Utilization Patterns and Projected Demand of Antiretroviral Drugs in Low- and Middle-Income Countries

Background. The rapid scale-up of antiretroviral therapy in resource-limited settings has greatly increased demand for antiretroviral medicines and raised the importance of good forward planning, especially in the context of the new 2010 WHO treatment guidelines. Methods. Forecasting of the number of people receiving antiretroviral therapy from 2010 to 2012 was produced using three approaches: linear projection, country-set targets, and a restricted scenario. Two additional scenarios were then used to project the demand for various antiretroviral medicines under a fast and slower phase-out of stavudine. Results. We projected that between 7.1 million and 8.4 million people would be receiving ART by the end of 2012. Of these, 6.6% will be on second-line therapy. High variation in forecast includes reductions in the demand for d4T and d4T increases in the demand for tenofovir, emtricitabine followed by efavirenz, ritonavir, zidovudine and lopinavir; lamivudine, atazanavir, and nevirapine. Conclusion. Despite the global economic crisis and in response to the revised treatment guidelines, our model forecasts an increasing and shifting demand for antiretrovirals in resource-limited settings not only to provide treatment to new patients, but also to those switching to less toxic regimens

Levels of Spending and Resource Allocation to HIV Programs and Services in Latin America and the Caribbean

BACKGROUND: An estimated 1.86 million people are living with HIV in Latin America and the Caribbean (LAC). The region is comprised of mainly middle-income countries with steady economic growth while simultaneously there are enormous social inequalities and several concentrated AIDS epidemics. This paper describes HIV spending patterns in LAC countries including analysis of the levels and patterns of domestic HIV spending from both public and international sources. METHODS AND FINDINGS: We conducted an extensive analysis of the most recently available data from LAC countries using the National AIDS Spending Assessment tool. The LAC countries spent a total of US$ 1.59 billion on HIV programs and services during the latest reported year. Countries providing detailed information on spending showed that high percentages are allocated to treatment and care (75.1%) and prevention (15.0%). Domestic sources accounted for 93.6 percent of overall spending and 79 percent of domestic funds were directed to treatment and care. International funds represented 5.4 percent of total HIV funding in the region, but they supplied the majority of the effort to reach most-at-risk-populations (MARPs). However, prevalence rates among men who have sex with men (MSM) still reached over 25 percent in some countries. CONCLUSIONS: Although countries in the region have increasingly sustained their response from domestic sources, still there are future challenges: 1) The growing number of new HIV infections and more people-living-with-HIV (PLWH) eligible to receive antiretroviral treatment (ART); 2) Increasing ART coverage along with high prices of antiretroviral drugs; and 3) The funding for prevention activities among MARPs rely almost exclusively on external donors. These threats call for strengthened actions by civil society and governments to protect and advance gains against HIV in LAC

Prevalencia y factores de riesgo asociados a sífilis en mujeres

INTRODUCTION: Although the incidence of syphilis is generally low, it remains an important global public health problem, given its interaction with other sexually transmitted diseases (STDs). It has been shown that syphilis, due to the genital ulcers it produces, is a co-factor for acquiring other STDs, principally those of viral origin such as herpes simples type 2, hepatitis B and HIV. Many female commercial sex workers (FCSW) in Mexico have been found to have acquired good levels of knowledge about STD prevention. Nevertheless, they constitute a heterogeneous group in terms of socio-economic level, health status and type of work site; these factors in turn appear to determine their attitudes, knowledge and behavior related to acquiring and transmitting STDs, including syphilis. This study, therefore, focused on the factors associated with Treponema pallidum infection in this group of women. METHOD: Based on a sample frame of sites where female commercial sex work takes place within Mexico City, a sample of 807 FCSWs was selected; after providing informed consent, they completed a structured questionnaire. A blood sample for identifying serologic markers for STDs was collected and analyzed according to a procedure manual for STD diagnosis. Treponema pallidum was diagnosed using the RPR (Bigaux Diagnostica) screening test, and FTA - ABS (Pasteur Diagnostics) for confirmation. RESULTS: The prevalence of syphilis in this sample of FCSWs was 6.4% (52/807), and was higher among women who worked at street sites than among those who worked in massage parlors. The age of the women interviewed ranged from 17 to 58 years, with a mean of 29.2 years (SD 7.3 years); syphilis was more prevalent among women over 30 years of age. Age at first sexual intercourse ranged from 11 to 30 years, with a mean of 16 years (SD 3.1 years), which is similar to that of the general female population in Mexico. Predictive factors for T. pallidum infection, determined adjusted logistic regression, included: tupe of by work site (bar and street sites); socio-economic level (middle and low); age (over 30 years); duration of involvement in sex work (>; 5 years) and number of clients per week (>; 10). CONCLUSION: In spite of some limitations regarding statistical precision, this study shows that FCSWs are heterogeneous in terms of risk of acquiring STDs, including syphilis; the principal differentiating factor was shown to be the type of work site. Given that it is not belonging to a risk group but rather participating in risky practices that leads to acquiring STDs, situations that facilitate riskier or safer practices (such as type of sex work site, for sex workers) should be taken into account when studying people's risk level. STD prevention campaigns must also consider these factors, in addition to focusing on FCSWs and their clients and personal partners, so that all involved assume their responsibility for safer sex.INTRODUCCIÓN: Se ha demostrado que la sífilis, debido a la ulceración genital que produce, es un cofactor asociado para adquirir otras enfermedades de transmisión sexual (ETS), principalmente de origen viral como herpes tipo-2, hepatitis B, y el VIH. Aunque las mujeres trabajadoras del sexo comercial (MTSC) han adquirido mejores conocimientos para prevenir las ETS, constituyen un grupo que por su heterogenicidad en términos de condición socioeconómica, estado de salud, ambiente y sitio de trabajo, manifiestan diferentes actitudes y conocimientos que hacen latente la posibilidad de adquirir y transmitir ETS incluyendo sífilis, por lo que lo estudio hace un acercamiento hacia los factores asociados a infección por Treponema pallidum en este grupo de mujeres. MÉTODO: Basado en un marco muestral, que identifica sitios donde se practica el comercio sexual femenino en la ciudad de México, se seleccionó una muestra de 807 MTSC, a quienes previo consentimiento informado, se entrevistó para que respondieran un cuestionario estructurado. Se obtuvo una muestra sanguínea para la identificación de diversos marcadores serológicos de ETS de acuerdo al manual de procedimientos para el diagnóstico de ETS. Para el diagnóstico de Treponema pallidum se utilizó una prueba de tamizaje de RPR (Bigaux Diagnóstica), y prueba confirmatoria de FTA-ABS (Pasteur Diagnostics). RESULTADOS: Las prevalencias de sífilis en la muestra de MTSC fue de 6,4% (52/807), siendo mayor en quienes trabajaban en sitios de calle comparadas con aquellas de estéticas. La edad de las mujeres entrevistadas osciló entre 17 y 58 años con una media de 29,2 años (d.s. 7,3 años). La prevalencia de sífilis fue mayor en los grupos etáreos mayores de 30 anos. La edad de inicio de relaciones sexuales varió desde 11 hasta 30 anos con una media de 16 años (d.s. 3,1 años). Los factores predictores de infección por T. pallidum, determinados mediante regresión logística ajustada, fueron: sitio de trabajo (bar y puntos de calle), NSE (medio y bajo), edad (mayores de 30 anos), antiguedad en el trabajo sexual (>; 5 años), y número de clientes en una semana (>;10). CONCLUSIONES: A pesar de las limitaciones de precisión estadística, queda demostrado que existe una heterogenicidad de MTSC, diferenciado principalmente por el sitio donde se desempeñan. Debe entenderse que más que grupos de riesgo de adquirir y transmitir ETS, existen prácticas sexuales de riesgo en cualquier individuo que tiene relaciones sexuales, que aunadas a infecciones predisponentes como sífilis, facilitan la transmisibilidad de otras ETS. Por lo tanto, las campañas de prevención y fomento de uso de condón, deben orientarse no sólo a las MTSC sino también a sus clientes y parejas, con la finalidad de que todos asuman la responsabilidad del sexo seguro

A Controlled Study of Funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as Resource Capacity Building in the Health System in Rwanda

Because human inmmunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) receives more donor funding globally than that for all other diseases combined, some critics allege this support undermines general health care. This empirical study evaluates the impact of HIV/AIDS funding on the primary health care system in Rwanda. Using a quasi-experimental design, we randomly selected 25 rural health centers (HCs) that started comprehensive HIV/AIDS services from 2002 through 2006 as the intervention group. Matched HCs with no HIV/AIDS services formed the control group. The analysis compared growth in inputs and services between intervention and control HCs with a difference-in-difference analysis in a random-effects model. Intervention HCs performed better than control HCs in most services (seven of nine), although only one of these improvements (Bacille Calmette-Guérin vaccination) reached or approached statistical significance. In conclusion, this six-year controlled study found no adverse effects of the expansion of HIV/AIDS services on non-HIV services among rural health centers in Rwanda

Hypertension in Guatemala’s Public Primary Care System: A Needs Assessment Using the Health System Building Blocks Framework

Background: Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system. Methods: We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala’s public system using the World Health Organization’s health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers. Results: Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor. Conclusions: This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala’s public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach.Fil: Fort, Meredith P.. University of Colorado; Estados UnidosFil: Mundo, William. University of Colorado; Estados UnidosFil: Paniagua Avila, Alejandra. No especifíca;Fil: Cardona, Sayra. No especifíca;Fil: Figueroa, Juan Carlos. No especifíca;Fil: Hernández Galdamez, Diego. No especifíca;Fil: Mansilla, Kristyne. No especifíca;Fil: Peralta García, Ana. No especifíca;Fil: Roche, Dina. No especifíca;Fil: Palacios, Eduardo Alberto. No especifíca;Fil: Glasgow, Russell E.. University of Colorado; Estados UnidosFil: Gulayin, Pablo Elías. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: He, Jiang. University of Tulane; Estados UnidosFil: Ramirez Zea, Manuel. No especifíca

Resource flows and levels of spending for the response to HIV and AIDS in Belarus

<p>Abstract</p> <p>Background</p> <p>Belarus has a focused HIV epidemic concentrated among injecting drug users, female sex workers and men who have sex with men. However, until 2008, Belarus had no way of evaluating HIV spending priorities. In 2008, Belarus committed to undertaking a comprehensive National AIDS Spending Assessment (NASA) in order to analyze HIV spending priorities. NASA was used to 'follow the money' from the funding sources to agents and providers, and eventually to beneficiary populations.</p> <p>Findings</p> <p>Belarus spent the majority of its funding on prevention, diagnosis and treatment of sexually transmitted infections and on securing the blood supply. International donors and NGOs working within Belarus spent the majority of their funding on preventative activities for high risk groups while Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) solely funded antiretroviral treatment.</p> <p>Conclusions</p> <p>The data and experience obtained through conducting NASA will help build capacity for future resource tracking activities for HIV and other health priorities. This experience established the foundation for enhanced and future consistent quality-reporting of National Health Accounts. Monitoring the flow of resources for Belarus' HIV response provides valuable strategic information that can improve operations and planning as well as mobilize greater resources. NASA offers Belarusian policy makers an overview of HIV activities that merit their priority attention. In addition, the findings from Belarus are particularly relevant for the rest of the Commonwealth of Independent States due to their similar epidemiological profiles and centrally planned systems. The Belarusian government faces future challenges, especially in increasing public investments in HIV prevention for female sex workers and their clients, men who have sex with men, and among intravenous drug users.</p

Desarrollo multidisciplinario en investigación y docencia del centro universitario UAEM Valle de México

DESARROLLO MULTIDISCIPLINARIO EN INVESTIGACIÓN Y DOCENCIA DEL CENTRO UNIVERSITARIO UAEM VALLE DE MÉXICOLa Universidad Autónoma del Estado de México ha evolucionado a través de sus 188 años de historia, dedicada a la educación, la investigación, la cultura y el deporte, como sus grandes ejes rectores, formadora de hombres y mujeres con un alto sentido humanista y ético, contribuyendo a lograr nuevas y mejores formas de existencia y convivencia social. Durante el proceso de desconcentración de la UAEM, se crearon las Unidades Académicas y Centros Universitarios para brindar el servicio de educación a más jóvenes en todo el Estado de México, este Centro Universitario fue uno de los primeros y a sus veinte años de existencia se está consolidando como uno de los mejores. Es en los últimos años que se ha venido impulsando la investigación al contar con cuerpos académicos, en formación y en consolidación, con infraestructura de primera tanto en equipo como en laboratorios especializados, con profesores de tiempo completo que participan en congresos, seminarios y presentan publicaciones en revistas indexadas. Por ello para celebrar esos veinte años de existencia de esta honorable institución, se planeó la compilación de esta obra que es parte del quehacer multidisciplinario en investigación y docencia como parte del Plan de Desarrollo 2013-2017, de esta administración. Esta obra reúne investigaciones tanto de profesores como de alumnos desde las diferentes ramas del saber en las que se inscriben sus siete licenciaturas, Actuaría, Administración, Contaduría, Derecho, Economía, Relaciones Económicas Internacionales e Informática Administrativa, tanto presencial como a distancia, así como sus tres ingenierías, Industrial, en Computación y Sistemas y Comunicaciones, así como gracias a la vinculación y colaboración académico – científica que se tiene con otras instituciones de educación superior a nivel nacional, como el Instituto Tecnológico de Orizaba, la Universidad Autónoma de San Luis Potosí, la Universidad Nacional Autónoma de México, la Universidad Autónoma Metropolitana, Universidad Politécnica de Victoria, el Instituto Politécnico Nacional entre otras. En el capítulo 1 se abordan seis temáticas diferentes de vanguardia en el área de las Ingenierías, en los capítulos 2 y 3 se incluyen temas de interés y gran relevancia en materia de ciencias sociales, política y economía. Se hace extensivo un reconocimiento para todos los que participaron tanto en la revisión de los trabajos, como en la compilación del producto final de este Libro intitulado “Desarrollo Multidisciplinario en Investigación y Docencia del Centro Universitario UAEM Valle de México”

How much can we gain from improved efficiency? An examination of performance of national HIV/AIDS programs and its determinants in low- and middle-income countries

<p>Abstract</p> <p>Background</p> <p>The economic downturn exacerbates the inadequacy of resources for combating the worldwide HIV/AIDS pandemic and amplifies the need to improve the efficiency of HIV/AIDS programs.</p> <p>Methods</p> <p>We used data envelopment analysis (DEA) to evaluate efficiency of national HIV/AIDS programs in transforming funding into services and implemented a Tobit model to identify determinants of the efficiency in 68 low- and middle-income countries. We considered the change from the lowest quartile to the average value of a variable a "notable" increase.</p> <p>Results</p> <p>Overall, the average efficiency in implementing HIV/AIDS programs was moderate (49.8%). Program efficiency varied enormously among countries with means by quartile of efficiency of 13.0%, 36.4%, 54.4% and 96.5%. A country's governance, financing mechanisms, and economic and demographic characteristics influence the program efficiency. For example, if countries achieved a notable increase in "voice and accountability" (e.g., greater participation of civil society in policy making), the efficiency of their HIV/AIDS programs would increase by 40.8%. For countries in the lowest quartile of per capita gross national income (GNI), a notable increase in per capita GNI would increase the efficiency of AIDS programs by 45.0%.</p> <p>Conclusions</p> <p>There may be substantial opportunity for improving the efficiency of AIDS services, by providing more services with existing resources. Actions beyond the health sector could be important factors affecting HIV/AIDS service delivery.</p

Acute retroviral syndrome and high baseline viral load are predictors of rapid HIV progression among untreated Argentinean seroconverters

<p>Abstract</p> <p>Background</p> <p>Diagnosis of primary HIV infection (PHI) has important clinical and public health implications. HAART initiation at this stage remains controversial.</p> <p>Methods</p> <p>Our objective was to identify predictors of disease progression among Argentinean seroconverters during the first year of infection, within a multicentre registry of PHI-patients diagnosed between 1997 and 2008. Cox regression was used to analyze predictors of progression (LT-CD4 < 350 cells/mm³, B, C events or death) at 12 months among untreated patients.</p> <p>Results</p> <p>Among 134 subjects, 74% presented with acute retroviral syndrome (ARS). Seven opportunistic infections (one death), nine B events, and 10 non-AIDS defining serious events were observed. Among the 92 untreated patients, 24 (26%) progressed at 12 months versus three (7%) in the treated group (p = 0.01). The 12-month progression rate among untreated patients with ARS was 34% (95% CI 22.5-46.3) versus 13% (95% CI 1.1-24.7) in asymptomatic patients (p = 0.04). In univariate analysis, ARS, baseline LT-CD4 < 350 cells/mm³, and baseline and six-month viral load (VL) > 100,000 copies/mL were associated with progression. In multivariate analysis, only ARS and baseline VL > 100,000 copies/mL remained independently associated; HR: 8.44 (95% CI 0.97-73.42) and 9.44 (95% CI 1.38-64.68), respectively.</p> <p>Conclusions</p> <p>In Argentina, PHI is associated with significant morbidity. HAART should be considered in PHI patients with ARS and high baseline VL to prevent disease progression.</p

Pattern and levels of spending allocated to HIV prevention programs in low- and middle-income countries

<p>Abstract</p> <p>Background</p> <p>AIDS continues to spread at an estimated 2.6 new million infections per year, making the prevention of HIV transmission a critical public health issue. The dramatic growth in global resources for AIDS has produced a steady scale-up in treatment and care that has not been equally matched by preventive services. This paper is a detailed analysis of how countries are choosing to spend these more limited prevention funds.</p> <p>Methods</p> <p>We analyzed prevention spending in 69 low- and middle-income countries with a variety of epidemic types, using data from national domestic spending reports. Spending information was from public and international sources and was analyzed based on the National AIDS Spending Assessment (NASA) methods and classifications.</p> <p>Results</p> <p>Overall, prevention received 21% of HIV resources compared to 53% of funding allocated to treatment and care. Prevention relies primarily on international donors, who accounted for 65% of all prevention resources and 93% of funding in low-income countries. For the subset of 53 countries that provided detailed spending information, we found that 60% of prevention resources were spent in five areas: communication for social and behavioral change (16%), voluntary counselling and testing (14%), prevention of mother-to-child transmission (13%), blood safety (10%) and condom programs (7%). Only 7% of funding was spent on most-at-risk populations and less than 1% on male circumcision. Spending patterns did not consistently reflect current evidence and the HIV specific transmission context of each country.</p> <p>Conclusions</p> <p>Despite recognition of its importance, countries are not allocating resources in ways that are likely to achieve the greatest impact on prevention across all epidemic types. Within prevention spending itself, a greater share of resources need to be matched with interventions that approximate the specific needs and drivers of each country's epidemic.</p