Intensive home haemodialysis: benefits and barriers

Accumulating evidence of the benefits of intensive home haemodialysis has led to increased international interest in this modality as a viable option for renal replacement therapy. Until the late 1970s, haemodialysis was primarily performed at home; however, the development of in-centre and satellite dialysis units and the advent of peritoneal dialysis led to decreased numbers of patients being managed by home haemodialysis. Over the past decade, a move towards once again providing and supporting haemodialysis at home has emerged, due to a desire to offer a more convenient form of dialysis for the patient in a more cost-effective manner. This shift has generated clinical evidence indicating benefits both from receiving haemodialysis at home, and from the option to provide intensive dialysis treatment in this setting. With the development of new home haemodialysis programs, specific patient-related, physician-related and cost-related barriers to their introduction have been encountered, including patient fear of self-cannulation and lack of expert medical knowledge in the area. This Review discusses the benefits and barriers associated with intensive home haemodialysis.     

African American Women,AIDS, and Resiliency

ABSTRACT

Ongoing shifts in the populations affected by the AIDS epidemic are reflected in the increasing proportion of AIDS cases in women-particularly women of color. While African American women represent approximately 13% of the U.S. female population, in 2000, 63% of all reported AIDS cases in women in the United States were among African American/non-Hispanic women. Despite these statistics, relatively few studies in the area of HIV research target African American women exclusively. As part of a larger study, we asked 105 African American women to describe in their own words how their lives have changed since becoming HIV positive. Despite multiple past and current stressors, the majority of participants provided responses that were decidedly positive. Clinical implications as well as future research directions based on these findings are discussed.     

Human immunodeficiency virus infection, AIDS, and smoking cessation: the time is now.

Treatments for persons who are infected with human immunodeficiency virus (HIV) or who have developed AIDS have advanced to the point where death is no longer the inevitable outcome of diagnosis. Combination antiretroviral therapy has made HIV infection less of a terminal condition and more of a medically manageable chronic disease. Thus, efforts to improve the health status and quality of life of HIV-infected persons have become one of the highest treatment priorities for the next decade. Cigarette smoking is highly prevalent among HIV-infected persons, and quitting smoking would greatly improve the health status of these individuals. However, to date, no studies have evaluated the efficacy of a smoking-cessation intervention specifically tailored to this population. This article reviews the evidence and rationale for advancing smoking-cessation treatments specifically tailored to the needs of HIV-infected persons and provides recommendations for future treatment studies.     

Women in Chinsapo,Malawi: vulnerability and risk to HIV/AIDS

Malawi, a very poor country located in southern Africa, is no exception to the growing trend and severity in HIV prevalence. By the end of 2003 there were 900 000 adults and children in Malawi living with HIV/AIDS. Adult prevalence was estimated to be 15%, which is higher than the 7.1% average rate for sub-Saharan Africa. In order to understand the spread of HIV/AIDS it is imperative to address the economic, social, cultural, and political issues that impact on women's contraction and spread of the virus. We do so in this paper by critically examining the gendered context of HIV/AIDS with reference to Malawi. The theoretical framework for this research focuses on poverty, gender relations, regional migration patterns, and global economic changes which place women in highly vulnerable situations. The study was conducted in a low-income area in Lilongwe, the capital city of Malawi. In 2003 and 2004, 60 randomly selected women who lived in a low socioeconomic residential area completed a structured interview on issues concerning individual economic situations, marriage history, fertility, family planning and social networks, gender, sexual partnerships, and HIV/AIDS. Focus group interviews were also conducted with an additional 20 women. The results of our study indicate that the rising epidemic among women in Malawi is firstly driven by poverty which limits their options. Secondly, gender inequality and asymmetrical sexual relations are basic to spreading HIV/AIDS among women. Thirdly, in spite of their awareness through media and health care professionals, women are unable to protect themselves, which further increases their vulnerability.     

A moment in time: AIDS and business

Business has transformed the planet. But this gives it new responsibilities. People now expect business leaders to lead--and not just respond when things go wrong. HIV/AIDS is a global problem, with over 16.3 million people now thought to have died of the disease (Global Summary of HIV/AIDS Epidemic, UNAIDS, December 1999). Without action now, the pandemic will worsen, health services will come under relentless pressure and the number of people dying will increase exponentially. So why should business sit up and take notice? First: money. AIDS is slowly strangling many businesses and economies--and in a global market, everyone eventually suffers. Without profit, there is no business--so the business community needs to act to protect its bottom line. Second: people. Over 80% of those dying are in their 20s, 30s, and 40s. Businesses are losing workers and customers, and human networks that have taken decades to build. Third: imagination. Business is inventive, creative and fast-moving. It has the opportunity to use these strengths for the benefit of the wider community. It's time to pit business ideas (and some money, too) against the threat of AIDS. The course of the AIDS epidemic is not inevitable. The world's businesses have the skills and intensity to make a measurable difference, especially if they find public sector and NGO partners with whom they share a vision. A focused, coordinated, results-driven effort will hit AIDS hard. The HIV virus moves fast (and is mutating all the time). Business has the opportunity to make a difference. It must grasp this opportunity. And grasp if fast.     

Gender and AIDS: time to act

Gender has long been recognized as being key to understanding and addressing HIV and AIDS. Gender roles and relations that structure and legitimate women's subordination and simultaneously foster models of masculinity that justify and reproduce men's dominance over women exacerbate the spread and impact of the epidemic. Notions of masculinity prevalent in many parts of the world that equate being a man with dominance over women, sexual conquest and risk-taking are associated with less condom use, more sexually transmitted infections, more partners, including more casual partners, more frequent sex, more abuse of alcohol and more transactional sex. They also contribute to men accessing treatment later than women and at greater cost to public health systems. The imperative of addressing the gender dimensions of AIDS has been clearly and repeatedly articulated. Many interventions have been shown to be effective in addressing gender-related risks and vulnerabilities including programmes designed to reach and engage men, improve women's legal and economic position, integrate gender-based violence prevention into HIV services, and increase girls' access to secondary and tertiary education. Despite this, the political will to act has been sorely lacking and not nearly enough has been done to hold governments and multilateral institutions to account. This paper argues that we can no longer simply pay lip service to the urgent need to act on what we know about gender and AIDS. Simply put, it is time to act.     

Multiple barriers prevent minorities' early treatment. AIDS stigma, lack of transportation top list

The most recent statistics show that HIV is the leading cause of death for young African-Americans and the third leading cause of death for both African-Americans and Latinos in the 35-44 age group. A Centers for Disease Control and Prevention study found that African-Americans and Latinos were more likely to be tested late for HIV than were whites. In addition, previous research has shown that HIV-infected African-Americans and Latinos are more likely to be uninsured, to have not received antiretroviral drugs, to lack transportation for visiting doctors, and to have had recent hospitalizations.     

Women in treatment: changing over time

The early 1970s marked the transition of experimentation with illicit drugs from a deviant behavior to a normative behavior among adolescents in the United States as well as the resurgence of the feminist movement in this country. A sample of 572 women from 21 treatment centers in 11 states was divided into two groups--age 35 and over, and under 35--to roughly correspond to whether they had reached adulthood before or after these cultural shifts. Younger and older women exhibit significant differences with respect to substance use patterns and prevalence of eating disorders, childhood antisocial behaviors, suicide attempts, and abuse by boyfriends and spouses.     

The survival benefits of AIDS treatment in the United States

BACKGROUND: As widespread adoption of potent combination antiretroviral therapy (ART) reaches its tenth year, our objective was to quantify the cumulative survival benefits of acquired immunodeficiency syndrome (AIDS) care in the United States. METHODS: We defined eras corresponding to advances in standards of human immunodeficiency virus (HIV) disease care, including opportunistic infection prophylaxis, treatment with ART, and the prevention of mother-to-child transmission (pMTCT) of HIV. Per-person survival benefits for each era were determined using a mathematical simulation model. Published estimates provided the number of adult patients with new diagnoses of AIDS who were receiving care in the United States from 1989 to 2003. RESULTS: Compared with survival associated with untreated HIV disease, per-person survival increased 0.26 years with Pneumocystis jiroveci pneumonia prophylaxis alone. Four eras of increasingly effective ART in addition to prophylaxis resulted in per-person survival increases of 7.81, 11.05, 11.57, and 13.33 years, compared with the absence of treatment. Treatment for patients with AIDS in care in the United States since 1989 yielded a total survival benefit of 2.8 million years. pMTCT averted nearly 2900 infant infections, equivalent to 137,000 additional years of survival benefit. CONCLUSIONS: At least 3.0 million years of life have been saved in the United States as a direct result of care of patients with AIDS, highlighting the significant advances made in HIV disease treatment.     

HIV/AIDS in Women and Racial/Ethnic Minorities in the U.S.

The clinical issues affecting women with HIV/AIDS differ little from those affecting men. However, current research shows that treatment and outcome disparities affect many women with HIV, hypothesized to result from a complex interplay of socioeconomic and gender role influences. These disparities are also a reflection of racial/ethnic differences in treatment and outcome, since 80% of women with HIV/AIDS are black or Hispanic. Women have unique needs for HIV prevention — both prevention of sexual transmission to or from sexual partners and prevention of perinatal transmission. Racial/ethnic minorities continue to be disproportionately affected by the HIV/AIDS epidemic in the U.S. Minorities are less likely to be in care and on HAART than others with HIV/AIDS. These disparities result in poorer outcomes for minorities, especially blacks, with HIV/AIDS. New strategies for optimizing engagement and retention in care, and for prevention hold great promise for women and minorities with HIV in the U.S.     

State TB and AIDS officials knock down barriers

Officials at the Centers for Disease Control and Prevention (CDC) are using Connecticut as a model for how AIDS and tuberculosis (TB) control programs share information. The two registries have been sharing information since 1986 and find that the match helps both programs monitor recent infection trends and target screening efforts. The law in Connecticut assures that providers will report the HIV status of TB patients and increase the chances that the patients receive proper treatment. By making latent TB a reportable condition in HIV-positive patients, officials also are able to offer preventive therapy and directly observed therapy (DOT) to patients who otherwise may develop active TB. Many civil rights groups have opposed sharing HIV or AIDS reporting with other health agencies because of potential breaches in confidentiality. Although the public health need for identifying co-infection cases is easily justified, confidentiality issues are politically sensitive. In urging TB and AIDS programs to create methods for facilitating detection of co-infection cases, the CDC used a co-infection survey of Chicago. Chicago has a confidentiality law prohibiting the direct reporting of co-infected people to the TB control program. However, the city health department has recently required cases to be reported to both the TB and AIDS registries, facilitating investigation and preventive therapy to contacts.     

Re-focusing the Gender Lens: Caregiving Women,Family Roles and HIV/AIDS Vulnerability in Lesotho

Gender and HIV risk have been widely examined in southern Africa, generally with a focus on dynamics within sexual relationships. Yet the social construction of women’s lives reflects their broader engagement with a gendered social system, which influences both individual-level risks and social and economic vulnerabilities to HIV/AIDS. Using qualitative data from Lesotho, we examine women’s lived experiences of gender, family and HIV/AIDS through three domains: (1) marriage; (2) kinship and social motherhood, and (3) multigenerational dynamics. These data illustrate how women caregivers negotiate their roles as wives, mothers, and household heads, serving as the linchpins of a gendered family system that both affects, and is affected by, the HIV/AIDS epidemic. HIV/AIDS interventions are unlikely to succeed without attention to the larger context of women’s lives, namely their kinship, caregiving, and family responsibilities, as it is the family and kinship system in which gender, economic vulnerability and HIV risk are embedded.     

Increasing survival time after AIDS in Italy: the role of new combination antiretroviral therapies. Tuscany AIDS Study Group

BACKGROUND: In Italy, antiretroviral combination therapy was adopted in mid-1995 and protease inhibitors in mid-1996. OBJECTIVE: To conduct a prospective, population-based, observational study to evaluate the effect of these therapies on the survival of persons with AIDS (PWA). METHODS: PWA living in the Tuscany region diagnosed between 1985 and 31 March 1997 (National AIDS Registry) were studied. Information on antiretroviral drugs, prophylactic treatment, CD4 cell count, and AIDS-defining illnesses was collected for PWA still alive at 1 January 1996 and those diagnosed thereafter (analysis cut-off date, 30 November 1997). Kaplan-Meier curves were calculated by year of diagnosis. A Cox model was then used to estimate the adjusted (by sex, age, HIV exposure category, CD4 cell count, type and number of AIDS-defining illnesses) relative hazard (RH) of death by year of diagnosis and calendar date (considered as a time-dependent variable). Similar analyses were repeated for PWA diagnosed after 1989, having been stratified by disease-specific AIDS condition. A final analysis was performed for PWA still alive at 1 January 1996 or diagnosed thereafter for estimating the effect of single, double and triple combination therapy (time-dependent variables), having adjusted for the above variables and for prophylactic treatment. RESULTS: A total of 1683 (79.5%) out of 2118 PWA died before 1 December 1997. Use of more potent combination therapies, including protease inhibitors, greatly increased during 1997. Median survival was 2.9, 12.3, 13.4, 11.4 and 17.6 months for diagnoses before 1987, in 1987-1990, 1991-1993, 1994 and 1995, respectively; an estimated 62% of those diagnosed in 1996-1997 had survived 15 months after diagnosis. The Cox model showed a trend of decrease of RH for calendar time starting in the first half of 1996, compared with 1994. When stratifying by specific AIDS-defining disease there was no statistically significant evidence that the improved overall survival was due to increased survival only for certain diseases. The final multivariate analysis for the 771 PWA still alive at 1 January 1996 or diagnosed thereafter estimated significant RH < 1.0 for double and triple therapy (RH, 0.61 and 0.36, respectively) compared with no therapy. CONCLUSIONS: A significant reduction in risk of death after AIDS was observed from the second half of 1996, apparently due to the widespread use of antiretroviral combination therapies.