Game changers: why did the scale-up of HIV treatment work despite weak health systems?

Game changers are radical innovations that result in fundamental and durable changes. The global HIV program scale-up witnessed over the past decade has included some innovations that are not well appreciated. The willingness to rapidly adopt and implement innovations, the flexibility and speed of program implementation, and the readiness to re-examine professional roles are just a few of such game changers.

Availability of nutritional support services in HIV care and treatment sites in sub-Saharan African countries.

Objective: To examine the availability of nutritional support services in HIV care and treatment sites across sub-Saharan Africa.

Design: In 2008, we conducted a cross-sectional survey of sites providing antiretroviral therapy (ART) in nine sub-Saharan African countries. Outcomes included availability of: (i) nutritional counselling; (ii) micronutrient supplementation; (iii) treatment for severe malnutrition; and (iv) food rations.

Microfluidics-based diagnostics of infectious diseases in the developing world.

One of the great challenges in science and engineering today is to develop technologies to improve the health of people in the poorest regions of the world. Here we integrated new procedures for manufacturing, fluid handling and signal detection in microfluidics into a single, easy-to-use point-of-care (POC) assay that faithfully replicates all steps of ELISA, at a lower total material cost. We performed this 'mChip' assay in Rwanda on hundreds of locally collected human samples.

Program-level and contextual-level determinants of low-median CD4+ cell count in cohorts of persons initiating ART in eight sub-Saharan African countries.

Objective: In sub-Saharan Africa, many patients initiate antiretroviral therapy (ART) at CD4 cell counts much lower than those recommended in national guidelines. We examined program-level and contextual-level factors associated with low median CD4 cell count at ART initiation in populations initiating ART.

Design: Multilevel analysis of aggregate and program-level service delivery data.

Patients enrolled in HIV care in Mozambique: baseline characteristics and follow-up outcomes.

Objective: To utilize routinely collected service delivery data from HIV care and treatment clinics in Mozambique to describe the patient population and programmatic outcomes from 2003 to 2009.

Methods: Data from patient charts were entered into an electronic database at 28 clinics in 5 Mozambican provinces. Patients' characteristics at enrollment in HIV care and at antiretroviral therapy (ART) initiation were examined.

Elevated triglycerides and risk of myocardial infarction in HIV-positive persons.

Objectives: To explore the relationship between elevated triglyceride levels and the risk of myocardial infarction (MI) in HIV-positive persons after adjustment for total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C) and nonlipid risk factors.

Background: Although elevated triglyceride levels are commonly noted in HIV-positive individuals, it is unclear whether they represent an independent risk factor for MI.

Methods: The incidence of MI during follow-up was stratified according to the latest triglyceride level.

Challenges of a hidden epidemic: HIV prevention among women in the United States.

HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two-thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk and by the broader scientific community.

Lessons from Africa.

Delayed access to HIV care and treatment in sub-Saharan Africa meant that the early years of HIV scale-up were characterized by a largely North-to-South transfer of knowledge and resources. Clinicians from wealthy countries were among the first to gain experience with antiretroviral treatment and care of people living with HIV and shared key lessons with their colleagues in sub-Saharan Africa. Ten years later, lessons from Africa learned from the remarkable achievements of HIV programs now have the potential to inform the response to the US domestic epidemic.

Antiretroviral therapy: a promising HIV prevention strategy?

The use of antiretroviral therapy (ART) has been associated with significant improvement in morbidity and survival of persons living with HIV. In addition, recently, there has also been intense interest in the potential impact of ART on HIV transmission and consequently on the trajectory of the HIV epidemic globally. Evidence from mathematical modeling analyses and observational and ecological studies supports the potential for ART as prevention.

Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases.

The dramatic scale-up of HIV services in lower-income countries has led to the development of service delivery models reflecting the specific characteristics of HIV and its treatment as well as local contexts and cultures. Given the shared barriers and challenges faced by health programmes in lower-income countries, many of the implementation approaches developed for HIV programmes have the potential to contribute to the continuity care framework needed to address non-communicable diseases (NCDs) in resource-limited settings. HIV programmes are, in fact, the first large-scale chronic disease programmes in many countries, offering local and effective tools, models and approaches that can be replicated, adapted and expanded.

Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study(*).

Objectives: The aim of the study was to estimate the rates of cardiovascular disease (CVD) events after stopping smoking in patients with HIV infection.

Methods: Patients who reported smoking status and no previous CVD prior to enrolment in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study were included in this study. Smoking status is collected at each visit as current smoker (yes/no) and ever smoker (yes/no).

HBV or HCV coinfections and risk of myocardial infarction in HIV-infected individuals: the D:A:D Cohort Study.

Background: Data on a link between HCV or HBV infection and the development of cardiovascular disease among HIV-negative and HIV-positive individuals are conflicting. We sought to investigate the association between HBV or HCV infection and myocardial infarction in HIV-infected individuals.

Methods: The prospective observational database of the D:A:D collaboration of 11 cohorts of HIV-infected individuals, including 212 clinics in Europe, the United States and Australia was used.

Keeping health facilities safe: one way of strengthening the interaction between disease-specific programmes and health systems.

The debate on the interaction between disease-specific programmes and health system strengthening in the last few years has intensified as experts seek to tease out common ground and find solutions and synergies to bridge the divide. Unfortunately, the debate continues to be largely academic and devoid of specificity, resulting in the issues being irrelevant to health care workers on the ground. Taking the theme 'What would entice HIV- and tuberculosis (TB)-programme managers to sit around the table on a Monday morning with health system experts', this viewpoint focuses on infection control and health facility safety as an important and highly relevant practical topic for both disease-specific programmes and health system strengthening.

Predictors of latent tuberculosis infection treatment completion in the United States: an inner city experience.

Background: Few studies have examined predictors of latent tuberculosis infection (LTBI) treatment completion in inner city populations in the United States.

Objective: To assess LTBI treatment completion rates and predictors in an inner city cohort.

Methods: Data from control groups of two sequentially conducted randomized controlled trials of LTBI treatment were analyzed for treatment completion rates.

Cardiovascular risk factors associated with lower baseline cognitive performance in HIV-positive persons.

Objective: To determine factors associated with baseline neurocognitive performance in HIV-infected participants enrolled in the Strategies for Management of Antiretroviral Therapy (SMART) neurology substudy.

Methods: Participants from Australia, North America, Brazil, and Thailand were administered a 5-test neurocognitive battery. Z scores and the neurocognitive performance outcome measure, the quantitative neurocognitive performance z score (QNPZ-5), were calculated using US norms.

CD4+ cell count testing more effective than HIV disease clinical staging in identifying pregnant and postpartum women eligible for antiretroviral therapy in resource-limited settings.

Objective: Identifying antiretroviral therapy (ART) eligible HIV-infected (HIV+) pregnant women and rapidly initiating treatment preserves maternal health and prevents mother-to-child transmission. However, there have been few investigations of the performance of ART eligibility criteria in pregnant and postpartum women in resource-limited settings.

Methods: Pregnant and recently postpartum HIV+ women received CD4+ cell count and World Health Organization (WHO) clinical staging at enrollment into the mother-to-child transmission Plus Initiative.

Predicting the risk of cardiovascular disease in HIV-infected patients: the data collection on adverse effects of anti-HIV drugs study.

Aims: HIV-infected patients receiving combination antiretroviral therapy may experience metabolic complications, potentially increasing their risk of cardiovascular diseases (CVDs). Furthermore, exposures to some antiretroviral drugs seem to be independently associated with increased CVD risk. We aimed to develop cardiovascular risk-assessment models tailored to HIV-infected patients.

Comparison of 2 doses of liposomal amphotericin B and conventional amphotericin B deoxycholate for treatment of AIDS-associated acute cryptococcal meningitis: a randomized, double-blind clinical trial of efficacy and safety.

BACKGROUND. It is generally acknowledged that amphotericin B is the most effective treatment for cryptococcal meningitis. However, administration of this drug is accompanied by substantial adverse effects.

Scale-up of services and research priorities for diagnosis, management, and control of tuberculosis: a call to action.

The Millennium Development Goal target for tuberculosis control is to halt the spread of tuberculosis by 2015, and begin to reverse the worldwide incidence. After the introduction of standard control practices in 1995, 36 million people were cured and about 6 million deaths were averted. However, substantial scientific advances and innovative solutions are urgently needed together with creative new strategies.