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Search Results: 1 - 10 of 3546 matches for " Alexandra Calmy "
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The first decade of antiretroviral therapy in Africa
Nathan Ford, Alexandra Calmy, Edward J Mills
Globalization and Health , 2011, DOI: 10.1186/1744-8603-7-33
Abstract: Since 2001, the international effort to scale up antiretroviral therapy (ART) in the developing world has been one of the most important programmes in global health [1]. Initially, there was considerable reluctance to provide ART in developing countries, due to concerns that treatment was too expensive, too complex, and that drug resistance would be promoted by inadequate programmes [2]. In particular, it was argued that ART was not cost-effective and that prevention interventions should be prioritized [3].Despite these concerns, treatment programmes began to deliver ART at scale, and in less than a decade, more than five million people were successfully started on treatment. This remarkable progress was supported by a global coalition of doctors, patients, civil society actors, governments, and non-governmental organizations, who refused to accept that millions of people could be consigned to an early death from a disease that in developed countries had been transformed into a chronic, manageable condition.This article provides an overview of the main policy and delivery challenges to the provision of effective ART in resource-limited settings, before outlining some of the future challenges for the coming years.The early reluctance to support ART for developing countries was driven by both public health caution and treatment cost. The fact that antiretroviral medicines were priced beyond the reach of most people who needed them in Africa had long been an international concern: at the International AIDS Conference in Stockholm in 1988 there was debate about how to ensure people in the developing world could access the treatment of that time - zidovudine monotherapy - which was marketed at a price of US$8000 per year [4]. Triple therapy, available in developed countries since late 1996, was considered far too expensive for resource-limited settings, and UN agencies [5], academics [3], and major donors alike [6] all argued against providing treatment in favour of focu
When to start antiretroviral therapy in resource-limited settings: a human rights analysis
Nathan Ford, Alexandra Calmy, Samia Hurst
BMC International Health and Human Rights , 2010, DOI: 10.1186/1472-698x-10-6
Abstract: According to our analysis, a policy of earlier ART initiation would better serve both public health and human rights objectives. We highlight a number of policy approaches that could be taken to help meet this aim, including increased international financial support, alternative models of care, and policies to secure the most affordable sources of appropriate antiretroviral drugs.Widespread implementation of earlier ART initiation is challenging in resource-limited settings. Nevertheless, rationing of essential medicines is a restriction of human rights, and the principle of least restriction serves to focus attention on alternative measures such as adapting health service models to increase capacity, decreasing costs, and seeking additional international funding. Progressive realisation using well-defined steps will be necessary to allow for a phased implementation as part of a framework of short-term targets towards nationwide policy adoption, and will require international technical and financial support.Highly active antiretroviral therapy (ART) has transformed HIV/AIDS from a death sentence into a manageable, chronic disease. Today, an adult 20 years of age diagnosed with HIV/AIDS in the developed world can expect to live at least 23 years [1,2]. In the developing world, fewer therapeutic options are available for patients; nevertheless current treatment approaches are effective at reducing mortality, with studies demonstrating similar survival outcomes compared to western countries, at least in the short term [3].Among the different strategies for improving long-term survival for people with HIV/AIDS in resource-limited settings, the question of when to start ART is gaining increasing attention. Studies from developed and developing country settings conclude that early initiation results in substantial gains in survival and reduced incidence of opportunistic infections, in particular tuberculosis (TB). However, a number of concerns have been put forward agains
HIV treatment for prevention
Ambrosioni Juan,Calmy Alexandra,Hirschel Bernard
Journal of the International AIDS Society , 2011, DOI: 10.1186/1758-2652-14-28
Abstract: "No virus, no transmission." Studies have repeatedly shown that viral load (the quantity of virus present in blood and sexual secretions) is the strongest predictor of HIV transmission during unprotected sex or transmission from infected mother to child. Effective treatment lowers viral load to undetectable levels. If one could identify and treat all HIV-infected people immediately after infection, the HIV/AIDS epidemic would eventually disappear. Such a radical solution is currently unrealistic. In reality, not all people get tested, especially when they fear stigma and discrimination. Thus, not all HIV-infected individuals are known. Of those HIV-positive individuals for whom the diagnosis is known, not all of them have access to therapy, agree to be treated, or are taking therapy effectively. Some on effective treatment will stop, and in others, the development of resistance will lead to treatment failure. Furthermore, resources are limited: should we provide drugs to asymptomatic HIV-infected individuals without indication for treatment according to guidelines in order to prevent HIV transmission at the risk of diverting funding from sick patients in urgent need? In fact, the preventive potential of anti-HIV drugs is unknown. Modellers have tried to fill the gap, but models differ depending on assumptions that are strongly debated. Further, indications for antiretroviral treatments expand; in places like Vancouver and San Francisco, the majority of HIV-positive individuals are now under treatment, and the incidence of new HIV infections has recently fallen. However, correlation does not necessarily imply causation. Finally, studies in couples where one partner is HIV-infected also appear to show that treatment reduces the risk of transmission. More definite studies, where a number of communities are randomized to either receive the "test-and-treat" approach or continue as before, are now in evaluation by funding agencies. Repeated waves of testing would precisely measure the incidence of HIV infection. Such trials face formidable logistical, practical and ethical obstacles. However, without definitive data, the intuitive appeal of "test-and-treat" is unlikely to translate into action on a global scale. In the meantime, based on the available evidence, we must strive to provide treatment to all those in medical need under the current medical guidelines. This will lead to a decrease in HIV transmission while "test-and-treat" is fully explored in prospective clinical trials.
Prospective evidence that HIV lipoatrophy and visceral adiposity are partially independent processes
Handan Wand, Dianne Carey, Alexandra Calmy, et al
Open Access Journal of Clinical Trials , 2011, DOI: http://dx.doi.org/10.2147/OAJCT.S14359
Abstract: ospective evidence that HIV lipoatrophy and visceral adiposity are partially independent processes Expert Opinion (2832) Total Article Views Authors: Handan Wand, Dianne Carey, Alexandra Calmy, et al Published Date January 2011 Volume 2011:3 Pages 1 - 7 DOI: http://dx.doi.org/10.2147/OAJCT.S14359 Handan Wand, Dianne Carey, Alexandra Calmy, Matthew Law, David Cooper, Sean Emery, Andrew Carr National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW, Australia Purpose: To investigate the patterns of change in objectively assessed body composition parameters and to determine to what extent the observed patterns correlate with modifiable variables and potential risk factors for lipodystrophy in human immunodeficiency virus (HIV)-infected lipoatrophic adults. Method: Changes from baseline in limb fat and visceral adipose tissue (VAT), and their associations with antiretroviral therapy, body composition, and metabolic variables were investigated using linear and logistic regression models. Results: Increases in limb fat were significantly associated with higher baseline limb fat (P < 0.0001), VAT (P = 0.023), and change from baseline to week 72 in VAT (P < 0.0001). On-study use of zidovudine or stavudine was negatively associated with a limb fat increase (P = 0.017). High baseline limb fat mass and VAT had negative effects on subsequent VAT increases at week 72 (P = 0.016 and P = 0.001, respectively). Conclusions: This large, prospective study in HIV-infected adults with moderate or severe lipoatrophy at baseline showed positive associations between changes in limb fat and VAT over 72 weeks. Risk factors for these two lipodystrophic features were different. Our findings suggest that lipoatrophy and fat accumulation are at least partially independent processes.
Squamous cell carcinoma of the anus-an opportunistic cancer in HIV-positive male homosexuals
Pascal Gervaz,Alexandra Calmy,Ymer Durmishi,Abdelkarim S Allal
World Journal of Gastroenterology , 2011, DOI: 10.3748/wjg.v17.i25.2987
Abstract: Squamous cell carcinoma of the anus (SCCA) is a common cancer in the human immunodeficiency virus (HIV)-infected population, and its incidence continues to increase in male homosexuals. Combined chemoradiation with mitomycin C and 5-fluorouracil was poorly tolerated by severely immunocompromised patients in the early 1990s. In the era of highly active antiretroviral therapy (HAART), however, recent data indicate that: (1) most HIV patients with anal cancer can tolerate standard chemotherapy regimens; and (2) this approach is associated with survival rates similar to those of HIV-negative patients. However, HIV-positive patients with SCCA are much younger, more likely to develop local tumor recurrence, and ultimately die from anal cancer than immune competent patients. Taken together, these findings suggest that anal cancer is an often fatal neoplasia in middle-aged HIV-positive male homosexuals. In this population, SCCA is an opportunistic disease resulting in patients with suboptimal immune function from persistent infection and prolonged exposition to oncogenic human papillomaviruses (HPVs). Large-scale cancer-prevention strategies (routine anuscopy and anal papanicolaou testing) should be implemented in this population. In addition, definitive eradication of oncogenic HPVs within the anogenital mucosa of high-risk individuals might require a proactive approach with repeated vaccination.
Prospective evidence that HIV lipoatrophy and visceral adiposity are partially independent processes
Handan Wand,Dianne Carey,Alexandra Calmy,et al
Open Access Journal of Clinical Trials , 2011,
Abstract: Handan Wand, Dianne Carey, Alexandra Calmy, Matthew Law, David Cooper, Sean Emery, Andrew CarrNational Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW, AustraliaPurpose: To investigate the patterns of change in objectively assessed body composition parameters and to determine to what extent the observed patterns correlate with modifiable variables and potential risk factors for lipodystrophy in human immunodeficiency virus (HIV)-infected lipoatrophic adults.Method: Changes from baseline in limb fat and visceral adipose tissue (VAT), and their associations with antiretroviral therapy, body composition, and metabolic variables were investigated using linear and logistic regression models.Results: Increases in limb fat were significantly associated with higher baseline limb fat (P < 0.0001), VAT (P = 0.023), and change from baseline to week 72 in VAT (P < 0.0001). On-study use of zidovudine or stavudine was negatively associated with a limb fat increase (P = 0.017). High baseline limb fat mass and VAT had negative effects on subsequent VAT increases at week 72 (P = 0.016 and P = 0.001, respectively).Conclusions: This large, prospective study in HIV-infected adults with moderate or severe lipoatrophy at baseline showed positive associations between changes in limb fat and VAT over 72 weeks. Risk factors for these two lipodystrophic features were different. Our findings suggest that lipoatrophy and fat accumulation are at least partially independent processes.Keywords: HIV, lipoatrophy, lipohypertrophy, pathogenesis
Driving a decade of change: HIV/AIDS, patents and access to medicines for all
Hoen Ellen 't,Berger Jonathan,Calmy Alexandra,Moon Suerie
Journal of the International AIDS Society , 2011, DOI: 10.1186/1758-2652-14-15
Abstract: Since 2000, access to antiretroviral drugs to treat HIV infection has dramatically increased to reach more than five million people in developing countries. Essential to this achievement was the dramatic reduction in antiretroviral prices, a result of global political mobilization that cleared the way for competitive production of generic versions of widely patented medicines. Global trade rules agreed upon in 1994 required many developing countries to begin offering patents on medicines for the first time. Government and civil society reaction to expected increases in drug prices precipitated a series of events challenging these rules, culminating in the 2001 World Trade Organization's Doha Declaration on the Agreement on Trade-Related Aspects of Intellectual Property Rights and Public Health. The Declaration affirmed that patent rules should be interpreted and implemented to protect public health and to promote access to medicines for all. Since Doha, more than 60 low- and middle-income countries have procured generic versions of patented medicines on a large scale. Despite these changes, however, a "treatment timebomb" awaits. First, increasing numbers of people need access to newer antiretrovirals, but treatment costs are rising since new ARVs are likely to be more widely patented in developing countries. Second, policy space to produce or import generic versions of patented medicines is shrinking in some developing countries. Third, funding for medicines is falling far short of needs. Expanded use of the existing flexibilities in patent law and new models to address the second wave of the access to medicines crisis are required. One promising new mechanism is the UNITAID-supported Medicines Patent Pool, which seeks to facilitate access to patents to enable competitive generic medicines production and the development of improved products. Such innovative approaches are possible today due to the previous decade of AIDS activism. However, the Pool is just one of a broad set of policies needed to ensure access to medicines for all; other key measures include sufficient and reliable financing, research and development of new products targeted for use in resource-poor settings, and use of patent law flexibilities. Governments must live up to their obligations to protect access to medicines as a fundamental component of the human right to health.
Preferred antiretroviral drugs for the next decade of scale up
Isabelle Andrieux-Meyer,Alexandra Calmy,Pedro Cahn,Polly Clayden
Journal of the International AIDS Society , 2012, DOI: 10.7448/ias.15.2.17986
Abstract: Global commitments aim to provide antiretroviral therapy (ART) to 15 million people living with HIV by 2015, and recent studies have demonstrated the potential for widespread ART to prevent HIV transmission. Increasingly, countries are adapting their national guidelines to start ART earlier, for both clinical and preventive benefits. To maximize the benefits of ART in resource-limited settings, six key principles need to guide ART choice: simplicity, tolerability and safety, durability, universal applicability, affordability and heat stability. Currently available drugs, combined with those in late-stage clinical development, hold great promise to simplify treatment in the short term. Over the longer term, newer technologies, such as long-acting formulations and nanotechnology, could radically alter the treatment paradigm. This commentary reviews recommendations made in an expert consultation on treatment scale up in resource-limited settings.
Persistent Difficulties in Switching to Second-Line ART in Sub-Saharan Africa — A Systematic Review and Meta-Analysis
Yoann Madec, Sandrine Leroy, Marie-Anne Rey-Cuille, Florence Huber, Alexandra Calmy
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0082724
Abstract: Objectives Switching to second-line antiretroviral therapy (ART) largely depends on careful clinical assessment and access to biological measurements. We performed a systematic review and meta-analysis to estimate the incidence of switching to second-line ART in sub-Saharan Africa and its main programmatic determinants. Methods We searched 2 databases for studies reporting the incidence rate of switching to second-line ART in adults living in sub-Saharan Africa. Data on the incidence rate of switching were pooled, and random-effect models were used to evaluate the effect of factors measured at the programme level on this incidence rate. Results Nine studies (157,340 patients) in 21 countries were included in the meta-analysis. All studies considered patients under first-line ART and conditions to initiate ART were similar across studies. Overall, 3,736 (2.4%) patients switched to second-line ART. Incidence rate of switch was in mean 2.65 per 100 person-years (PY) (95% confidence interval: 2.01–3.30); it ranged from 0.42 to 4.88 per 100 PY and from 0 to 4.80 per 100 PY in programmes with and without viral load monitoring, respectively. No factors measured at the programme level were associated with the incidence rate of switching to second-line ART. Conclusion The low incidence rate of switching to second-line ART suggests that the monitoring of patients under ART is challenging and that access to second-line ART is ineffective; efforts should be made to increase access to second-line ART to those in need by providing monitoring tools, education and training, as well as a more convenient regimen.
Impact of drug classes and treatment availability on the rate of antiretroviral treatment change in the TREAT Asia HIV Observational Database (TAHOD)
Preeyaporn Srasuebkul, Alexandra Calmy, Jialun Zhou, Nagalingeswaran Kumarasamy, Matthew Law, Poh Lim, The TREAT Asia HIV Observational Database
AIDS Research and Therapy , 2007, DOI: 10.1186/1742-6405-4-18
Abstract: Rates of ART changes were examined in patients who started first line triple or more ART combination in TAHOD, and had at least one follow-up visit. Rates of ART changes were summarised per follow-up year, and factors associated with changes assessed using random-effect Poisson regression. The Kaplan-Meier method was used to determine durations of patients in their first, second and third regimen.A total of 1846 patients initiated an ART combination with at least three drugs. Median follow up time for the first treatment was 3.2 years. The overall rate of ART change was 29 per 100-person-year.In univariate analyses, rate of treatment change was significantly associated with exposure category, the country income category, the drug class combination, calendar year and the number of combinations. In multivariate analysis, compared to d4T/3TC/NVP, starting ART with another NNRTI-containing regimen, with PI only or with a triple NRTI regimen was associated with a higher risk of combination change (relative risk (RR) 1.6 (95% CI 1.64 – 1.96), p < 0.001, RR 3.39 (2.76 – 4.16) p < 0.001, RR 6.37 (4.51 – 9.00), p < 0.001). Being on a second or a third combination regimen was also associated with a decreased rate of ART change, compared with first ART combination (RR 0.82 (0.68 – 0.99), p = 0.035, RR 0.77 (0.61 – 0.97), p = 0.024). Sites with fewer than 12 drugs used had an increased rate of treatment changes (1.31 (1.13 – 1.51), p < 0.001). Injecting drug users, and other/unknown exposure was found to increase rate of treatment change (1.24 (1.00 – 1.54), p = 0.055). Percentages of patients who stopped treatment due to adverse events were 31, 27 and 32 in 1st, 2nd and 3rd treatment combinations, respectively.Our study suggests that drug availability impacts on ART prescription patterns. Our data, reflecting real clinic use in Asia, suggest that around half of all patients require second combination ART by 3 years after treatment initiation.In South and South-East Asia the nu
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