Accès aux traitements antirétroviraux dans les pays en développement : quelles stratégies de financement ?

BackgroundIn low- and middle-income countries, access to combination antiretroviral therapy for all people living with Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS) in need of treatment is a major public health challenge. The objective of this paper was to provide an overview of the different financing modalities of HIV/AIDS care at the microeconomic level and analysis their advantages and limitations.MethodsA review of the published literature using mainly Medline and Science Direct databases in English and French for the period 1990 to 2008 made it possible to explore different financing strategies for access to combination antiretroviral therapy using as case studies specific countries from different regions: Ivory Coast, Uganda, Senegal and Rwanda for sub-Saharan Africa, Brazil and Haiti in the Latin America/Caribbean region and Thailand for Asia.ResultsIn these settings, direct payment through user fees is the most frequent financing mechanism in place for HIV/AIDS care and treatment, including combination antiretroviral therapy. Nevertheless, other mechanisms are being implemented to improve access to treatment such as community-based health insurance schemes with free care for poor and vulnerable households and public-private partnerships.ConclusionThe type of financing strategy for HIV/AIDS care and treatment depends on the context. As direct payment through user fees limits access to care and does not enable programme sustainability, national and donor agencies are introducing alternative strategies such as community financing system (mutual health organizations, microinsurance, community health funds) and public-private partnership. Finally, access to combination antiretroviral therapy has improved in resource-limited settings; however, there is a need to introduce alternative financial mechanisms to assure long-term universal and equitable access to treatment and care, including combination antiretroviral therapy.     

Access to antiretroviral treatment in developing countries: Which financing strategies are possible?

BackgroundIn low- and middle-income countries, access to combination antiretroviral therapy for all people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in need of treatment is a major public health challenge. The objective of this paper was to provide an overview of the different financing modalities of HIV/AIDS care at the microeconomic level and an analysis of their advantages and limitations.MethodsA review of the published literature using mainly the Medline and Science Direct databases for the 1990–2008 period in English and French made it possible to explore different financing strategies for the access to combination antiretroviral therapy using as case studies specific countries from different regions: Ivory Coast, Uganda, Senegal, and Rwanda for sub-Saharan Africa, Brazil and Haiti in the Latin America/Caribbean region, and Thailand for Asia.ResultsIn these settings, direct payment through user fees is the most frequent financing mechanism in place for HIV/AIDS care and treatment, including combination antiretroviral therapy. Nevertheless, other mechanisms are being implemented to improve access to treatment such as community-based health insurance schemes with free care for the poor and vulnerable households and public–private partnerships.ConclusionThe type of financing strategy for HIV/AIDS care and treatment depends on the context. As direct payment through user fees limits access to care and does not enable program sustainability, national and donor agencies are introducing alternative strategies such as community financing systems (mutual health organizations, micro insurance, community health funds) and public–private partnerships. Finally, access to combination antiretroviral therapy has improved in resource-limited settings; however, there is a need to introduce alternative financial mechanisms to ensure long-term universal and equitable access to treatment and care, including combination antiretroviral therapy.     

The United States government's response to HIV/AIDS today: 'Test and treat' as prevention

Three decades into the HIV/AIDS epidemic, HIV prevention programs have been only partially effective. New prevention tools are providing new reasons for optimism. Effective use of these new tools, including the 'test-and-treat' strategy, will require considerable effort to assure that their potential for prevention is fully realized. Challenges with the test-and-treat strategy are global ones, and include retention in care and adherence to treatment. Worldwide, those with HIV infection become less adherent to antiretroviral therapy over time. Many factors contributing to retention in care and adherence to therapy differ among countries and regions of the world. HIV-infected persons receiving treatment in sub-Saharan Africa have been reported to have higher adherence rates than those receiving treatment on the North American continent; higher health literacy and perception of treatment as a social obligation may enhance adherence to treatment and retention in care. The HIV test-and-treat strategy offers a major step forward when combined with other prevention efforts; we need to consider what additional steps are needed to deliver on the promise of prevention through treatment.     

Illicit drugs, alcohol, and addiction in human immunodeficiency virus

Drug and alcohol use complicate both the prevention and treatment of human immunodeficiency virus (HIV) infection. Substance use is one of the major engines driving HIV transmission, directly, through the sharing of injection drug use equipment and indirectly, through increasing risky sexual behaviors. Drug and alcohol dependence compromise effective HIV treatment by influencing both access and adherence to antiretroviral therapy. Exposure to addictive substances may have direct immunosuppressive effects independent of their impact on access and adherence to treatment. Measures effective at minimizing HIV transmission attributable to drug and alcohol use include HIV testing and referral to treatment, syringe and needle exchange programs, opioid replacement therapy (i.e., methadone and buprenorphine), and behavioral interventions targeting HIV risk behaviors among both HIV-infected and HIV-uninfected people. Measures effective at optimizing HIV treatment among alcohol and drug-dependent patients include HIV testing with referral to treatment and substance use treatment that is linked to or integrated into HIV treatment. Due to the intertwining problems of substance use and HIV infection, physicians and other health care providers must address the issues of illicit drugs and alcohol use as mainstream medical problems in order to provide optimal care for HIV-infected patients.     

AIDS treatment in Africa: the risk of antiretroviral resistance

--In recent years, implementation of antiretroviral therapy in developing countries with a high prevalence of HIV-1 has been recognised as a public health priority. Consequently, the availability ofantiretroviral combination therapy for people with HIV is increasing rapidly in sub-Saharan Africa. --HIV treatment programmes are implemented according to the standardised, simplified public health guidelines developed by the World Health Organization (WHO). --However, the implementation of treatment programmes in Africa is hindered by several factors, including the lack of adequate immunological and virological laboratory monitoring, insufficient support for adherence to therapy, vulnerable health care systems and the use of suboptimal drug combinations. --These suboptimal treatment conditions increase the risk that resistant virus strains will emerge that are less susceptible to standard first-line combination therapy, thus threatening the long-term success of the treatment programmes. --The WHO has initiated HIVResNet, an international expert advisory board that has developed a global strategy for surveillance and prevention of antiretroviral drug resistance. --The Dutch initiative known as 'PharmAccess African studies to evaluate resistance' (PASER) is contributing to this strategy by creating a surveillance network in sub-Saharan Africa.     

Communication strategies to improve HIV treatment adherence

Although antiretroviral therapy has increased the survival of HIV-positive patients, traditional approaches to improving medication adherence have failed consistently. Acknowledging the role of communication in health behavior, we conducted a qualitative study to learn about patients' HIV treatment adherence experiences and to identify which communication strategies might influence adherence. Findings indicate that five constructs--cultural beliefs/language, stigma, cues to action, self-efficacy, and mood state--are potentially modifiable by improved communication. Results will be used to create a direct marketing campaign targeted to HIV-infected patients.     

Adherence to antiretroviral therapy during HIV infection, a multidisciplinary approach

Since HIV infection has become a chronic disease, antiretroviral therapy is now used on a long-term basis. Response to treatment is conditioned by numerous inter-dependent factors, including non-compliance, which can result in failure of the therapeutic regimen. Although compliance is crucial for long-term efficacy of the treatment, it is a dynamic factor, and therefore difficult to evaluate. This literature review proposes a multidisciplinary approach to treatment adherence during HIV infection, and deals with the following questions: how should adherence and non-adherence be defined? How are they correlated to the treatment response? How is adherence measured in trials and cohorts, as well as in clinical practice? By what factors is it influenced? What tools can be implemented to improve adherence? The interaction between adherence and response to antiretroviral therapy requires communication between clinicians, healthcare providers, patients, virologists, pharmacologists, and the companies responsible for developing drugs. The pharmaceutical industry must sustain its efforts to ensure a balance between demands for efficacy and adherence when developing new drugs. And the methods implemented by numerous healthcare teams plead in favour of a dynamic approach to adherence, with the active participation of all.     

高效抗反转录病毒治疗双药简化方案的研究进展

高效抗反转录病毒治疗三联方案是治疗HIV感染的主流,然而,随着治疗人群扩大到所有HIV感染者,以及治疗时间延长,人们对高效、高依从性、低不良反应、低耐药及低治疗成本方案的需求日益增加,双药简化治疗成为个性化治疗的备选方案,一些方案已经被纳入国内外抗病毒治疗指南。本文对近年来双药简化方案的发展进行综述,为临床正确应用该方案提供依据。     

Stigma management intervention to improve antiretroviral therapy adherence: Phase-I test of concept trial,Cape Town South Africa

Combination antiretroviral therapy (cART) has transformed HIV infection from a universally fatal disease to a medically manageable chronic illness. We conducted a Phase-I test of concept intervention trial to examine feasibility and potential efficacy of behavioural self-regulation counselling designed to improve care retention and cART adherence. The intervention was culturally adapted from client-centered evidence–based interventions that are grounded in behavioural self-regulation theory and available in the US. The intervention adaptation included enhancements to directly address HIV stigma and alcohol-related sources of nonadherence. Fifty patients receiving cART in Cape Town, South Africa were randomised to receive either: (a) five weekly cellphone-delivered sessions of stigma and alcohol-enhanced behavioural self-regulation counselling or (b) a contact matched control condition. Participants were baseline assessed and followed for two weeks post-intervention, with 94% of participants retained throughout the study. Participants receiving the intervention significantly improved cART adherence from baseline-to-follow up and improvement was significantly greater than the control condition. Behaviours related to stigma and alcohol use that impede cART adherence were significantly reduced, and there was uptake of adherence improvement strategies. The current study supports the potential efficacy of relatively brief behavioural self-regulation counselling delivered by cellphone in a context of differentiated care in South Africa.     

Access to highly active antiretroviral therapy for injection drug users: adherence, resistance, and death

Injection drug users (IDUs) continue to comprise a major risk group for HIV infection throughout the world and represent the focal population for HIV epidemics in Asia and Eastern Europe/Russia. HIV prevention programs have ranged from HIV testing and counseling, education, behavioral and network interventions, drug abuse treatment, bleach disinfection of needles, needle exchange and expanded syringe access, as well as reducing transition to injection and primary substance abuse prevention. With the advent of highly active antiretroviral therapy (HAART) in 1996, dramatic clinical improvements have been seen. In addition, the treatment's impact on reducing HIV viral load (and therefore transmission by all routes) provides a stronger rationale for an expansion of the focus on prevention to emphasize early identification and treatment of HIV infected individuals. However, treatment of IDUs has many challenges including adherence, resistance and relapse to high risk behaviors, all of which impact issues of access and ultimately effectiveness of potent antiretroviral treatment. A major current challenge in addressing the HIV epidemic revolves around an appropriate approach to HIV treatment for IDUs.     

Communication Strategies to Improve HIV Treatment Adherence

Although antiretroviral therapy has increased the survival of HIV-positive patients, traditional approaches to improving medication adherence have failed consistently. Acknowledging the role of communication in health behavior, we conducted a qualitative study to learn about patients' HIV treatment adherence experiences and to identify which communication strategies might influence adherence. Findings indicate that five constructs – cultural beliefs/language, stigma, cues to action, self-efficacy, and mood state – are potentially modifiable by improved communication. Results will be used to create a direct marketing campaign targeted to HIV-infected patients.     

Socioeconomic Factors in Adherence to HIV Therapy in Low- and Middle-income Countries

It is not clear what effect socioeconomic factors have on adherence to antiretroviral therapy (ART) among patients in low- and middle-income countries.  We performed a systematic review of the association of socioeconomic status (SES) with adherence to treatment of patients with HIV/AIDS in low- and middle-income countries. We searched electronic databases to identify studies concerning SES and HIV/AIDS and collected data on the association between various determinants of SES (income, education, occupation) and adherence to ART in low- and middle-income countries. From 252 potentially-relevant articles initially identified, 62 original studies were reviewed in detail, which contained data evaluating the association between SES and adherence to treatment of patients with HIV/AIDS. Income, level of education, and employment/occupational status were significantly and positively associated with the level of adherence in 15 studies (41.7%), 10 studies (20.4%), and 3 studies (11.1%) respectively out of 36, 49, and 27 studies reviewed. One study for income, four studies for education, and two studies for employment found a negative and significant association with adherence to ART. However, the aforementioned SES determinants were not found to be significantly associated with adherence in relation to 20 income-related (55.6%), 35 education-related (71.4%), 23 employment/occupational status-related (81.5%), and 2 SES-related (100%) studies. The systematic review of the available evidence does not provide conclusive support for the existence of a clear association between SES and adherence to ART among adult patients infected with HIV/AIDS in low- and middle-income countries. There seems to be a positive trend among components of SES (income, education, employment status) and adherence to antiretroviral therapy in many of the reviewed studies.Key words: Antiretroviral therapy, highly active; Education; Employment; Income; Occupations; Social class     

Achieving plasma HIV RNA below the level of detection in clinical practice

Clinical trials have shown that highly active antiretroviral therapy (HAART) reduces plasma HIV RNA below the detection level in up to 90 per cent of patients. To assess the independent predictors that are associated with achieving undetectable plasma HIV RNA in the daily clinical practice, we carried out a retrospective study. Among 106 HIV-infected patients treated with HAART, 63 (59 per cent) achieved undetectable plasma HIV RNA (less than 400 copies/ml) at their last visit. Adherence with HAART (greater than 80 per cent of prescribed dose) was self-reported by 81 patients (76 per cent). Independent predictors of achieving undetectable plasma HIV RNA were: self-reported adherence to therapy (Odds ratio [OR] 11.79, 95 per cent Confidence intervals [CI]: 3.55-33.17, p = 0.0001) and lack of previous antiretroviral therapy (OR: 3.12, 95 per cent CI: 1.09-8.96, p = 0.03). The efficacy of antiretroviral therapy observed in the daily clinical practice was noticeably lower than that reported in clinical trials. Patient adherence with prescribed HAART and lack of previous antiretroviral therapy are important factors related to successful therapy in the real world.     

Directly observed highly active antiretroviral therapy for HIV-infected children in Cambodia

Antiretroviral medications are becoming available for HIV-infected children in resource-limited settings. Maryknoll, an international Catholic charity, provided directly observed antiretroviral therapy to HIV-infected children in Phnom Penh, Cambodia. Child care workers administered generic antiretroviral drugs twice daily to children, ensuring adherence. Treatment began with 117 late-stage HIV-infected children; 22 died of AIDS during the first 6 months. The rest were treated for at least 6 months and showed CD4 count increases comparable to those achieved in US and European children. Staffing cost for this program was approximately US $5 per child per month, or 15% more than the price of the medications. Drug toxicities were uncommon and easily managed. Directly observed antiretroviral therapy appears to be a promising, low-cost strategy for ensuring adherent treatment for HIV-infected children in a resource-limited setting.     

Adherence to HIV combination therapy

The emergence of drug-resistant strains of HIV virus and treatment failure can result from non-adherence to antiretroviral therapy. While non-adherence to therapy is not a new issue or specific to HIV/AIDS, it has received renewed attention because of the complicated combination treatment regimens being prescribed. This paper reviews the relevant background literature on the contributions of social and behavioural science to non-adherence to HIV medications. Data indicating problems with adherence prior to combination therapy are reported. Despite limitations, even self-report assessments have already succeeded in showing that adherence to combination therapy is significantly related to HIV viral load. Recent research data are discussed. Implications of findings for counselling patients to increase their adherence are presented.     

How HIV treatment advances affect the cost-effectiveness of prevention.

OBJECTIVE: The cost-effectiveness of an HIV prevention program depends, in part, on its potential to avert HIV-related medical care costs. Recent advances in antiretroviral therapy have made HIV/AIDS treatment both more effective and more costly, which might make HIV prevention either more or less cost-effective. The objective of the present study was to explicate the relationship between the effectiveness and costs of HIV treatment and the cost-effectiveness of HIV prevention programs. METHODS: A basic analytic framework was used to compare the cost-effectiveness of HIV prevention interventions with respect to different HIV/AIDS medical care scenarios. Algebra was used to calculate a cost-effectiveness threshold that distinguishes prevention programs that become more cost-effective when therapeutic advances simultaneously increase or decrease the cost and effectiveness of treatment from those that become less cost-effective. Recent estimates of the costs and consequences of combination antiretroviral therapy were used to illustrate the calculation method. RESULTS: The advent of combination antiretroviral therapies for HIV has increased the cost-effectiveness of some, but not all, HIV prevention interventions. CONCLUSIONS: Whether a particular prevention program becomes more or less cost-effective as a consequence of advancements in the medical treatment of HIV/AIDS depends upon the specific characteristics of both the program and the therapy.     

Highly active antiretroviral therapy and tuberculosis control in Africa: synergies and potential

HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) and TB (tuberculosis) are two of the world's major pandemics, the brunt of which falls on sub-Saharan Africa. Efforts aimed at controlling HIV/AIDS have largely focused on prevention, little attention having been paid to care. Work on TB control has concentrated on case detection and treatment. HIV infection has complicated the control of tuberculosis. There is unlikely to be a decline in the number of cases of TB unless additional strategies are developed to control both this disease and HIV simultaneously. Such strategies would include active case-finding in situations where TB transmission is high, the provision of a package of care for HIV-related illness, and the application of highly active antiretroviral therapy. The latter is likely to have the greatest impact, but for this therapy to become more accessible in Africa the drugs would have to be made available through international support and a programme structure would have to be developed for its administration. It could be delivered by means of a structure based on the five-point strategy called DOTS, which has been adopted for TB control. However, it may be unrealistic to give TB control programmes the responsibility for running such a programme. A better approach might be to deliver highly active antiretroviral therapy within a comprehensive HIV/AIDS management strategy complementing the preventive work already being undertaken by AIDS control programmes. TB programmes could contribute towards the development and implementation of this strategy.