(ARV-) Free State? The moratorium’s threat to patients’ adherence and the development of drug-resistant HIV

Despite early fears that people living with HIV (PLWHs) in Africa would not be able to adhere to antiretrovirals (ARVs).1, 2 Research has shown that the proportion of PLWH reporting ≥95% adherence in sub-Saharan Africa is higher than in North America.3 However, maintaining adherence is a complex phenomenon and different ecological factors affect patient ability to access and adhere to ARVs: patient characteristics and context, ARV line regimen, clinical situation and the patient-health staff relationship. 4 In October 2008, the new minister of health announced that 550,000 PLWHs were on ARVs in South Africa, which is the highest number in the world.5 This achievement was recently tarnished by increasing alarm over the Free State public sector ARV programme. The Free State has the third highest HIV prevalence in the country (31%) 6. Since December 2008, the department of health has stopped initiating new patients on ARVs 7 because of drug stock-out and lack of funds. It is estimated that in this province 30 PLWHs are dying every day the moratorium continues.8While it is clear that this moratorium will increase morbidity and mortality, the loss of trust in the health system and the potential impact of the ARVs crisis on existing patient adherence should also be considered. Campero et.al. reported that patients already on ARVs share their medication with neighbors, relatives and/or friends who are delayed to start on ARVs 9. This practice could lead to drug resistance development in both people sharing the medication if they will have differential exposure to ARVs, 10-13 and on a public health level, raises serious concerns about drug failure, subsequent more expensive drug regimens and the spread of drug resistant strains of HIV. Patients’ perceptions of staff attitudes and waiting time were reported to be key factors for patients’ ARV adherence. 14 It is plausible that PLWHs will seek care in other provinces, and would consequently be required to return to outlying clinics on a monthly basis to pick-up their ARVs. Transport costs and the time needed to reach clinics are risk factors to both adherence and retention in care.15, 16 Patients currently on treatment – in the Free State and elsewhere - are understandably anxious about the health system’s ability to guarantee life-long access to ARVs. It was shown estimated that 300 000 people had died of AIDS in a preventable manner if the South African government had only responded to the AIDS crisis quickly in a coherent manner. 17 How the government now contains and repairs the damage being done in the Free State will be a litmus test for the long-term success of South Africa’s ARV programme. References 1. Moatti JP, Spire B, Kazatchkine M. Drug resistance and adherence to HIV/AIDS antiretroviral treatment: against a double standard between the north and the south. Aids 2004;18 Suppl 3:S55-61. 2. Check E. Staying the course. Nature 2006;442:617-9. 3. Mills EJ, Nachega JB, Buchan I, et al. Adherence to Antiretroviral Therapy in Sub-Saharan Africa and North America. JAMA 2006;296:679-90. 4. Bangsberg DR, Ware N, Simoni JM. Adherence without access to antiretroviral therapy in sub-Saharan Africa? AIDS 2006;20:140-1. 5. Media room - Departmenf of health - South Africa. Speech by the minister of health Ms. Barbara Hogan at the HIV vaccine research conference (http://www.doh.gov.za/docs/sp/sp1013-f.html). In: Vaccine research conference; 2008; Cape Town Oct.13-16; 2008. 6. Department of Health - Pretoria - South Africa. National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa 2006; 2007. 7. ART crisis - Free State province, Dec. 2008 (http://www.sahivsoc.org). 2009. (Accessed March 18, 2009, at 8. Thom A. 30 dying every day in the Free State - HIV Clinicians (http://www.health-e.org.za/news/article.php?uid=20032192). Health-e 2009 Feb. 19. 9. Campero L, Herrera C, Kendall T, Caballero M. Bridging the gap between antiretroviral access and adherence in Mexico. Qualitative Health Research 2007;17:599-611. 10. Bangsberg DR. Preventing HIV antiretroviral resistance through better monitoring of treatment adherence. JID 2008;197:S272-S8. 11. Bangsberg DR, Acosta EP, Gupta R, et al. Adherence-resistance relationships for protease and non-nucleoside reverse transcriptase inhibitors explained by virological fitness. AIDS 2006;20:223-31. 12. Boulle A, Ford N. Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges? Sex Transm Inf 2007;83:503-5. 13. Gardner EM, Sharma S, Peng G, et al. Differential adherence to combination antiretroviral therapy is associated with virological failure with resistance. AIDS 2008;22:75-82. 14. Dahab M, Charalambous S, Hamilton R, et al. "That is why I stopped the ART": Patients' & providers' perspectives on barriers to and enablers of HIV treatment adherence in a South African workplace programme. BMC Public Health 2008;8:doi:10.1186/471-2458-8-63. 15. Murray LK, Semrau K, McCurley E, et al. Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: a qualitative study. AIDS Care 2009;21:78-86. 16. Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation Costs Impede Sustained Adherence and Access to HAART in a Clinic Population in Southwestern Uganda: A Qualitative Study. AIDS Behav 2009. 17. Chigwedere P, Seage GR, 3rd, Gruskin S, Lee TH, Essex M. Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa. J Acquir Immune Defic Syndr 2008

Syrian refugees, between rocky crisis in Syria and hard inaccessibility to healthcare services in Lebanon and Jordan

Around 3% of the world’s population (n = 214 million people) has crossed international borders for various reasons. Since March 2011, Syria has been going through state of political crisis and instability resulting in an exodus of Syrians to neighbouring countries. More than 1 million Syrian refugees are residents of Lebanon, Jordan, Turkey, Egypt and North Africa. The international community must step up efforts to support Syrian refugees and their host governments

Ecological study of road traffic injuries in the eastern Mediterranean region: country economic level, road user category and gender perspectives

Background: The Eastern Mediterranean region has the second highest number of road traffic injury mortality rates after the African region based on 2013 data, with road traffic injuries accounting for 27% of the total injury mortality in the region. Globally the number of road traffic deaths has plateaued despite an increase in motorization, but it is uncertain whether this applies to the Region. This study investigated the regional trends in both road traffic injury mortality and morbidity and examined country-based differences considering on income level, categories of road users, and gender distribution. Methods: Register-based ecological study linking data from Global Burden of Disease Study with the United Nations Statistics Division for population and World Bank definition for country income level. Road traffic injury mortality rates and disability-adjusted life years were compiled for all ages at country level in 1995, 2005, 2015 and combined for a regional average (n = 22) and a global average (n = 122). The data were stratified by country economic level, road user category and gender. Results: Road traffic injury mortality rates in the Region were higher than the global average for all three reference years but suggest a downward trend. In 2015 mortality rates were more than twice as high in low and high income countries compared to global income averages and motor vehicle occupants had a 3-fold greater mortality than the global average. Severe injuries decreased by more than half for high/middle income countries but remained high for low income countries; three times higher for males than females. Conclusion: Despite a potential downward trend, inequalities in road traffic injury mortality and morbidity burden remain high in the Eastern Mediterranean region. Action needs to be intensified and targeted to implement and enforce safety measures that prevent and mitigate severe motor vehicle crashes in high income countries especially and invest in efforts to promote public, active transport for vulnerable road users in the resource poor countries of the Region.Institute for Social and Health Studies (ISHS

The impact of educational camp on glycemic control of Rwandan type 1 diabetes youth

In Rwanda, the prevalence of known type 1 diabetes mellitus in seven  districts of the country is 16.4 per 100,000 in young adults under 25 years old. The objective of this study was to compare the glycemic control of type 1 diabetes youth before and after the diabetes camp in Rwanda. A quasi experimental design using a longitudinal approach to compare the glycemic control before and after camp was used; 97 type 1 diabetes youth of both sexes, average age of 21 years were assigned into 8 groups and every group attended 5 days of diabetes education at the camp. Medical records about glycated hemoglobin levels before and 3 months after the camp were extracted from the database of Rwanda Diabetes Association and were analyzed to identify the impact of the educational camp. The mean  difference between the glycemic control before and 3 months after the camp revealed a statistically  significant decrease of 2.1% HbA1c (P-value = 0.02). As conclusion, this study found that diabetes educational camp is an effective strategy to improve Rwandan type 1 diabetes youth’s glycemic control. ________________________________________________________________________Key words: Rwanda, type 1 diabetes, youth, camp, glycemic contro