Bernard Taverne

Access to antiretroviral drugs and Aids management in Senegal

ObjectivesDescription and analysis of the Senegalese Antiretroviral Drug Access Initiative (ISAARV), the first governmental highly active antiretroviral therapy (HAART) treatment programme in Africa, launched in 1998. Methods and resultsISAARV was initially an experimental project designed to evaluate the feasibility, efficacy and acceptability of HAART in an African context. It was based on four principles: collective definition of the strategy, with involvement of the health professionals who would be called on to execute the programme; matching the objectives to available means (gradual enrollment according to drug availability); monitoring by several research programmes; and ongoing adaptation of treatment and follow-up according to the latest international recommendations.Persons qualifying for antiretroviral (ARV) therapy are selected on the basis of immunological and clinical criteria, regardless of economic and social considerations. A system of subsidies was created to favor access to ARV. Following the ARV price reductions that occurred in November 2000, 100% subsidies were created for the poorest participants. Optimal adherence was ensured by monthly follow-up by pharmacists and support groups held by social workers and patient associations. The chosen supply and distribution system allowed drug dispensing to be strictly controlled. ConclusionThe ISAARV programme demonstrates that HAART can be successfully prescribed in Africa. This experience has served as the basis for the creation of a national treatment programme in Senegal planned to treat 7000 patients by 2006.

Revisiting Long-Term Adherence to Highly Active Antiretroviral Therapy in Senegal Using Latent Class Analysis

Background:Adherence is one of the main predictors of antiretroviral treatment success. A governmental initiative was launched in 1998 for HIV-infected patients in Senegal to provide access to highly active antiretroviral therapy. Methods:Between August 1998 and April 2002, 404 adult patients were enrolled. Adherence measurements, defined as pills taken/pills prescribed, were assessed between November 1999 and April 2009 using a pill count along with a questionnaire for 330 patients. Predictors of adherence were explored through a random-intercept Tobit model and a latent class analysis (LCA) was performed to identify adherence trajectories. We also performed a survival analysis taking into account gender and latent adherence classes. Results:Median treatment duration was 91 months (interquartile range, 84-101). On average, adherence declined by 7% every year, was 30% lower for patients taking indinavir, and 12% higher for those receiving cotrimoxazole prophylaxis. Based on the predicted probability of having an adherence ≥ 95%, LCA revealed 3 adherence behaviors and a better adherence for women. A quarter of patients had a high adherence trajectory over time and half had an intermediate one. Male gender and low adherence behavior over time were independently associated with a higher mortality rate. Conclusions:This study shows that an overall good adherence can be obtained in the long term in Senegal. LCA suggests a better adherence for women and points out a large subsample of patients with intermediate level of adherence behavior who are at risk for developing resistance to antiretroviral drugs. This study warrants further research into gender issues.

Diabetes and Hypertension among Patients Receiving Antiretroviral Treatment Since 1998 in Senegal: Prevalence and Associated Factors

Cardiovascular risk factors in people on antiretroviral treatment (ART) are poorly documented in resource-constrained settings. A cross-sectional study was conducted in 2009 to assess prevalence of diabetes and hypertension in a sample of 242 HIV-infected patients who had initiated ART between 1998 and 2002 in Dakar, Senegal (ANRS 1215 observational cohort). World Health Organization (WHO) criteria were applied to diagnose diabetes and hypertension. Multiple logistic regressions were used to identify factors associated with diabetes and hypertension. Patients had a median age of 46 years and had received ART for a median duration of about 9 years. 14.5% had diabetes and 28.1% had hypertension. Long duration of ART (≥119 months), older age, higher body mass index (BMI), and higher levels of total cholesterol were associated with higher risks of diabetes. Older age, higher BMI at ART initiation, and higher levels of triglycerides were associated with higher risk of hypertension. This study shows that diabetes and hypertension were frequent in these Senegalese HIV patients on ART. It confirms the association between duration of ART and diabetes and highlights the need to implement programs for prevention of cardiovascular risk factors in HIV patients from resource-constrained settings.

Reduced Quantitative Ultrasound Bone Mineral Density in HIV-Infected Patients on Antiretroviral Therapy in Senegal

Background Bone status in HIV-infected patients on antiretroviral treatment (ART) is poorly documented in resource-limited settings. We compared bone mineral density between HIV-infected patients and control subjects from Dakar, Senegal. Methods A total of 207 (134 women and 73 men) HIV-infected patients from an observational cohort in Dakar (ANRS 1215) and 207 age- and sex-matched controls from the general population were enrolled. Bone mineral density was assessed by quantitative ultrasound (QUS) at the calcaneus, an alternative to the reference method (i.e. dual X-absorptiometry), often not available in resource-limited countries. Results Mean age was 47.0 (±8.5) years. Patients had received ART for a median duration of 8.8 years; 45% received a protease inhibitor and 27% tenofovir; 84% had undetectable viral load. Patients had lower body mass index (BMI) than controls (23 versus 26 kg/m2, P<0.001). In unadjusted analysis, QUS bone mineral density was lower in HIV-infected patients than in controls (difference: −0.36 standard deviation, 95% confidence interval (CI): −0.59;−0.12, P = 0.003). Adjusting for BMI, physical activity, smoking and calcium intake attenuated the difference (−0.27, CI: −0.53;−0.002, P = 0.05). Differences in BMI between patients and controls explained a third of the difference in QUS bone mineral density. Among patients, BMI was independently associated with QUS bone mineral density (P<0.001). An association between undetectable viral load and QUS bone density was also suggested (β = 0.48, CI: 0.02;0.93; P = 0.04). No association between protease inhibitor or tenofovir use and QUS bone mineral density was found. Conclusion Senegalese HIV-infected patients had reduced QUS bone mineral density in comparison with control subjects, in part related to their lower BMI. Further investigation is needed to clarify the clinical significance of these observations.

Call for action to secure universal access to ART in developing countries

1 Usher AD. GAVI enters its second decade with massive funding gap. Lancet 2010; 375: 791. 2 Bill & Melinda Gates Foundation. Bill and Melinda Gates pledge

Anticiper les flambées épidémiques à virus Ebola : pas sans les sciences sociales !

10 billion in call for decade of vaccines. http://www. gatesfoundation.org/press-releases/Pages/ decade-of-vaccines-wec-announcement -100129.aspx (accessed April 7, 2010). 3 Davos 2010 Press Conference. Bill & Melinda Gates Foundation pledges new commitment to vaccines. Jan 29, 2010. http://www.livestream.com/ worldeconomicforum03/video?clipId=pl a_0a5ad43d-be31-42e8-b92479b5fd46885e (accessed April 22, 2010).

Mobilising experience from Ebola to address plague in Madagascar and future epidemics

L’utilite des sciences sociales pour faire face a l’epidemie a virus Ebola ne fait plus debat aujourd’hui. Dans les pays en situation epidemique, des chercheurs en sciences sociales (anthropologues et sociologues) ont ete precocement associes a la reponse pour adapter les messages d’information vers la population, favoriser l’acceptation des decisions de sante publique (surveillance communautaire des cas suspects, isolement des cas confirmes, enterrements securises, etc.), pour « humaniser » les pratiques de soins et les pratiques funeraires ; mais aussi pour evaluer les impacts sociaux de l’epidemie. Une experience de la contribution des sciences sociales a ete acquise dans l’action sur le terrain. Dans les pays voisins d’un foyer epidemique, les systemes de sante tentent de prevenir une flambee epidemique tout en s’y preparant. Ils anticipent l’organisation de la reponse medicale pour prendre en charge les malades et limiter les transmissions en disposant des equipements, en formant le personnel medical, en definissant des espaces de soins, etc. Les connaissances empiriques acquises dans les pays les plus touches permettent aux autres pays de se preparer mieux et plus vite, en ameliorant la strategie et les procedures. Les sciences sociales doivent etre associees a cette preparation des systemes de sante car desormais les epidemies « se precedent elles-memes », au sens ou la diffusion des interpretations et leurs effets sociaux precedent celle du virus. Une des consequences de l’acceleration et de la globalisation des echanges d’informations est qu’ avant meme qu’un cas ne soit avere dans une region ou un pays, des rumeurs, interpretations conspirationnistes (par exemple : c’est une maladie importee par les Occidentaux, c’est le vaccin qui inocule la maladie, etc.) ou des politiques (interferant avec les messages sanitaires destines a la population), reactions xenophobes, revendications de fermeture des frontieres ou refus des dispositifs de traitement sont deja en place. De plus, la vulnerabilite des pays a l’epidemie depend etroitement de determinants sociaux preexistants qu’il faut comprendre, pour ajuster la reponse, tels que les flux migratoires entre pays et le statut des frontieres par rapport aux decoupages identitaires, l’acceptabilite du dispositif de prevention et depistage de la maladie mis en place, les rapports de la population au systeme de sante, les tensions intercommunautaires, la memoire d’autres epidemies qui conditionne les attitudes, l’intervention de l’Etat sur un mode repressif ou inclusif vis-a-vis des societes civiles, les parti-pris des medias, etc. La propagation de l’epidemie a virus Ebola en Afrique de l’Ouest a revele la fragilite et les defaillances des systemes de sante des pays touches. Au-dela de la reponse immediate a l’epidemie, la contribution des sciences sociales doit, a present, se situer dans une perspective d’analyse des causes sociales et politiques, locales et globales, de cette epidemie. Il est egalement temps d’envisager des a present la situation post-Ebola, dans la perspective de la promotion de la sante, qui prenne en compte les aspects politiques (de gouvernance), sociaux (l’engagement de la societe civile), economiques et culturels.Comme toute discipline scientifique, les sciences sociales necessitent des ressources specifiques et du temps de travail, pour etudier ces aspects sociaux, et pouvoir accompagner les reponses aux defaillances des systemes sanitaires ou a la defiance des populations. Dans plusieurs pays a risque epidemique d’Afrique de l’Ouest, des equipes de sciences sociales ont engage des recherches sur la maladie a virus Ebola et participent aux dispositifs nationaux de reponse. Elles se sont regroupees au sein d’un reseau pour favoriser leurs echanges et pour developper une approche regionale de l’epidemie. Or, a ce jour, la plupart de ces equipes peinent encore a trouver les financements qui leur permettraient de developper des etudes pourtant indispensables.L’urgence est de soutenir financierement et institutionnellement les recherches en sciences sociales, a l’echelon regional, dans les pays a risque epidemique : les decideurs doivent en etre conscients et leur accorder les moyens de leur action.

Impact a long terme des traitements antiretroviraux en Afrique, etat des connaissances

www.thelancet.com Published online November 28, 2017 http://dx.doi.org/10.1016/S0140-6736(17)33088-X 1 the rapid knowledge, attitudes, beliefs, and practices surveys proposed by many public health programmes; and adapting public health measures to local contexts. As the Madagascar plague epidemic expands, expert knowledge gained from the Ebola virus disease epidemic will be crucial to address topics that are relevant to both diseases—for example, avoidance of patients by health workers, hiding of the sick by their relatives, resistance to contact tracing and safe burials, over-reaction of the media, and discordance between the biomedical and lay representations of the illness. Anthropologists in Madagascar have been asked to examine burial practices, therapeutic itineraries, and the population’s relationship to (and fear of) global health interventions. Although the contexts are different from the west African Ebola virus disease epidemic, this previous experience is useful to help anthropologists face current situations. On Oct 22, 2017, an epidemic of Marburg virus disease was declared at the Uganda–Kenya border, and social scientists should be rapidly identi fied to join in emergency response efforts. As highlighted by anthropologists working on plague response in Madagascar, relevant connections with other scholars are essential. The contribution of anthropology to addressing the Marburg virus disease epidemic should include circulating relevant theoretical and practical knowledge within the social sciences, adapting findings to share with public health professionals and clinicians, developing appropriate research methodologies, and translating individual experience into collective knowledge and skills. Networks in medical anthropology should be supported to work toward this emergency epidemic preparedness, engage more anthropologists in rapid response efforts, and develop complementary in-depth studies related to haemorrhagic fevers, plague, and other epidemics. Mobilising experience from Ebola to address plague in Madagascar and future epidemics

Impact à long terme des traitements antirétroviraux en Afrique, état des connaissances Long-term impact of antiretroviral therapy in Africa: current knowledge

By the end of 2013, 11 million PLHIV were taking ARVs in Africa; application of the WHO recommendation to initiate treatment earlier (at CD4 count of 500 cells/mm3 or less) should further increase this number. Currently, twothirds of patients in Africa have been on treatment for less than five years, and less than 10% have received treatment for eight years or more. Given the historical perspective is in its early stages, the long-term impact of ARV therapy is still unclear. This article reviews the knowledge gained over the period marking the first ten years of implementation of the universal access strategy (2003-2013) in Africa, through a review of the literature documenting the long-term consequence of ARV treatment, focusing on medical care for adults with an emphasis on the patient-centered approach. The goal is to understand the interrelationships between biological and social factors and individual and collective aspects that affect the lives of PLHIV and determine the impacts of ARV treatment over the long term. The biomedical and social factors are addressed successively, based on the most significant results. Key knowledge on the long-term outcomes for PLHIVon ARV treatment offers vital information on the necessary conditions and adaptations for care systems needed to ensure the benefits of treatment endure over time.

[Long-term impact of antiretroviral therapy in Africa: current knowledge].

By the end of 2013, 11 million PLHIV were taking ARVs in Africa; application of the WHO recommendation to initiate treatment earlier (at CD4 count of 500 cells/mm3 or less) should further increase this number. Currently, twothirds of patients in Africa have been on treatment for less than five years, and less than 10% have received treatment for eight years or more. Given the historical perspective is in its early stages, the long-term impact of ARV therapy is still unclear. This article reviews the knowledge gained over the period marking the first ten years of implementation of the universal access strategy (2003-2013) in Africa, through a review of the literature documenting the long-term consequence of ARV treatment, focusing on medical care for adults with an emphasis on the patient-centered approach. The goal is to understand the interrelationships between biological and social factors and individual and collective aspects that affect the lives of PLHIV and determine the impacts of ARV treatment over the long term. The biomedical and social factors are addressed successively, based on the most significant results. Key knowledge on the long-term outcomes for PLHIVon ARV treatment offers vital information on the necessary conditions and adaptations for care systems needed to ensure the benefits of treatment endure over time.