Long-term costs and health impact of continued global fund support for antiretroviral therapy

Background

By the end of 2011 Global Fund investments will be supporting 3.5 million people on antiretroviral therapy (ART) in 104 low- and middle-income countries. We estimated the cost and health impact of continuing treatment for these patients through 2020.

Methods and Findings

Survival on first-line and second-line ART regimens is estimated based on annual retention rates reported by national AIDS programs. Costs per patient-year were calculated from country-reported ARV procurement prices, and expenditures on laboratory tests, health care utilization and end-of-life care from in-depth costing studies. Of the 3.5 million ART patients in 2011, 2.3 million will still need treatment in 2020. The annual cost of maintaining ART falls from $1.9 billion in 2011 to $1.7 billion in 2020, as a result of a declining number of surviving patients partially offset by increasing costs as more patients migrate to second-line therapy. The Global Fund is expected to continue being a major contributor to meeting this financial need, alongside other international funders and domestic resources. Costs would be $150 million less in 2020 with an annual 5% decline in first-line ARV prices and $150–370 million less with a 5%–12% annual decline in second-line prices, but $200 million higher in 2020 with phase out of stavudine (d4T), or $200 million higher with increased migration to second-line regimens expected if all countries routinely adopted viral load monitoring. Deaths postponed by ART correspond to 830,000 life-years saved in 2011, increasing to around 2.3 million life-years every year between 2015 and 2020.

Conclusions

Annual patient-level direct costs of supporting a patient cohort remain fairly stable over 2011–2020, if current antiretroviral prices and delivery costs are maintained. Second-line antiretroviral prices are a major cost driver, underscoring the importance of investing in treatment quality to improve retention on first-line regimens.     

Diet of bluegill Lepomis macrochirus in a South African reservoir during winter and summer

Alien fishes are considered a major threat to aquatic biodiversity in South Africa, yet relatively little regional information on their biology and ecology is available for many of these species. Seasonal changes in the diet of the bluegill Lepomis macrochirus in Howieson’s Poort Dam, Grahamstown, were assessed during summer and winter in 2014–2015, using stomach content analysis. In winter, juvenile and adult fish diets were dominated by crustacean zooplankton and insects, respectively. In summer, juvenile fish fed on crustaceans and insects, whereas adults consumed mostly fish eggs, indicating a potential impact by these invasive fish on native fish through oophagy.     

Phagocytosis as a Biomarker of Immunotoxicity in Wildlife Species Exposed to Environmental Xenobiotics

In the present paper, we are reviewing experimental evidencedemonstrating that phagocytic cells, such as macrophages, maybe used as a biomarker of immunotoxicity in wildlife studies.We will first present data obtained after exposure in vitrowith selected chemicals showing the comparative sensitivityof phagocytic cells from different species. These results demonstratethat, at least for metals, each species produce a similar shapeddose-response curve, although considerate interspecies sensitivityis evident. These results also demonstrate the sensitivity ofthe phagocytic activity, suggesting indeed that this functioncould be used to monitor exposure to chemicals. The similarshaped dose-response curves imply that mechanisms of actionmay also be similar. Furthermore, based on the relative speicessensitivity, sentinel species could be selected for field monitoring.Such an approach may also be useful to establish correctionfactors required to extrapolate results between species. Thissensitivity of the phagocytic activity of macrophages will befurther under controlled conditions in laboratory animal models.Finally, the reliability of this approach will be demonstratedusing case studies with wildlife species.     

The effect of prenatal exposure to the n-butylester of 2,4-dichlorophenoxyacetic acid (2,4-D) on the immune response in mice

Pregnant CD-1 mice were administered the n-butylester of 2,4-dichlorophenoxyacetic acid (2,4-D) by gastric intubation on day 11 of gestation at dosages ranging from 0 to 200 mg/kg (2,4-D content). The immune response in the female offspring was elevated at 6 weeks of age. The humoral immune response, antibody production against sheep red blood cells, was not altered by 2,4-D ester exposure during gestation. The mitogen responses of lymphocytes induced by concanavalin A, a T-lymphocyte mitogen, or by Escherichia coli lipopolysaccharide, a B-lymphocyte mitogen, were reduced in the highest exposure group (200 mg/kg), although the T-lymphocyte suppression was not statistically significant. A similar response pattern was observed in the background nonstimulated lymphocyte cultures, suggesting that the suppression was a generalized lymphocyte abnormality. Evaluation of the mitogen responses using stimulation indices to correct for the variable background responses demonstrated that 2,4-D produced no net suppressive effect in any of the treatment groups. Since in utero 2,4-D ester exposure produced no alterations in humoral immunity and only subtle effects on lymphocyte blastogenesis, it is unlikely to be of any immunotoxicological or immunoteratological significance. Further studies investigating commercial-grade 2,4-D formulations are necessary since these formulations contain other components that may potentially induce alterations in the immune system.     

Biotic unpredictability and sexual reproduction: Do aphid genotype-host genotype interactions favor aphid sexuality?

Summary The possibility that genetic variation among host plants favors sexuality in aphids is explored in the context of Williams and Mitton's (1973) aphid-rotifer model of sib competition. A survey of studies concerning plant resistance to aphids suggests that conditions favoring sexuality can occur where different aphid genotypes are adapted to different host plant species, or where major plant resistance genes differentially affect colonizing success of aphid genotypes. These phenomena are apparently uncommon, however. Thus it is unlikely that genetic heterogeneity among host plants is of major importance for the retention of sexuality in aphid life cycles.     

13C NMR evidence of the slow exchange of tryptophans in dihydrofolate reductase between stable conformations.

¹³C NMR spectra are reported for dihydrofolate reductase of $\text{Streptococcus}\text{faecium}$ labeled with [γ-¹³C]tryptophan. Two of the four tryptophans generate unusual resonances indicating slow exchange of the residues between alternative stable conformations. Since 3′, 5′-dichloromethotrexate sharpens two of the resonances, it apparently locks the corresponding residues into one conformation.     

Molecular phylogenetic and biogeochemical studies of sulfate-reducing bacteria in the rhizosphere of spartina alterniflora

The population composition and biogeochemistry of sulfate-reducing bacteria (SRB) in the rhizosphere of the marsh grass Spartina alterniflora was investigated over two growing seasons by molecular probing, enumerations of culturable SRB, and measurements of SO42- reduction rates and geochemical parameters. SO42- reduction was rapid in marsh sediments with rates up to 3.5 &mgr;mol ml-1 day-1. Rates increased greatly when plant growth began in April and decreased again when plants flowered in late July. Results with nucleic acid probes revealed that SRB rRNA accounted for up to 43% of the rRNA from members of the domain Bacteria in marsh sediments, with the highest percentages occurring in bacteria physically associated with root surfaces. The relative abundance (RA) of SRB rRNA in whole-sediment samples compared to that of Bacteria rRNA did not vary greatly throughout the year, despite large temporal changes in SO42- reduction activity. However, the RA of root-associated SRB did increase from <10 to >30% when plants were actively growing. rRNA from members of the family Desulfobacteriaceae comprised the majority of the SRB rRNA at 3 to 34% of Bacteria rRNA, with Desulfobulbus spp. accounting for 1 to 16%. The RA of Desulfovibrio rRNA generally comprised from <1 to 3% of the Bacteria rRNA. The highest Desulfobacteriaceae RA in whole sediments was 26% and was found in the deepest sediment samples (6 to 8 cm). Culturable SRB abundance, determined by most-probable-number analyses, was high at >10(7) ml-1. Ethanol utilizers were most abundant, followed by acetate utilizers. The high numbers of culturable SRB and the high RA of SRB rRNA compared to that of Bacteria rRNA may be due to the release of SRB substrates in plant root exudates, creating a microbial food web that circumvents fermentation.     

Codon use and the rate of divergence of land plant chloroplast genes

Codon fitnesses for chloroplast genes were estimated using the relative synonymous codon use of psbA, which has a different pattern of codon use than other chloroplast genes and is the major translation product of the chloroplast. These estimates were used to calculate the codon adaptation index (CAI) of chloroplast genes from Marchantia polymorpha, Nicotiana tabacum, and Chlamydomonas reinhardtii. The genes with the highest CAI values in M. polymorpha correspond to those that are expressed at the highest levels. The rate of divergence between M. polymorpha and both C. reinhardtii and N. tabacum is inversely related to the CAI value of the M. polymorpha gene. The data suggest that selection is acting on the synonymous codon use of the highly expressed genes of the M. polymorpha chloroplast genome. The data set is inconclusive about N. tabacum genes, but, as there is a weaker correspondence between CAI value and expression level, it suggests that selection is not operating in this lineage.