HIV/AIDS epidemic in Eastern Europe: Recent developments in the Russian Federation and Ukraine among women

Background: The Russian Federation and the Ukraine are among the Eastern European countries with the fastest growing number of cases of HIV. According to data from the Joint United Nations Program on HIV/AIDS, nearly 90% of newly reported HIV diagnoses in Eastern Europe in 2006 were from the Russian Federation (66%) and the Ukraine (21%). A growing number of women are infected with HIV. The impact of gender on HIV/AIDS is an important factor in understanding the development and evolution of the HIV/AIDS epidemic in Eastern Europe.Objective: The aim of this study was to assess the importance of integrating gender consideration into the creation of HIV programs and to examine the effect of gender on HIV/AIDS.Methods: Reported HIV/AIDS cases from the official epidemiological register of the Ukrainian Centre for AIDS Prevention alongside data from the Russian Federal AIDS Center were analyzed. Joint United Nations Program on HIV/AIDS country fact sheets were reviewed and analyzed, and this information was supplemented with published HIV prevalence and sexually transmitted disease case reporting information, unpublished reports, and expert evaluations.Results: Of the newly registered cases of HIV, the proportion of women rose from 13.0% in 1995 to 44.0% in 2006 in the Russian Federation, and from 37.2% in 1995 to 41.9% in 2006 in the Ukraine. There has also been a considerable increase in mother-to-child transmission of HIV since 1995. Between 1987 and 1994, the proportion of children among the people newly infected with HIV in the Ukraine was 2.2%; in 2006 it was 17.6%. In 2006, 16,078 new HIV cases were registered in the Ukraine and 39,652 new HIV cases in the Russian Federation. Large increases in the number of HIV-infected women were reported from both countries.Conclusions: The data examined in this study suggest subregional differences in the magnitude of the HIV/AIDS epidemic in the Russian Federation and the Ukraine and the importance of the impact of gender on the rapid spread of the HIV/AIDS epidemic among women and women of child-bearing age. To protect women from HIV infection, it is important to find ways to empower them by implementing policies and specific prevention measures that increase their access to knowledge about HIV/AIDS; the empowerment of women is vital to reversing the HIV/AIDS epidemic.     

AIDS-related tuberculosis in Rio de Janeiro, Brazil

Background

We studied the incidence of tuberculosis, AIDS, AIDS deaths and AIDS-TB co-infection at the population level in Rio de Janeiro, Brazil where universal and free access to combination antiretroviral therapy has been available since 1997.

Methodology/Principal Findings

This was a retrospective surveillance database match of Rio de Janeiro databases from 1995–2004. Proportions of tuberculosis occurring within 30 days and between 30 days and 1 year after AIDS diagnosis were determined. Generalized additive models fitted with cubic splines with appropriate estimating methods were used to describe rates and proportions over time. Overall, 90,806 tuberculosis cases and 16,891 AIDS cases were reported; 3,125 tuberculosis cases within 1 year of AIDS diagnosis were detected. Tuberculosis notification rates decreased after 1997 from a fitted rate (fR per 100,000) of 166.5 to 138.8 in 2004. AIDS incidence rates increased 26% between 1995 and 1998 (30.7 to 38.7) followed by a 33.3% decrease to 25.8 in 2004. AIDS mortality rates decreased dramatically after antiretroviral therapy was introduced between 1995 (27.5) and 1999 (13.4). The fitted proportion (fP) of patients with tuberculosis diagnosed within one year of AIDS decreased from 1995 (24.4%) to1998 (15.2%), remaining stable since. Seventy-five percent of tuberculosis diagnoses after an AIDS diagnosis occurred within 30 days of AIDS diagnosis.

Conclusions/Significance

Our results suggest that while combination ART should be considered an essential component of the response to the HIV and HIV/tuberculosis epidemics, it may not be sufficient alone to prevent progression from latent TB to active disease among HIV-infected populations. When tuberculosis is diagnosed prior to or at the same time as AIDS and ART has not yet been initiated, then ART is ineffective as a tuberculosis prevention strategy for these patients. Earlier HIV/AIDS diagnosis and ART initiation may reduce TB incidence in HIV/AIDS patients. More specific interventions will be required if HIV-related tuberculosis incidence is to continue to decline.     

End of life care in HIV-infected children who died in hospital

The aim of this study was to evaluate terminal care among hospitalized children who died of HIV/AIDS. The design was a retrospective chart review of the terminal hospitalization. The setting was a public, secondary and tertiary children's hospital in Cape Town, South Africa (SA). The patients included a consecutive series of in-patient deaths from HIV-related causes. The main outcome measures included: documentation of do not resuscitate (DNR) orders and comfort care plans, intensity of diagnostic and therapeutic interventions in last 24 hours of life, and presence of pain and distress in last 48 hours of life. The results are based on the review of 165 out of 167 in-patient deaths. Of those, 79% of patients died in general wards. Median age and length of stay were 4 months and 6 days respectively. A total of 84% of patients had a DNR order. DNR orders appeared simultaneously in only 41% of medical and nursing notes. Only 44% of patients had a comfort care plan. Pain and distress in the last 48 hours was documented in 55% of patients who died in the general wards. Respiratory symptomatology and painful skin conditions accounted for most discomfort. Half (36/72) the patients with pain and distress, including 16 with a comfort care plan, received no analgesia. Conclusions drawn found that, despite clinical uncertainty, doctors made tough end of life decisions that included DNR orders and comfort care plans. The lower rate of comfort care plans suggests doctors had difficulty making the transition from curative to palliative care. Many comfort care plans were incoherent and included interventions unlikely to promote patients' comfort. In light of the HIV/AIDS pandemic in SA, reforms are needed to integrate palliative care within mainstream hospital medicine. However, without adequate human resources including trained interpreters, doctors and nurses will struggle to deliver optimal terminal care in acute hospitals.     

Incidence of tuberculosis among reported AIDS cases in Quebec from 1979 to 1996

BACKGROUND: The impact of HIV infection on tuberculosis (TB) rates in Quebec has not been fully established. Because concurrent HIV infection is the single most important factor in TB reactivation, the authors used Quebec AIDS surveillance data to quantify the extent of TB among reported AIDS cases and to identify the characteristics of AIDS patients with TB. METHODS: The study population comprised people aged 15 years and over with AIDS diagnosed between Jan. 1, 1979, and Dec. 31, 1996, and reported by Mar. 13, 1997. Patients with TB (all forms) and those without TB were compared. Multivariate logistic regression analysis was used to examine the independent effect of each variable on the AIDS-TB cases. The authors also compared the number of AIDS-TB cases with the number of TB cases to estimate the effect of HIV infection on TB incidence. RESULTS: Of the 4684 people with AIDS reported in Quebec, 242 (5.2%) had active TB at some point during the course of their illness. During 1992-1995, 9.6% of the people with TB in Montreal, and 5.8% in the province of Quebec, also had HIV infection. Those with AIDS and TB were predominantly male (75.2%), manual workers (40.1%) and residents of Montreal (86.4%) and were born in an HIV-endemic country (63.8%). The multivariate analysis indicated that AIDS patients who were born in HIV-endemic countries in the Caribbean, sub-Saharan Africa or other developing regions were 21.8 times (95% confidence interval [CI] 19.5-28.5), 17.9 times (95% CI 12.7-27.1) and 4.9 times (95% CI 3.5-7.0) more likely to have TB than those born in Canada; manual workers and unemployed people with AIDS were 1.6 times (95% CI 1.3-2.0) and 2.0 times (95% CI 1.5-2.6) more likely to have TB than professional workers; and people who acquired HIV infection through heterosexual contact were 2.1 times (95% CI 1.6-3.1) more likely to have TB than men who acquired it through sexual contact with other men. INTERPRETATION: AIDS seems to contribute significantly to the number of TB cases. The results of this study reinforce the importance of offering HIV testing to people in high-risk groups, such as those born in a country where HIV and TB is endemic.     

"Side" effects of HAART: decreasing and changing occupational exposure to HIV-infected patients.

To investigate percutaneous exposures to HIV in the highly active antiretroviral therapy (HAART) era, we performed an analysis of all percutaneous exposures reported from January 1994 to December 1998 in 18 Italian acute-care hospitals. Frequency and rate per 100 prevalent AIDS cases of HIV exposures decreased by 40% (from 4.3% to 2.6%, and from 1.0% to 0.6%, respectively; p<0.001), which were mainly those related to the insertion/manipulation of peripheral vascular access devices (from 7.2% to 4.8%; p=0.05). We conclude that the benefits of HAART have changed the complexity of care required and therefore, the number and type of procedures performed on HIV patients that place the HCW at risk of injury.     

Incidence of AIDS and excess of mortality associated with HIV in haemophiliacs in the United Kingdom: report on behalf of the directors of haemophilia centres in the United Kingdom.

OBJECTIVE--To estimate the cumulative incidence of AIDS by time since seroconversion in haemophiliacs positive for HIV and to examine the evidence for excess mortality associated with HIV in those who had not yet been diagnosed as having AIDS. DESIGN--Analysis of data from ongoing national surveys. SETTING--Haemophilia centres in the United Kingdom. PATIENTS--A total of 1201 men with haemophilia who had lived in the United Kingdom during 1980-7 and were positive for HIV. INTERVENTION--None. END POINTS--Diagnosis of AIDS; death in those not diagnosed as having AIDS. MEASUREMENTS AND MAIN RESULTS--Estimation of cumulative incidence of AIDS and number of excess deaths in seropositive patients not diagnosed with AIDS. Median follow up after seroconversion was 5 years 2 months. Eight five patients developed AIDS. Cumulative incidence of AIDS five years after seroconversion was 4% among patients aged less than 25 at first test positive for HIV, 6% among those aged 25-44, and 19% among those aged greater than or equal to 45. There was little evidence that type or severity of haemophilia or type of factor VIII or IX that had caused HIV infection affected the rate of progression to AIDS. Mortality was increased among those who had not been diagnosed as having AIDS, especially among those with "AIDS related complex." Thirteen deaths were observed among 36 patients diagnosed as having AIDS related complex against 0.65 expected, and 34 deaths in 1080 other patients against 22.77 expected; both calculations were based on mortality rates observed in haemophiliacs in the United Kingdom in the late 1970s. CONCLUSIONS--Rate of progression to AIDS depended strongly on age. There is a substantial burden of fatal disease among patients positive for HIV who have not been formally diagnosed as having AIDS.     

Resurgence of HIV Infection among Men Who Have Sex with Men in Switzerland: Mathematical Modelling Study

Background

New HIV infections in men who have sex with men (MSM) have increased in Switzerland since 2000 despite combination antiretroviral therapy (cART). The objectives of this mathematical modelling study were: to describe the dynamics of the HIV epidemic in MSM in Switzerland using national data; to explore the effects of hypothetical prevention scenarios; and to conduct a multivariate sensitivity analysis.

Methodology/Principal Findings

The model describes HIV transmission, progression and the effects of cART using differential equations. The model was fitted to Swiss HIV and AIDS surveillance data and twelve unknown parameters were estimated. Predicted numbers of diagnosed HIV infections and AIDS cases fitted the observed data well. By the end of 2010, an estimated 13.5% (95% CI 12.5, 14.6%) of all HIV-infected MSM were undiagnosed and accounted for 81.8% (95% CI 81.1, 82.4%) of new HIV infections. The transmission rate was at its lowest from 1995–1999, with a nadir of 46 incident HIV infections in 1999, but increased from 2000. The estimated number of new infections continued to increase to more than 250 in 2010, although the reproduction number was still below the epidemic threshold. Prevention scenarios included temporary reductions in risk behaviour, annual test and treat, and reduction in risk behaviour to levels observed earlier in the epidemic. These led to predicted reductions in new infections from 2 to 26% by 2020. Parameters related to disease progression and relative infectiousness at different HIV stages had the greatest influence on estimates of the net transmission rate.

Conclusions/Significance

The model outputs suggest that the increase in HIV transmission amongst MSM in Switzerland is the result of continuing risky sexual behaviour, particularly by those unaware of their infection status. Long term reductions in the incidence of HIV infection in MSM in Switzerland will require increased and sustained uptake of effective interventions.     

Patterns of primary care of patients infected with human immunodeficiency virus.

To determine the patterns of care of patients infected with the human immunodeficiency virus (HIV), data from 2 sources were analyzed. Initial data obtained from the Washington State HIV/Acquired Immunodeficiency Syndrome (AIDS) Epidemiology Unit indicate that 46% of patients with class IV AIDS were seen by physicians who reported fewer than 5 patients with AIDS, and 68% of all Washington physicians who reported treating patients with AIDS have reported only 1 patient. Subsequent data obtained from a questionnaire distributed in 4 Northwest states suggest that 74% of primary care internists and 73% of family practitioners have some experience in caring for patients with HIV infection, but most of these physicians report fewer than 6 patients in the past 2 years. Although most providers seeing large numbers of HIV-infected patients in their practices were based in the region''s major metropolitan area, 59% of the internists and 55% of the family practitioners surveyed outside of the metropolitan area had seen at least 1 HIV-infected patient in their practices. These results suggest that primary care physicians with relatively little experience treating HIV infection are providing care for a large number of HIV-infected persons. Further study is needed to determine the extent and quality of care provided.     

Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies.

OBJECTIVE: To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams. DESIGN: One year retrospective and a 2 1/2 year prospective study. SETTING: Two hospitals in West London and 88 general practitioners in 72 general hospitals. SUBJECTS: 209 adults with HIV infection. INTERVENTION: General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced. MAIN OUTCOME MEASURES: Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners. RESULTS: The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved. CONCLUSIONS: This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success.     

Twenty years of human immunodeficiency virus infection in Croatia--an epidemic that is still in an early stage

Croatia has a low-level HIV epidemic; 553 persons were diagnosed with HIV infection in the period 1985-2005. The principal mode of transmission was sex between men (40% of cases) and heterosexual contact (40%). Only about 10% of cases were injecting drug users. Testing data also suggest a low prevalence of HIV infection in Croatia, even in vulnerable groups. Behavioral data indicate risky sexual behaviors, with the clear need for interventions. National policy towards HIVIAIDS is operated through the National Committee on HIV/AIDS, a multisectorial advisory body to the Government of Croatia. Croatia applied to the Global Fund to fight AIDS, tuberculosis and malaria in 2002 which resulted in a 4,9 million USD grant for scaling up prevention interventions. Croatia has a centralized system of treatment and care which is provided at the University Hospital for Infectious Diseases in Zagreb. Highly active antiretroviral treatment is provided free of charge from April 1998.     

Outcomes and Impact of HIV Prevention,ART and TB Programs in Swaziland – Early Evidence from Public Health Triangulation

Introduction

Swaziland’s severe HIV epidemic inspired an early national response since the late 1980s, and regular reporting of program outcomes since the onset of a national antiretroviral treatment (ART) program in 2004. We assessed effectiveness outcomes and mortality trends in relation to ART, HIV testing and counseling (HTC), tuberculosis (TB) and prevention of mother to child transmission (PMTCT).

Methods

Data triangulated include intervention coverage and outcomes according to program registries (2001-2010), hospital admissions and deaths disaggregated by age and sex (2001-2010) and population mortality estimates from the 1997 and 2007 censuses and the 2007 demographic and health survey.

Results

By 2010, ART reached 70% of the estimated number of people living with HIV/AIDS with CD4<350/mm³, with progressively improving patient retention and survival. As of 2010, 88% of health facilities providing antenatal care offered comprehensive PMTCT services. The HTC program recorded a halving in the proportion of adults tested who were HIV-infected; similarly HIV infection rates among HIV-exposed babies halved from 2007 to 2010. Case fatality rates among hospital patients diagnosed with HIV/AIDS started to decrease from 2005–6 in adults and especially in children, contrasting with stable case fatality for other causes including TB. All-cause child in-patient case fatality rates started to decrease from 2005–6. TB case notifications as well as rates of HIV/TB co-infection among notified TB patients continued a steady increase through 2010, while coverage of HIV testing and CPT for co-infected patients increased to above 80%.

Conclusion

Against a background of high, but stable HIV prevalence and decreasing HIV incidence, we documented early evidence of a mortality decline associated with the expanded national HIV response since 2004. Attribution of impact to specific interventions (versus natural epidemic dynamics) will require additional data from future household surveys, and improved routine (program, surveillance, and hospital) data at district level.     

The Increased Effectiveness of HIV Preventive Intervention among Men Who Have Sex with Men and of Follow-Up Care for People Living with HIV after ‘Task-Shifting’ to Community-Based Organizations: A ‘Cash on Service Delivery’ Model in China

Background

A large number of men who have sex with men (MSM) and people living with HIV/AIDS (PLHA) are underserved despite increased service availability from government facilities while many community based organizations (CBOs) are not involved. We aimed to assess the feasibility and effectiveness of the task shifting from government facilities to CBOs in China.

Methods

HIV preventive intervention for MSM and follow-up care for PLHA were shifted from government facilities to CBOs. Based on ‘cash on service delivery’ model, 10 USD per MSM tested for HIV with results notified, 82 USD per newly HIV cases diagnosed, and 50 USD per PLHA received a defined package of follow-up care services, were paid to the CBOs. Cash payments were made biannually based on the verified results in the national web-based HIV/AIDS information system.

Findings

After task shifting, CBOs gradually assumed preventive intervention for MSM and follow-up care for PLHA from 2008 to 2012. HIV testing coverage among MSM increased from 4.1% in 2008 to 22.7% in 2012. The baseline median CD4 counts of newly diagnosed HIV positive MSM increased from 309 to 397 cells/µL. HIV tests among MSM by CBOs accounted for less than 1% of the total HIV tests in Nanjing but the share of HIV cases detected by CBOs was 12.4% in 2008 and 43.6% in 2012. Unit cost per HIV case detected by CBOs was 47 times lower than that by government facilities. The coverage of CD4 tests and antiretroviral therapy increased from 71.1% and 78.6% in 2008 to 86.0% and 90.1% in 2012, respectively.

Conclusion

It is feasible to shift essential HIV services from government facilities to CBOs, and to verify independently service results to adopt ‘cash on service delivery’ model. Services provided by CBOs are cost-effective, as compared with that by government facilities.     

The determinants of the spread of HIV among injection drug addicts in Ukraine

The main tendencies in the development of drug addiction in the Ukraine, the dynamics of the spread of HIV among drug addicts introducing drugs intravenously, epidemiological data on HIV, AIDS and drug addiction, as well as prognoses on the development of HIV infection are presented. Since 1995 the number of HIV-infected persons grew 34-fold, the number of cases of HIV infection resulting from the intravenous use drugs rose to 70% simultaneously with the rise (about 34-fold) of the number of persons infected with HIV through sexual contacts (about 13 fold). In 1996-1997 such tendency increased. On the whole, the proportion of drug addicts introducing drugs by intravenous injection was 83% in the Ukraine. By April 1, 1998, official registration covered 18,800 HIV-infected persons, including 270 foreign nationals, as well as 499 AIDS patients, including 487 Ukrainian citizens, among them 28 children. Out of 18,800 HIV-infected persons, 78.3% were drug addicts, most of them young people aged 15-30 years; about 18% were young people under 20 years of age, 80% being males. According to the model the rapid spread of HIV from the group of drug addicts to the heterosexual population, the total number of HIV-infected persons reaching 1,500,000 is expected in the country by 2014.     

The Vancouver Lymphadenopathy-AIDS Study: 5. Antecedent behavioural,clinical and laboratory findings in patients with AIDS and HIV-seropositive controls.

In a group of homosexual men in Vancouver studied prospectively since November 1982, 26 cases of acquired immune deficiency syndrome (AIDS) have arisen. To identify behavioural, clinical and laboratory findings that might predict the development of AIDS in people with antibody to human immunodeficiency virus (HIV), we compared data for 25 patients with AIDS with corresponding data for 80 controls serologically positive for HIV selected from the cohort. The clinical and laboratory data for the patients with AIDS preceded the diagnosis of the syndrome by a mean of 17.5 months. The controls had been both seropositive and AIDS-free for a mean of 16.7 months after acquisition of their data. We detected significant differences between the patients with AIDS and the controls in IgG and IgA levels, absolute number of helper T cells and ratio of helper to suppressor T cells but not in lifetime number of male sexual partners, frequency of receptive anal intercourse or receptive fisting, illicit drug use or history of infectious disease. We also detected an increased risk of AIDS among those who had an elevated number of sexual contacts in AIDS-endemic areas in the 5 years before enrollment. A history of increased early sexual contact in AIDS-endemic areas is likely to be associated with early infection and with an increased risk of AIDS among men with HIV infection of unknown duration. Thus, although our analysis had limited statistical power, we conclude that most lifestyle variables appear to act as exposure factors in HIV infection but not as cofactors in the development of AIDS.     

Late Diagnosis and Entry to Care after Diagnosis of Human Immunodeficiency Virus Infection: A Country Comparison

Background

Testing for HIV infection and entry to care are the first steps in the continuum of care that benefit individual health and may reduce onward transmission of HIV. We determined the percentage of people with HIV who were diagnosed late and the percentage linked into care overall and by demographic and risk characteristics by country.

Methods

Data were analyzed from national HIV surveillance systems. Six countries, where available, provided data on two late diagnosis indicators (AIDS diagnosis within 3 months of HIV diagnosis, and AIDS diagnosis within 12 months before HIV diagnosis) and linkage to care (≥1 CD4 or viral load test result within 3 months of HIV diagnosis) for people diagnosed with HIV in 2009 or 2010 (most recent year data were available).

Principal Findings

The percentage of people presenting with late stage disease at HIV diagnosis varied by country, overall with a range from 28.7% (United States) to 8.8% (Canada), and by transmission categories. The percentage of people diagnosed with AIDS who had their initial HIV diagnosis within 12 months before AIDS diagnosis varied little among countries, except the percentages were somewhat lower in Spain and the United States. Overall, the majority of people diagnosed with HIV were linked to HIV care within 3 months of diagnosis (more than 70%), but varied by age and transmission category.

Conclusions

Differences in patterns of late presentation at HIV diagnosis among countries may reflect differences in screening practices by providers, public health agencies, and people with HIV. The percentage of people who received assessments of immune status and viral load within 3 months of diagnosis was generally high.     

What Triggers a Diagnosis of HIV Infection in the Tokyo Metropolitan Area? Implications for Preventing the Spread of HIV Infection in Japan

Background

Japan has not succeeded in reducing the annual number of new HIV-infected patients, although the prevalence of HIV infection is low (0.02%).

Methods

A single-center observational study was conducted at the largest HIV clinic in Tokyo, which treats 15% of the total patients in Japan, to determine the reasons for having diagnostic tests in newly infected individuals. HIV-infected patients who visited our clinic for the first time between 2011 and 2014 were analyzed.

Results

The 598 study patients comprised one-third of the total reported number of new patients in Tokyo during the study period. 76% were Japanese MSM. The reasons for being tested which led to the diagnosis was voluntary testing in 32%, existing diseases in 53% (AIDS-defining diseases in 22%, sexually transmitted infections (STI) in 8%, diseases other than AIDS or STIs in 23%) and routine pre-surgery or on admission screening in 15%. 52% and 74% of the study patients and patients presented with AIDS, respectively, had never been tested. The median CD4 count in patients with history of previous testing (315/μL) was significantly higher than that of patients who had never been tested (203/μL, p<0.001).

Conclusions

Only 32% of the newly HIV diagnosed patients were diagnosed because of voluntary testing, and 53% were diagnosed due to presence of other diseases. These results remain unchanged from our previous report 10 years earlier (2000–2004) on newly diagnosed patients at the same clinic. HIV testing has not been widely used by newly diagnosed patients in the Tokyo metropolitan area.     

Emerging technologies for point-of-care CD4 T-lymphocyte counting

A CD4 T-lymphocyte count determines eligibility for antiretroviral therapy (ART) in patients recently diagnosed with HIV and also monitors the efficacy of ART treatment thereafter. ART slows the progression of HIV to AIDS. In the developing world, CD4 tests are often performed in centralized laboratories, typically in urban areas. The expansion of ART programs into rural areas has created a need for rapid CD4 counting because logistical barriers can delay the timely dissemination of test results and affect patient care through delay in intervention or loss of follow-up care. CD4 measurement at the point-of-care (POC) in rural areas could help the facilitation of ART and monitoring of treatment. This review highlights recent technology developments with applications towards determining CD4 counts at the POC.     

Decline in mortality,AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland

Objective To describe changes in demographic factors, disease progression, hospital admissions, and use of antiretroviral therapy in children with HIV.Design Active surveillance through the national study of HIV in pregnancy and childhood (NSHPC) and additional data from a subset of children in the collaborative HIV paediatric study (CHIPS).Setting United Kingdom and Ireland.Participants 944 children with perinatally acquired HIV-1 under clinical care.Main outcome measures Changes over time in progression to AIDS and death, hospital admission rates, and use of antiretroviral therapy.Results 944 children with perinatally acquired HIV were reported in the United Kingdom and Ireland by October 2002; 628 (67%) were black African, 205 (22%) were aged ≥ 10 years at last follow up, 193 (20%) are known to have died. The proportion of children presenting who were born abroad increased from 20% in 1994-5 to 60% during 2000-2. Mortality was stable before 1997 at 9.3 per 100 child years at risk but fell to 2.0 in 2001-2 (trend P < 0.001). Progression to AIDS also declined (P < 0.001). From 1997 onwards the proportion of children on three or four drug antiretroviral therapy increased. Hospital admission rates declined by 80%, but with more children in follow up the absolute number of admissions fell by only 26%.Conclusion In children with HIV infection, mortality, AIDS, and hospital admission rates have declined substantially since the introduction of three or four drug antiretroviral therapy in 1997. As infected children in the United Kingdom and Ireland are living longer, there is an increasing need to address their medical, social, and psychological needs as they enter adolescence and adult life.     

The acquired immune deficiency syndrome and epidemic of infection with human immunodeficiency virus: costs of care and prevention in an inner London district.

The epidemic of the acquired immune deficiency syndrome (AIDS) and infection with human immunodeficiency virus (HIV) necessitates early planning of services and allocation of resources. The use of hospital resources by patients with AIDS and the planned additional costs of clinical and preventive services for the epidemic of infection with HIV were calculated for an inner London health district that has treated 18% of the cases in the United Kingdom. Patients with AIDS required on average 50 days of inpatient hospital care each at an estimated current average lifetime cost of pounds 6800. These costs, however, underestimated the additional capital and revenue costs of planned new preventive and treatment services, estimated as being pounds 388,000 revenue and pounds 472,000 capital for 1986-7. It is important to invest now in preventive services throughout the United Kingdom to reduce the future social and financial costs of AIDS.     

Funding policies for HIV and AIDS: time for change.

Funding for HIV and AIDS in England has been allocated to regions by a formula based on the number of cases of AIDS and HIV infection and on population size. Regions have distributed the resources directly to hospitals and community services. A survey of staff and managers in North East Thames region showed that funding arrangements have led to unsatisfactory development of services for HIV and AIDS. Firstly, because hospitals are funded according to current numbers of patients services are highly developed at the central London hospitals and underdeveloped in outer districts. Secondly, specialised community care teams have been established rather than integrating care for HIV and AIDS into generic primary care. Thirdly, the information on district of residence of infected patients is inaccurate, limiting allocation of funds according to population needs. Fourthly, prevention of infection has been given far less attention than treatment and care despite the lack of effective treatment. In future allocations for HIV and AIDS should be made to purchasers rather than directly to providers.