Suchergebnisse

The concepts of health and self have become intimately entangled in contemporary western society. Health is figured as a marker of identity, as a vehicle of self-production and self-actualisation, while the individual is also made increasingly responsible for his or her health. In this paper, we explore how "self" is constituted in discourses that shape the ways in which people understand and do health and medicine, particularly discourses of neoliberalism and of the immune system. Of interest here is how the productive and unpredictable intra-action of medicine and bodies may come to trouble these discursive selves. We situate our discussion in the context of efavirenz, an antiretroviral drug prescribed and consumed for the treatment of HIV infection. This drug, commonly described as "potent", can have a number of troubling effects on a person's everyday sense of self, including insomnia, confusion, cognitive disorders, depression, depersonalisation, psychosis, and suicidal ideation. While efavirenz may be clinically effective in its capacity to suppress the virus, these effects are at odds with the implicit aim of HIV medicine to restore and secure the self by way of immunological integrity and strength. These effects also bring into focus the predicament of choice under the contemporary political conditions of neoliberalism with its emphasis on health as an enterprise of the autonomous, rational self. In exploring first-person accounts, the paper unpacks a number of the binary concepts on which contemporary discourses of health and medicine rely, such as immunity and vulnerability, potency and fragility, rationality and madness, self and non-self, and asks whether the individual under neoliberalism is being asked the impossible.

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

IntroductionRecent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost‐effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum.MethodsWe constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm3) with delayed initiation at CD4 ≤350 cells/mm3; primary outcomes were incident cases, deaths, quality‐adjusted‐life‐years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum.ResultsAssuming "idealistic" engagement in HIV care, early ART initiation is highly cost‐effective ($442/QALY‐gained) compared to delayed initiation at CD4 ≤350 cells/mm3 and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost‐effective ($530/QALY‐gained). We project 1,285,000 new HIV infections and 973,000 AIDS‐related deaths with deferred ART initiation with current levels of care‐engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS‐related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction).ConclusionsEarly ART initiation is highly cost‐effective in India but only has modest epidemiological benefits at current levels of care‐engagement. Improved retention in care is needed to realize the full potential of earlier treatment.

Antiretroviral therapy (ART) has the potential to change processes of HIV stigmatisation. In this article, changing processes of stigmatisation among a group of people living with HIV (PLWH) on ART in Wakiso District, Uganda, are analysed using qualitative data from a study of PLWH's self‐management of HIV on ART. There were 38 respondents (20 women, 18 men) who had been taking ART for at least 1 year. They were purposefully selected from government and non‐government ART providers. Two in‐depth interviews were held with each participant. Processes of reduced self‐stigmatisation were clearly evident, caused by the recovery of their physical appearance and support from health workers. However most participants continued to conceal their status because they anticipated stigma; for example, they feared gossip, rejection and their status being used against them. Anticipated stigma was gendered: women expressed greater fear of enacted forms of stigma such as rejection by their partner; in contrast men's fears focused on gossip, loss of dignity and self‐stigmatisation. The evidence indicates that ART has not reduced underlying structural drivers of stigmatisation, notably gender identities and inequalities, and that interventions are still required to mitigate and tackle stigmatisation, such as counselling, peer‐led education and support groups that can help PLWH reconstruct alternative and more positive identities.

Antiretroviral therapy (ART) has the potential to change processes of HIV stigmatisation. In this article, changing processes of stigmatisation among a group of people living with HIV (PLWH) on ART in Wakiso District, Uganda, are analysed using qualitative data from a study of PLWH's self-management of HIV on ART. There were 38 respondents (20 women, 18 men) who had been taking ART for at least 1 year. They were purposefully selected from government and non-government ART providers. Two in-depth interviews were held with each participant. Processes of reduced self-stigmatisation were clearly evident, caused by the recovery of their physical appearance and support from health workers. However most participants continued to conceal their status because they anticipated stigma; for example, they feared gossip, rejection and their status being used against them. Anticipated stigma was gendered: women expressed greater fear of enacted forms of stigma such as rejection by their partner; in contrast men's fears focused on gossip, loss of dignity and self-stigmatisation. The evidence indicates that ART has not reduced underlying structural drivers of stigmatisation, notably gender identities and inequalities, and that interventions are still required to mitigate and tackle stigmatisation, such as counselling, peer-led education and support groups that can help PLWH reconstruct alternative and more positive identities.

The number of people on highly active antiretroviral therapy (HAART) in South Africa has risen from ,2000 in October 2003, to almost 200,000 by the end of 2005. Yet South Africa's performance in terms of HAART coverage is poor both in comparison with other countries and the targets set by the government's own Operational Plan. The public-sector HAART ''rollout'' has been uneven across South Africa's nine provinces and the role of external assistance from NGOs and funding agencies such as the Global Fund and PEPFAR has been substantial. The National Treasury seems to have allocated sufficient funding to the Department of Health for a larger HAART rollout, but the Health Minister has not mobilized it accordingly. Failure to invest sufficiently in human resources— especially nurses—is likely to constrain the growth of HAART coverage.

Antiretroviral therapy (ART) has the potential to change processes of HIV stigmatisation. In this article, changing processes of stigmatisation among a group of people living with HIV (PLWH) on ART in Wakiso District, Uganda, are analysed using qualitative data from a study of PLWH's self-management of HIV on ART. There were 38 respondents (20 women, 18 men) who had been taking ART for at least 1 year. They were purposefully selected from government and non-government ART providers. Two in-depth interviews were held with each participant. Processes of reduced self-stigmatisation were clearly evident, caused by the recovery of their physical appearance and support from health workers. However most participants continued to conceal their status because they anticipated stigma; for example, they feared gossip, rejection and their status being used against them. Anticipated stigma was gendered: women expressed greater fear of enacted forms of stigma such as rejection by their partner; in contrast men's fears focused on gossip, loss of dignity and self-stigmatisation. The evidence indicates that ART has not reduced underlying structural drivers of stigmatisation, notably gender identities and inequalities, and that interventions are still required to mitigate and tackle stigmatisation, such as counselling, peer-led education and support groups that can help PLWH reconstruct alternative and more positive identities. A video abstract of this article can be found at: https://youtu.be/WtIaZJQ3Y_8.

The number of people on highly active antiretroviral therapy (HAART) in South Africa has risen from ,2000 in October 2003, to almost 200,000 by the end of 2005. Yet South Africa's performance in terms of HAART coverage is poor both in comparison with other countries and the targets set by the government's own Operational Plan. The public-sector HAART ''rollout'' has been uneven across South Africa's nine provinces and the role of external assistance from NGOs and funding agencies such as the Global Fund and PEPFAR has been substantial. The National Treasury seems to have allocated sufficient funding to the Department of Health for a larger HAART rollout, but the Health Minister has not mobilized it accordingly. Failure to invest sufficiently in human resources— especially nurses—is likely to constrain the growth of HAART coverage.

The concepts of health and self have become intimately entangled in contemporary western society. Health is figured as a marker of identity, as a vehicle of self-production and selfactualisation, while the individual is also made increasingly responsible for his or her health. In this paper, we explore how "self" is constituted in discourses that shape the ways in which people understand and do health and medicine, particularly discourses of neoliberalism and of the immune system. Of interest here is how the productive and unpredictable intra-action of medicine and bodies may come to trouble these discursive selves. Drawing on qualitative interviews, we situate our discussion in the context of efavirenz, an antiretroviral drug prescribed and consumed for the treatment of HIV infection. This drug, commonly described as "potent", can have a number of troubling effects on a person's everyday sense of self, including insomnia, confusion, cognitive disorders, depression, depersonalisation, psychosis, and suicidal ideation. While efavirenz may be clinically effective in its capacity to suppress the virus, these effects are at odds with the implicit aim of HIV medicine to restore and secure the self by way of immunological integrity and strength. These effects also bring into focus the predicament of choice under the contemporary political conditions of neoliberalism with its emphasis on health as an enterprise of the autonomous, rational self. In exploring first person accounts of efavirenz, the paper unpacks a number of the binary concepts on which contemporary discourses of health and medicine rely, such as immunity and vulnerability, potency and fragility, rationality and madness, self and non-self, and asks whether the individual under neoliberalism is being asked the impossible.

IntroductionHIV‐1 resistance data to inform treatment sequencing are limited for children with virological failure on first‐ and second‐line antiretroviral therapy (ART) in Sub‐Saharan Africa.MethodsHIV‐1‐infected children aged ≤15 years were retrospectively identified from an ART cohort in Cape Town, South Africa (2003 to 2010). First‐line ART was either non‐nucleoside reverse transcriptase inhibitor (NNRTI) or lopinavir/ritonavir‐based (with the exception of children <6 months old who received full‐dose ritonavir as the sole protease inhibitor (PI) from 2004 to 2007). Second‐line ART was the alternative regimen. Treatment outcomes, including virological failure, loss to care, death or remaining in care, were determined. Genotypic resistance testing was conducted on stored serum from children at first‐ or second‐line virological failure (two consecutive HIV‐1 RNA levels >1000 copies/ml). International AIDS Society criteria defined resistance mutations.ResultsOf 472 children starting first‐line ART, 352 (75%) remained in care, 45 (9%) were lost and 4 (1%) died on first‐line treatment. Seventy‐one (15%) had observed virological failure, and 37 of these children had specimens available for genotype testing. Eight children (22%) had wild‐type virus, seven (19%) had thymidine analog mutations (TAMs), 24 (65%) had NNRTI resistance and two (5.4%) had multiple protease resistance (PR). Of the 78 children who received second‐line ART, 54 (71%) remained in care, 6 (8%) were lost and 1 (1%) died during second‐line treatment. Fifteen (20%) had observed virological failure; 13 had samples available for genotype. Three (23%) had wild‐type virus, eight (62%) had TAMs, nine (69%) had NNRTI resistance, and five (38%) had multiple PI resistance all of whom had received full‐dose ritonavir.ConclusionAlthough virological failure was infrequent in children on first‐ and second‐line ART, rates of observed resistance including multiple PR resistance after failure were high. Reasons for high rates of resistance include use of full‐dose ritonavir and continued viremia. Wild‐type virus was common, suggesting poor adherence or challenges in correct dosing. Genotype resistance testing in children with virological failure may optimize selection of subsequent regimens and inform recommendations for sequencing of existing ART.

PurposeBone turnover markers (BTM) ‐ aminoterminal propeptide of type 1 collagen (P1NP) and C‐terminal telopeptide of type 1 collagen (β‐CTX) ‐ are related to bone density and fracture risk. A high prevalence of osteopenia/osteoporosis and hypovitaminosis D has been reported in HIV patients, however there are few data about BTM in this population. Our aim was to analyse the prevalence of elevated serum levels of BTM in HIV patients before starting antiretroviral therapy (ART), and related factors.MethodsCross‐sectional study of a series of HIV‐patients who started ART during June/11–June/12 in our hospital. Patients with presence of diseases or treatments known to affect bone metabolism were excluded. Epidemiological, clinical, and immunovirological data in addition to serum fasting levels of glucose, lipid profile, calcium, phosphate, alkaline phosphatase, 25‐hydroxyvitamin D3 (25OHD), parathyroid hormone (PTH), P1NP, and β‐CTX were collected. Definitions: hypovitaminosis D if 25OHD<30 ng/ml, vitamin D deficiency if 25OHD<20 ng/ml; elevated levels of BTM if β‐CTX (ng/ml) >0.64 (men<70 years),>0.85 (men >70 years),>0.58 (pre‐menopause women), >0.99 (post‐menopause women), or P1NP (ng/mL)>69.4 (men <60 years), >71.1 (men>60 years), >55.7 (pre‐menopause women), >61.2 (post‐menopause women).Results47 patients were included, 91.5% men, median age 37.1 years (30.0–44.3), and 93.6% sexual transmission of HIV (34 HMX, 10 HTX). Median time since the diagnosis of HIV was 3.4 months (1.4–31.7); there were 7 (14.9%) Aids cases, median CD4 count was 277/mm3 (155–433), and HIV‐VL 4.8 log10 (4.1–5.2). Median serum 25OHD was 29 µg/L (21.9–41.1), with a prevalence of hypovitaminosis of 52.2%, and deficiency of 17.4%. PTH was in range in all cases. Median serum P1NP was 33.3 ng/mL (24.5–52.5) and β‐CTX 0.25 ng/mL (0.20–0.45); five (11.4%) patients presented high levels of BTM: 4 men, median age 37.1 years, median CD4 count 247/mm3, median HIV‐VL 5.18 log10, and one with hypovitaminosis D. Elevated BTM were related with no clinical, analytical, immunovirological parameters nor with serum levels of 25OHD nor PTH.ConclusionsThe prevalence of elevated BTM was high in this series of HIV‐patients, mostly young men, with short time of HIV infection and with no immunovirologic control. BTM were related with no clinical nor analytical data.

Introduction: In response to the increasing burden of HIV, the Ugandan government has employed different service delivery models since 2004 that aim to reduce costs and remove barriers to accessing HIV care. These models include community-based approaches to delivering antiretroviral therapy (ART) and delegating tasks to lower-level health workers. This study aimed to provide data on annual ART cost per client among three different service delivery models in Uganda. Methods: Costing data for the entire year 2012 were retrospectively collected as part of a larger task-shifting study conducted in three organizations in Uganda: Kitovu Mobile (KM), the AIDS Support Organisation (TASO) and Uganda Cares (UC). A standard cost data capture tool was developed and used to retrospectively collect cost information regarding antiretroviral (ARV) drugs and non-ARV drugs, ART-related lab tests, personnel and administrative costs. A random sample of four TASO centres (out of 11), four UC clinics (out of 29) and all KM outreach units were selected for the study. Results: Cost varied across sites within each organization as well as across the three organizations. In addition, the number of annual ART visits was more frequent in rural areas and through KM (the community distribution model), which played a major part in the overall annual ART cost. The annual cost per client (in USD) was $404 for KM, $332 for TASO and $257 for UC. These estimates were lower than previous analyses in Uganda or the region compared to data from 2001 to 2009, but comparable with recent estimates using data from 2010 to 2013. ARVs accounted for the majority of the total cost, followed by personnel and operational costs. Conclusions: The study provides updated data on annual cost per ART visit for three service delivery models in Uganda. These data will be vital for in-country budgetary efforts to ensure that universal access to ART, as called for in the 2015 World Health Organization (WHO) guidelines, is achievable. The lower annual ART cost found in ...