Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011-2050

Background

Antiretroviral Treatment (ART) significantly reduces HIV transmission. We conducted a cost-effectiveness analysis of the impact of expanded ART in South Africa.

Methods

We model a best case scenario of 90% annual HIV testing coverage in adults 15–49 years old and four ART eligibility scenarios: CD4 count <200 cells/mm³ (current practice), CD4 count <350, CD4 count <500, all CD4 levels. 2011–2050 outcomes include deaths, disability adjusted life years (DALYs), HIV infections, cost, and cost per DALY averted. Service and ART costs reflect South African data and international generic prices. ART reduces transmission by 92%. We conducted sensitivity analyses.

Results

Expanding ART to CD4 count <350 cells/mm³ prevents an estimated 265,000 (17%) and 1.3 million (15%) new HIV infections over 5 and 40 years, respectively. Cumulative deaths decline 15%, from 12.5 to 10.6 million; DALYs by 14% from 109 to 93 million over 40 years. Costs drop $504 million over 5 years and $3.9 billion over 40 years with breakeven by 2013. Compared with the current scenario, expanding to <500 prevents an additional 585,000 and 3 million new HIV infections over 5 and 40 years, respectively. Expanding to all CD4 levels decreases HIV infections by 3.3 million (45%) and costs by $10 billion over 40 years, with breakeven by 2023. By 2050, using higher ART and monitoring costs, all CD4 levels saves $0.6 billion versus current; other ART scenarios cost $9–194 per DALY averted. If ART reduces transmission by 99%, savings from all CD4 levels reach $17.5 billion. Sensitivity analyses suggest that poor retention and predominant acute phase transmission reduce DALYs averted by 26% and savings by 7%.

Conclusion

Increasing the provision of ART to <350 cells/mm3 may significantly reduce costs while reducing the HIV burden. Feasibility including HIV testing and ART uptake, retention, and adherence should be evaluated.     

Risk and Protective Factors for Cigarette Use in Young Adolescents in a School Setting: What Could Be Done Better?

Smoking among Malaysian adolescents remains a public health concern despite concerted efforts in tobacco control. The aims of this study were to examine the prevalence and determinants of current-smoking status in young adolescents. This cross sectional study used the first round of the Malaysian Health and Adolescents Research Team’s prospective cohort study. It was conducted in three States of the Central and Northern regions of Peninsular Malaysia between March and May 2012. The study used the multistage stratified sampling design. A total of 1,342 adolescents of both sexes, aged 12-13 years, were sampled from randomly selected urban and rural national schools. Information on current smoking status and associated factors were collected by a self-administered, pre-tested, validated, structured questionnaire. Seven percent of the samples were current-smokers; the majority (62%) of them started smoking at the age of 11 years or below. The prevalence of current smoking was significantly higher in males (odds ratio [OR] = 2.37; 95% CI: 1.46, 3.84), those who were influenced by smoker friends (OR = 8.35; 95% CI: 4.90, 14.25), who were unaware of the health risks of smoking (OR =1.85; 95% CI: 1.02, 3.36) and who reported a lack of satisfaction about their overall life (OR =3.26; 95% CI: 1.73, 6.12). The study findings provide valuable information to strengthen the existing school-based smoking prevention program through integration of social competence and social influence curricula. The program should empower the young adolescents to refuse tobacco offers, to overcome social influences and to resist peer pressure to avoid starting smoking. Particular focuses to include mental health service to prevent both emotional and behavioural problems are needed.     

Interactions between humic matter and bacteria when disinfecting water with UV light

Aims:  To investigate the impact of aquatic humic matter on the inactivation of Escherichia coli and Bacillus subtilis by ultraviolet (UV) light.
Methods and Results:  A bench-scale study investigated the potential for Aldrich^® humic acid (AHA) and Suwannee River natural organic matter (SR-NOM) to coat the surface of E. coli and B. subtilis and offer protection from low-pressure UV light. UV doses of 5 and 14 mJ cm⁻² were applied using a collimated beam at four concentrations of humic matter (0, 10, 50 and 120 mg l⁻¹) in reagent grade water. Both AHA and SR-NOM were found to offer statistically significant protection of both E. coli and B. subtilis at concentrations of 50 and 120 mg l⁻¹ for a UV dose of 14 mJ cm⁻².
Conclusions:  Both E. coli and B. subtilis are susceptible to coating by humic matter which can reduce the sensitivity of the cells to UV light.
Significance and impact of the study:  Micro-organisms in the environment may acquire characteristics through interaction with humic matter that render them more resistant to UV disinfection than would be predicted based on laboratory inactivation studies using clean cells.     

The use of graft copolymers to inhibit the adhesion of bacteria to solid surfaces

Twelve graft copolymers have been evaluated for their ability to prevent the adhesion of bacteria to substrata. The copolymers had polyethylene glycol (PEG) side-chains (‘teeth’) and a backbone that was either uncharged, acidic, basic or amphoteric. The copolymers were adsorbed onto glass, stainless steel and hydroxyapatite substrata, and 2-hpetri-dish adhesion experiments performed with bacteria isolated from marine (Pseudomonas sp. NCMB 2021), paper mill (S. marcescens NCIB 12211) and oral (S. mutans NCTC 10449) environments. The copolymers containing the most charged groups in the backbone had the most significant effect on bacterial adhesion levels, with anti-adhesive effects up to 99% achieved. An amphoteric copolymer (Compound 12) on glass, and acidic copolymer (Compound 11) on stainless steel and hydroxyapatite gave the most impressive anti-adhesive effects. These copolymers had non-specific bacterial anti-adhesive properties.It is proposed that the graft copolymers adsorbed onto hydrophilic surfaces via their charged backbone in such a way that the PEG side-chains were pointing out into the aqueous phase, and it was this orientation that was responsible for the observed anti-adhesive effect.     

Primary structure and processing of the Candida tsukubaensis alpha-glucosidase. Homology with the rabbit intestinal sucrase-isomaltase complex and human lysosomal alpha-glucosidase.

The nucleotide sequence of a 4.39-kb DNA fragment encoding the alpha-glucosidase gene of Candida tsukubaensis is reported. The cloned gene contains a major open reading frame (ORF 1) which encodes the alpha-glucosidase as a single precursor polypeptide of 1070 amino acids with a predicted molecular mass of 119 kDa. N-terminal amino acid sequence analysis of the individual subunits of the purified enzyme, expressed in the recombinant host Saccharomyces cerevisiae, confirmed that the alpha-glucosidase precursor is proteolytically processed by removal of an N-terminal signal peptide to yield the two peptide subunits 1 and 2, of molecular masses 63-65 kDa and 50-52 kDa, respectively. Both subunits are secreted by the heterologous host S. cerevisiae in a glycosylated form. Coincident with its efficient expression in the heterologous host, the C. tsukubaensis alpha-glucosidase gene contains many of the canonical features of highly expressed S. cerevisiae genes. There is considerable sequence similarity between C. tsukubaensis alpha-glucosidase, the rabbit sucrase-isomaltase complex (proSI) and human lysosomal acid alpha-glucosidase. The cloned DNA fragment from C. tsukubaensis contains a second open reading frame (ORF 2) which has the capacity to encode a polypeptide of 170 amino acids. The function and identity of the polypeptide encoded by ORF 2 is not known.     

Applications of transposition mutagenesis in antibiotic producing streptomycetes

Several transposons have been developed from the streptomycete insertion sequence IS493. They have broad host specificity in Streptomyces species and insert relatively randomly into a consensus target sequence of gNCaNTgNNy. Collectively, they have specialized features that facilitate the following: cloning of DNA flanking insertions; physical mapping of insertions; construction of highly stable mutants; and efficient construction of mutant libraries. All of the transposons can be introduced into streptomycetes by conjugation from E. coli, and can be delivered by curing the temperature sensitive delivery plasmid. Tn5099 was used to physically map genes involved in daptomycin and red pigment production in Streptomyces roseosporus, and to clone daptomycin biosynthetic genes. Tn5099 was also used in Streptomyces fradiae to identify and clone a neutral genomic site for the insertion of a second copy of the tylF gene. Recombinants containing two copies of the tylF gene carried out the no rmally rate limiting conversion of macrocin to tylosin very efficiently, thus causing substantial increases in tylosin yield.