflict with the medical profession of which they were a part. How is it that these people would play such an important and active role in making change happen

Growth patterns and scaling laws governing AIDS epidemic in Brazilian cities

Brazil holds approximately 1/3 of population living infected with AIDS (acquired immunodeficiency syndrome) in Central and South Americas, and it was also the first developing country to implement a large-scale control and intervention program against AIDS epidemic. In this scenario, we investigate the temporal evolution and current status of the AIDS epidemic in Brazil. Specifically, we analyze records of annual absolute frequency of cases for more than 5000 cities for the first 33 years of the infection in Brazil. We found that (i) the annual absolute frequencies exhibit a logistic-type growth with an exponential regime in the first few years of the AIDS spreading; (ii) the actual reproduction number decaying as a power law; (iii) the distribution of the annual absolute frequencies among cities decays with a power law behavior; (iv) the annual absolute frequencies and the number of inhabitants have an allometric relationship; (v) the temporal evolution of the annual absolute frequencies have different profile depending on the average annual absolute frequencies in the cities. These findings yield a general quantitative description of the AIDS infection dynamics in Brazil since the beginning. They also provide clues about the effectiveness of treatment and control programs against the infection, that has had a different impact depending on the number of inhabitants of cities. In this framework, our results give insights into the overall dynamics of AIDS epidemic, which may contribute to select empirically accurate models.Comment: 12 pages, 6 figure

Audit of Antenatal Testing of Sexually Transmissible Infections and Blood Borne Viruses at Western Australian Hospitals

In August 2007, the Western Australian Department of Health (DOH) released updated recommendations for testing of sexually transmissible infections (STI) and blood-borne viruses (BBV) in antenates. Prior to this, the Royal Australian & New Zealand College of Obstetricians & Gynaecologists (RANZCOG) antenatal testing recommendations had been accepted practice in most antenatal settings. The RANZCOG recommends that testing for HIV, syphilis, hepatitis B and C be offered at the first antenatal visit. The DOH recommends that in addition, chlamydia testing be offered. We conducted a baseline audit of antenatal STI/BBV testing in women who delivered at selected public hospitals before the DOH recommendations. We examined the medical records of 200 women who had delivered before 1st July 2007 from each of the sevenWAhospitals included in the audit. STI and BBV testing information and demographic data were collected. Of the 1,409 women included, 1,205 (86%) were non-Aboriginal and 200 (14%) were Aboriginal. High proportions of women had been tested for HIV (76%), syphilis (86%), hepatitis C (87%) and hepatitis B (88%). Overall, 72% of women had undergone STI/BBV testing in accordance with RANZCOG recommendations. However, chlamydia testing was evident in only 18% of records. STI/BBV prevalence ranged from 3.9% (CI 1.5– 6.3%) for chlamydia, to 1.7% (CI 1–2.4%) for hepatitis C, 0.7% (CI 0.3–1.2) for hepatitis B and 0.6% (CI 0.2–1) for syphilis. Prior to the DOH recommendations, nearly three-quarters of antenates had undergone STI/BBV testing in accordance with RANZCOG recommendations, but less than one fifth had been tested for chlamydia. The DOH recommendations will be further promoted with the assistance of hospitals and other stakeholders. A future audit will be conducted to determine the proportion of women tested according to the DOH recommendations. The hand book from this conference is available for download Published in 2008 by the Australasian Society for HIV Medicine Inc © Australasian Society for HIV Medicine Inc 2008 ISBN: 978-1-920773-59-

Evaluation of HIV-DNA and inflammatory markers in HIV-infected individuals with different viral load patterns

Abstract Background: Persistent residual viremia (RV) and low grade inflammation and immune activation have been associated with non-AIDS defining events. The impact of persistent RV and HIV-DNA load on immune activation/ inflammation remains unclear. The purpose of this study was to gain new insights into the relation between viremia, markers of inflammation and HIV-DNA levels. Methods: Three hundred and twenty-one HIV-infected patients were studied. A retrospective analysis of viremia values, prospectively collected for 48 months, was performed. Patients were separated into three groups: 113 TND (Target Not Detected, patients with sustained undetectable viremia); 113 RV (Residual Viremia, patients who had at least three detectable viral load (VL) values <37 copies/ml); 95 LLV (Low Level Viremia, patients with at least two VL values >37 but <200 copies/ml). HIV-DNA, TNF-α, IL-6 and sCD14 were analyzed. Results: HIV-DNA, sCD14 and TNF-α were significantly lower in the TND group than in the RV and LLV groups. In addition, RV patients showed lower levels of HIV-DNA and sCD14 than LLV individuals. HIV-DNA load was not related to markers of inflammation. The ordinal logistic analysis showed that two independent variables were significantly associated with VL pattern: sCD14, HIV-DNA. In addition NRTIs plus NNRTIs and NRTIs plus PIs were negatively associated to VL pattern compared to INI-containing regimen. Conclusions: Persistent undetectable viremia was associated with lower levels of inflammatory markers and HIVDNA. However, the lack of normalization of these biomarkers in the TND group and the fact that HIV-DNA load was not associated with inflammation strongly suggest that other mechanisms play a major role in maintaining inflammation over time

A sex-role-preference model for HIV transmission among men who have sex with men in China

Background: Men who have sex with men (MSM) are much more likely to be infected with HIV than the general population. China has a sizable population of MSM, including gay, bisexual men, money boys and some rural workers. So reducing HIV infection in this population is an important component of the national HIV/AIDS prevention and control program. Methods: We develop a mathematical model using a sex-role-preference framework to predict HIV infection in the MSM population and to evaluate different intervention strategies. Results: An analytic formula for the basic reproduction ratio R0 was obtained; this yields R0 = 3.9296 in the current situation, so HIV will spread very fast in the MSM population if no intervention measure is implemented in a timely fashion. The persistence of HIV infection and the existence of disease equilibrium (or equilibria) are also shown. We utilized our model to simulate possible outcomes of antiretroviral therapy and vaccination for the MSM population. We compared the effects of these intervention measures under different assumptions about MSM behaviour. We also found that R0 is a decreasing function of the death rate of HIV-infected individuals, following a power law at least asymptotically. Conclusion: HIV will spread very fast in the MSM population unless intervention measures are implemented urgently. Antiretroviral therapy can have substantial impact on the reduction of HIV among the MSM population, even if disinhibition is considered. The effect of protected sexual behaviour on controlling the epidemic in the MSM population largely depends on the sex-ratio preference of different sub-populations

Combination antiretroviral therapy -associated lipodystrophy : insights into pathogenesis and treatment

Introduction: Combination antiretroviral therapy (cART) has decreased morbidity and mortality of individuals infected with human immunodeficiency virus type 1 (HIV-1). Its use, however, is associated with adverse effects which increase the patients risk of conditions such as diabetes and coronary heart disease. Perhaps the most stigmatizing side effect is lipodystrophy, i.e., the loss of subcutaneous adipose tissue (SAT) in the face, limbs and trunk while fat accumulates intra-abdominally and dorsocervically. The pathogenesis of cART-associated lipodystrophy is obscure. Nucleoside reverse transcriptase inhibitors (NRTI) have been implicated to cause lipoatrophy via mitochondrial toxicity. There is no known effective treatment for cART-associated lipodystrophy during unchanged antiretroviral regimen in humans, but in vitro data have shown uridine to abrogate NRTI-induced toxicity in adipocytes. Aims: To investigate whether i) cART or lipodystrophy associated with its use affect arterial stiffness; ii) lipoatrophic SAT is inflamed compared to non-lipoatrophic SAT; iii) abdominal SAT from patients with compared to those without cART-associated lipoatrophy differs with respect to mitochondrial DNA (mtDNA) content, adipose tissue inflammation and gene expression, and if NRTIs stavudine and zidovudine are associated with different degree of changes; iv) lipoatrophic abdominal SAT differs from preserved dorsocervical SAT with respect to mtDNA content, adipose tissue inflammation and gene expression in patients with cART-associated lipodystrophy and v) whether uridine can revert lipoatrophy and the associated metabolic disturbances in patients on stavudine or zidovudine based cART. Subjects and methods: 64 cART-treated patients with (n=45) and without lipodystrophy/-atrophy (n=19) were compared cross-sectionally. A marker of arterial stiffness, heart rate corrected augmentation index (AgIHR), was measured by pulse wave analysis. Body composition was measured by magnetic resonance imaging and dual-energy X-ray absorptiometry, and liver fat content by proton magnetic resonance spectroscopy. Gene expression and mtDNA content in SAT were assessed by real-time polymerase chain reaction and microarray. Adipose tissue composition and inflammation were assessed by histology and immunohistochemistry. Dorsocervical and abdominal SAT were studied. The efficacy and safety of uridine for the treatment of cART-associated lipoatrophy were evaluated in a randomized, double-blind, placebo-controlled 3-month trial in 20 lipoatrophic cART-treated patients. Results: Duration of antiretroviral treatment and cumulative exposure to NRTIs and protease inhibitors, but not the presence of cART-associated lipodystrophy, predicted AgIHR independent of age and blood pressure. Gene expression of inflammatory markers was increased in SAT of lipodystrophic as compared to non-lipodystrophic patients. Expression of genes involved in adipogenesis, triglyceride synthesis and glucose disposal was lower and of those involved in mitochondrial biogenesis, apoptosis and oxidative stress higher in SAT of patients with than without cART-associated lipoatrophy. Most changes were more pronounced in stavudine-treated than in zidovudine-treated individuals. Lipoatrophic SAT had lower mtDNA than SAT of non-lipoatrophic patients. Expression of inflammatory genes was lower in dorsocervical than in abdominal SAT. Neither depot had characteristics of brown adipose tissue. Despite being spared from lipoatrophy, dorsocervical SAT of lipodystrophic patients had lower mtDNA than the phenotypically similar corresponding depot of non-lipodystrophic patients. The greatest difference in gene expression between dorsocervical and abdominal SAT, irrespective of lipodystrophy status, was in expression of homeobox genes that regulate transcription and regionalization of organs during embryonal development. Uridine increased limb fat and its proportion of total fat, but had no effect on liver fat content and markers of insulin resistance. Conclusions: Long-term cART is associated with increased arterial stiffness and, thus, with higher cardiovascular risk. Lipoatrophic abdominal SAT is characterized by inflammation, apoptosis and mtDNA depletion. As mtDNA is depleted even in non-lipoatrophic dorsocervical SAT, lipoatrophy is unlikely to be caused directly by mtDNA depletion. Preserved dorsocervical SAT of patients with cART-associated lipodystrophy is less inflamed than their lipoatrophic abdominal SAT, and does not resemble brown adipose tissue. The greatest difference in gene expression between dorsocervical and abdominal SAT is in expression of transcriptional regulators, homeobox genes, which might explain the differential susceptibility of these adipose tissue depots to cART-induced toxicity. Uridine is able to increase peripheral SAT in lipoatrophic patients during unchanged cART.Johdanto: Ihmisen immuunikatoviruksen (HIV) hoitoon käytetyt lääkeyhdistelmät ovat vähentäneet HIV-positiivisten henkilöiden sairastuvuutta ja kuolleisuutta. Yhdistelmähoitoon liittyy kuitenkin vakavia sivuvaikutuksia, jotka lisäävät potilaiden riskiä sairastua mm. diabetekseen ja sepelvaltimotautiin. Yksi leimaavimpia sivuvaikutuksia on lipodystrofia eli ihonalaisen rasvakudoksen häviäminen (lipoatrofia) kasvoista, raajoista ja vatsalta samalla kun rasvaa kertyy ylen määrin vatsaonteloon ja niskaan. Ilmiön syyt ovat epäselvät. Useiden HIV:ta vastaan suunnattujen lääkeaineiden on epäilty aiheuttavan lipodystrofiaa mm. tuhoamalla mitokondrioita, solujen energiatehtaita . Lipodystrofiaan ei ole tehokasta hoitoa, ellei HIV-lääkitystä muuteta, mutta esim. uridiini on ollut lupaava apu solumallitutkimusten valossa. Tavoitteet: Tutkia liittyykö yhdistelmähoitoon tai sen käyttöön liittyvään lipodystrofiaan verisuonien jäykistymistä, onko lipoatrofinen rasvakudos tulehtunutta verrattuna ei-lipoatrofiseen rasvakudokseen, eroaako lipoatrofinen ei-lipoatrofisesta rasvakudoksesta mm. mitokondriomäärän ja aineenvaihduntaan vaikuttavien geenien ilmentymisen suhteen sekä poikkeaako lipodystrofiassa paremmin säilyvä niskan rasva häviävästä vatsan ihonalaisrasvasta ja onko se mahdollisesti ruskeata rasvaa. Lisäksi tutkimme, voiko ravintolisänä käytetty uridiini parantaa lipoatrofiaa ja siihen liittyviä aineenvaihduntahäiriöitä, kuten rasvamaksaa ja heikentynyttä insuliiniherkkyyttä. Menetelmät: Tutkimuksiin osallistui 64 HIV-positiivista yhdistelmähoidettua potilasta, joista 45:lla oli ja 19:lla ei ollut kehittynyt lääkitykseen liittyviä rasvakudoksen muutoksia. Verisuonijäykkyys tutkittiin pulssiaaltoanalyysilla, kehon koostumus mitattiin kaksienergisella röntgenabsorptiometria- sekä magneettikuvaantamisella ja maksan rasvapitoisuus protonispektroskopialla. Rasvakudosnäytteet otettiin potilaiden vatsan ja niskan ihoalaisrasvasta ja niistä mitattiin eri geenien ilmentymistä sekä mitokondrioiden ja tulehdussolujen määrää mm. DNA:n monistustekniikalla ja kudosleikevärjäyksin. Uridiinin tehoa lipoatrofian hoidossa arvioitiin 3kk satunnaistetussa lumelääkekontrolloidussa tutkimuksessa, johon osallistui 20 HIV-positiivista yhdistelmähoidettua lipoatrofista henkilöä. Tulokset: HIV-lääkityksen kesto, mutta ei lipodystrofia, altistaa verisuonien jäykistymiselle iästä ja verenpainetasosta riippumatta. Lipoatrofisessa rasvakudoksessa tulehdukseen liittyvien geenien ilmentyminen ja tulehdussolujen määrä ovat lisääntyneet, kun taas mitokondriomäärä sekä rasvasolujen muodostumiseen ja toimintaan liittyvien geenien ilmentyminen vähentyneet verrattuna ei-lipoatrofiseen rasvakudokseen. Lipodystrofiassa säilyvä/lisääntyvä niskan rasva on vähemmän tulehtunutta kuin herkemmin häviävä vatsan ihonalaisrasva eikä se ole ruskeata rasvaa. Lipodystrofisten henkilöiden niskan rasvassa on vähemmän mitokondrioita kuin ei-lipodystrofisten henkilöiden niskan rasvassa, vaikka kudokset ovat ulkoisesti samannäköisiä. Niskan ja vatsan alueen ihonalaisrasva eroaa eniten ns. homeobox-geenien ilmentymisessä eli sellaisten geenien, jotka määrittelevät kudosten sijainnin ja ominaisuudet sikiökehityksen varhaisvaiheessa. Uridiini lisää ihonalaisrasvan määrää lipoatrofisilla potilailla, mutta ei vaikuta maksan rasvapitoisuuteen tai insuliiniherkkyyteen. Johtopäätökset: HIV:n hoitoon käytettyjen lääkkeiden pitkäaikaiskäyttö lisää verisuonien jäykkyyttä ja siten potilaiden riskiä sairastua sydän- ja verisuonitauteihin. Lipoatrofinen rasva on tulehtunut ja sen mitokondriovarannot vähentyneet. Koska mitokondrioiden vähyys on todettavissa niskarasvassa myös sellaisilla lipodystrofisilla henkilöillä, joilla se on säilynyt atrofialta, mitokondriokatoa ei voida pitää lipoatrofiaa suoraan aiheuttavana tekijänä. Niskan ja vatsan ihonalaisrasvan merkittävin ero on elinkehitystä ohjaavissa geeneissä, mikä voi selittää kudosten erilaisen alttiuden lääkkeiden sivuvaikutuksille. Uridiini on tehokas hoito HIV-potilaiden lipodystrofiaan muuttumattoman yhdistelmähoidon aikana

Increasing risk behaviour can outweigh the benefits of antiretroviral drug treatment on the HIV incidence among men-having-sex-with-men in Amsterdam

Background: The transmission through contacts among MSM (men who have sex with men) is one of the dominating contributors to HIV prevalence in industrialized countries. In Amsterdam, the capital of the Netherlands, the MSM risk group has been traced for decades. This has motivated studies which provide detailed information about MSM's risk behavior statistically, psychologically and sociologically. Despite the era of potent antiretroviral therapy, the incidence of HIV among MSM increases. In the long term the contradictory effects of risk behavior and effective therapy are still poorly understood.Methods: Using a previously presented Complex Agent Network model, we describe steady and casual partnerships to predict the HIV spreading among MSM. Behavior-related parameters and values, inferred from studies on Amsterdam MSM, are fed into the model; we validate the model using historical yearly incidence data. Subsequently, we study scenarios to assess the contradictory effects of risk behavior and effective therapy, by varying corresponding values of parameters. Finally, we conduct quantitative analysis based on the resulting incidence data.R