Tuberculosis, HIV disease, and directly observed therapy.

Directly observed therapy (DOT) to enable completion of antituberculous therapy works. DOT is largely responsible for the recent improvement in tuberculosis case rates in New York City. Despite this favorable trend, the factors of significant HIV disease rates and of multidrug resistant forms of tuberculosis bacteria in the population are of grave concern. Therefore, in addition to DOT other means of preventing tuberculosis spread should be encouraged. These include directly observed preventive therapy (DOPT) programs, use of masks, improved ventilation in crowded settings such as homeless shelters, and ultraviolet light germicidal irradiation of upper room air in such locations.     

A systematic review of task- shifting for HIV treatment and care in Africa

Background  

Shortages of human resources for health (HRH) have severely hampered the rollout of antiretroviral therapy (ART) in sub-Saharan Africa. Current rollout models are hospital- and physician-intensive. Task shifting, or delegating tasks performed by physicians to staff with lower-level qualifications, is considered a means of expanding rollout in resource-poor or HRH-limited settings.     

2002 — 2014年中国免费艾滋病抗病毒治疗进展

  目的  分析成都市2008 — 2018年抗病毒治疗（ART）的艾滋病病毒感染者/艾滋病病人（HIV/AIDS）病毒学失败率及影响因素。  方法  采用回顾性队列研究方法,利用国家艾滋病综合防治信息系统选取成都市2008年1月1日 — 2017年12月31日开始ART的病例信息,随访时间截至2018年12月31日。采用Cox比例风险模型分析病毒学失败的影响因素。  结果  共纳入19 945例HIV/AIDS,病毒学失败率为4.45/100人年。多因素Cox分析结果显示,治疗前基线CD₄ ⁺ T淋巴细胞计数（CD₄）为0～、50～、200～349个/μL组HIV/AIDS病毒学失败的风险是CD₄ ≥ 500个/μL组的11.908（95 % CI = 9.838～14.412）、2.824（95 % CI = 2.484～3.212）和1.586（95 % CI = 1.420～1.771）倍。确证到治疗间隔 ≤ 30 d、31～365 d组病毒学失败的风险是 ≥ 366 d组的0.829（95 % CI = 0.734～0.935）和0.840（95 % CI = 0.755～0.934）倍。男性HIV/AIDS病毒学失败的风险是女性的1.216（95 % CI = 1.090～1.356）倍,含齐多夫定初始治疗方案组病毒学失败的风险是含替诺福韦治疗方案组的1.272（95 % CI = 1.153～1.402）倍。  结论  成都市HIV/AIDS治疗病毒学失败的危险因素包括治疗前基线CD₄水平较低,确证后启动ART时间间隔较长、男性、含齐多夫定的初始治疗方案。     

Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HCSUS Consortium. HIV Cost and Services Utilization Study

OBJECTIVE: To employ the behavioral model of health services use in examining the extent to which predisposing, enabling, and need factors explain the treatment of the HIV-positive population in the United States with highly active antiretroviral therapy (HAART). DATA SOURCE: A national probability sample of 2,776 adults under treatment for human immunodeficiency virus (HIV) infection. STUDY DESIGN: The article uses data from the baseline and six-month follow-up surveys. The key independent variables describe vulnerable population groups including women, drug users, ethnic minorities, and the less educated. The dependent variable is whether or not a respondent received HAART by December 1996. DATA COLLECTION: All interviews were conducted using computer-assisted personal interview instruments designed for this study. Ninety-two percent of the baseline interviews were conducted in person and the remainder over the telephone. PRINCIPAL FINDINGS: A multistage logit regression shows that the predisposing factors that have previously described vulnerable groups in the general population with limited access to medical care also define HIV-positive groups who are less likely to gain early access to HAART including women, injection drug users, African Americans, and the least educated (odds ratios, controlling for need, ranged from 0.35 to 0.59). CONCLUSIONS: Those HIV-positive persons with the greatest need (defined by a low CD4 count) are most likely to have early access to HAART, which suggests equitable access. However, some predisposing and enabling variables continue to be important as well, suggesting inequitable access, especially for African Americans and lower-income groups. Policymakers and clinicians need to be sensitized to the continued problems of African Americans and other vulnerable populations in gaining access to such potentially beneficial therapies. Higher income, anonymous test sites, and same-day appointments are important enabling resources.     

HIV epidemic and human rights among men who have sex with men in sub-Saharan Africa: Implications for HIV prevention,care, and surveillance

Recent research has presented evidence that men who have sex with men (MSM) bear a disproportionate burden of HIV and are at increased risk for HIV in sub-Saharan Africa (SSA). However, many countries in SSA have failed to address the needs of MSM in national HIV/AIDS programmes. Furthermore, many MSM face structural barriers to HIV prevention and care, the most significant of which include laws that criminalise male-to-male sexual contact and facilitate stigma and discrimination. This in turn increases the vulnerability of MSM to acquiring HIV and presents barriers to HIV prevention, care, and surveillance. This relationship illustrates the link between human rights, social justice, and health outcomes and presents considerable challenges to addressing the HIV epidemic among MSM in SSA. The response to the HIV epidemic in SSA requires a non-discriminatory human rights approach to all at-risk groups, including MSM. Existing international human rights treaties, to which many SSA countries are signatories, and a ‘health in all policies’ approach provides a strong basis to reduce structural barriers to HIV prevention, care, surveillance, and research, and to ensure that all populations in SSA, including MSM, have access to the full range of rights that help ensure equal opportunities for health and wellness.     

Commentary: Early antiretroviral therapy for HIV infection in sub-Saharan Africa, a challenging new step

Recent changes in guidelines (World Health Organization (WHO), USA, and likely Europe soon) all move towards earlier initiation of antiretroviral therapy in asymptomatic patients infected with human immunodeficiency virus (HIV). Sonia Menon appropriately questions the feasibility and consequences at both individual and community levels of the early initiation of antiretroviral therapy in sub-Saharan Africa as likely effects will be both positive and negative. Local context should drive the uptake process in every country. Money, national and international, will be essential for the successful implementation of the new WHO recommendation. Leaders at both levels must take their responsibilities and mobilize the necessary resources, for example, doubling those for the Global Fund to Fight AIDS, Tuberculosis and Malaria from $10 billion to $20 billion USD for 2011-2013.     

Engendering care: HIV,humanitarian assistance in Africa and the reproduction of gender stereotypes

This paper draws upon recent research in Durban, South Africa to unravel the complexities of care ethics in the context of humanitarian aid. It investigates how the gendering of care shapes the provision of aid in the context of the HIV in Africa constructing an image of ‘virile’ and ‘violent’ African masculinity. Humanitarian organisations construct imagined relations of caring, invoking notions of a shared humanity as informing the imperative to facilitate change. This paper draws on varied examples of research and NGO activity to illustrate how these relations of care are strongly gendered. Humanitarian interventions that invoke universalising conceptions of need could instead draw on feminist care ethics that seeks to balance rights, justice and care in ways that attend to the webs of relationships through which specific lived realities are shaped. Essentialising feminised discourses on care result in a skewed analysis of international crises that invariably construct women (and children) as victims in need of care, which at best ignore the lived experiences of men and, at worst, cast men as virile and violent vectors of disease and social disorder.     

抗逆转录病毒治疗用于男男性行为人群艾滋病病毒暴露前预防

全球HIV新发感染的形势依然严峻,男男性行为人群是HIV感染的高危人群。传统的行为干预策略未能有效遏制艾滋病的流行,当前迫切需要新的预防策略来控制艾滋病的传播。作为一种新型生物干预策略,暴露前预防（PrEP）在一定程度上可以降低男男性行为人群HIV感染的风险。此文就抗逆转录病毒治疗用于男男性行为人群HIV暴露前预防的现况、知晓情况、可接受性及存在的问题作一综述。     

Relationship between ambulatory care accessibility and hospitalization for persons with advanced HIV disease.

Specific features of ambulatory care, such as accessibility, may influence hospital use for patients with HIV infection. To identify clinic features associated with a lower risk of hospitalization, 6,280 New York state Medicaid enrollees diagnosed with AIDS in 1987-1992 and managed by one of 157 surveyed clinics were studied. The odds of hospitalization in the year before AIDS diagnosis were associated with five clinic features that facilitate the accessibility of care: (1) evening/weekend hours, (2) case manager, (3) appointments within 48 hours, (4) telephone consultation, and (5) whether the clinic handled urgent care. Hospitalization in the year before AIDS diagnosis occurred for 49 percent of patients. Three of the five accessibility features had unadjusted associations with lower hospitalization rates. The adjusted odds of hospitalization were lower for patients in clinics with extended hours (OR = 0.77, 95% CI = 0.63, 0.93) and for patients in clinics with four or more accessibility features compared with those in clinics with less than two features (OR = 0.67; 95% CI = 0.50, 0.89).     

Outcomes of isoniazid prophylaxis among HIV-infected children attending routine HIV care in Kenya

Setting:

Three human immunodeficiency virus (HIV) care clinics in Eastern Province, Kenya.

Objectives:

To establish rates of treatment completion, loss to follow-up, adverse drug reactions, tuberculosis (TB) disease and mortality among 606 HIV-infected children during 6 months of isoniazid preventive therapy (IPT).

Design:

Retrospective record review.

Results:

Of 606 HIV-infected children started on IPT, 556 (91.7%) successfully completed treatment, while 20 (3.3%) completed with interruptions. Cumulatively, 30 children (4.9%) did not complete IPT: 4 (0.7%) were lost to follow-up, 4 (0.7%) discontinued because of treatment interruptions, 2 (0.3%) developed adverse drug reactions, 1 developed a chronic cough, 1 was transferred to a non-IPT facility and 18 (3%) developed TB, including 2 who eventually died. TB disease was diagnosed in a median of 3 weeks (interquartile range [IQR] 2–16) post-IPT initiation. The median CD4 cell count for those aged 1–4 years who developed TB disease was 1023 cells/mm³ (IQR 375–1432), while for those aged 5–14 years it was 149 cells/mm³ (IQR 16–332). Isoniazid resistance was not detected in the four culture-confirmed TB cases.

Conclusion:

The high treatment completion, low loss to follow-up rate and few adverse drug reactions affirm the feasibility of IPT provision to children in HIV care clinics.