Debrework Zewdie

Coming to terms with complexity : a call to action for HIV prevention

A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to prevent it, yet every day, around the world, nearly 7000 people become infected with the virus. Although HIV prevention is complex, it ought not to be mystifying. Local and national achievements in curbing the epidemic have been myriad, and have created a body of evidence about what works, but these successful approaches have not yet been fully applied. Essential programmes and services have not had sufficient coverage; they have often lacked the funding to be applied with sufficient quality and intensity. Action and funding have not necessarily been directed to where the epidemic is or to what drives it. Few programmes address vulnerability to HIV and structural determinants of the epidemic. A prevention constituency has not been adequately mobilised to stimulate the demand for HIV prevention. Confident and unified leadership has not emerged to assert what is needed in HIV prevention and how to overcome the political, sociocultural, and logistic barriers in getting there. We discuss the combination of solutions which are needed to intensify HIV prevention, using the existing body of evidence and the lessons from our successes and failures in HIV prevention.

What policymakers should know about drug resistance and adherence in the context of scaling-up treatment of HIV infection.

With the imminent massive scale up of antiretroviral therapy in developing countries concerns have been raised regarding the spectre of widespread viral drug resistance. These concerns should not lead to a slowing of the pace at which these life-preserving medications are made available to the millions in need in those countries. With proper HAART regimens and proper adherence, development of drug resistance is not a common event. Increasing simplicity of antiretroviral drug regimens, as well as supportive services, promote adherence and have been shown to lead to extremely high therapeutic success rates in both developed and developing countries. Moreover, the possibility of drug resistance has not discouraged industrialized countries from offering universal access to antiretrovirals. If anything, the situation in developing countries, where few patients have been previously exposed to suboptimal drug regimens and where a public health approach may be taken to the treatment of HIV infection, is in many respects more favourable to the prevention of widespread viral drug resistance than that in the developed world. This conclusion is underscored by available evidence presented in this supplement. Experience in developing countries also suggests that greater treatment access will help alleviate HIV-related stigma and provide major new incentives for individuals to learn their serostatus, thus strengthening prevention efforts.

HIV-1 in Ethiopia : phylogenetic divergence from other HIV-1 strains

Phylogenetic tree analysis was performed on selected polymerase chain reaction (PCR)-amplified and sequenced regions of the gag and env reading frames of several Ethiopian and Swedish human immunodeficiency virus type 1 (HIV-1) strains. These regions are considered to be conserved parts of the HIV-1 genome and correspond to the p7 of the core (gag) and part of the carboxy terminal of the gp41 protein of env respectively. Comparisons were made with all available HIV-1 sequences.The tree analysis showed that gag sequences from nine and env sequences from four Ethiopian strains all grouped together in separate branches distinct from all other sequenced European, North American, and African HIV-1 isolates. Thus, the Ethiopian strains seem to represent a highly divergent group of HIV-1, which might have developed during a relatively early stage of HIV-1 evolution.

Relationship between cell-free viraemia, antigenaemia and antibody levels in HIV-1-infected Ethiopian patients.

ObjectiveTo determine the relationship and occurrence of cell-free viraemia, free or immune-complexed p24-antigen and p24-antibody levels in blood from HIV-1-infected patients in Ethiopia. MethodsPeripheral blood was obtained from 66 Ethiopian and 137 Swedish HIV-1-seropositive patients. Blood samples were analysed for free or immune-complex bound p24 antigen by enzyme-linked immunosorbent assay before and after acid hydrolysis of immune complexes for infectious virus in plasma and peripheral blood mononuclear cells (PBMC), and for p24-antibody levels. We compared the kinetics of viral replication of Ethiopian with Swedish isolates in vitro. ResultsInfectious virus was isolated from PBMC in 95% and from plasma in 81% of Ethiopian AIDS patients. In contrast, p24 antigen was detected in only 5% of AIDS patients from Ethiopia, compared with 76% of those from Sweden. p24-antibody levels were much higher and more persistent in Ethiopian than in Swedish subjects. The ratio between reverse transcriptase activity and p24 antigen was significantly higher in Ethiopian isolate culture than in those of the Swedish isolates. ConclusionsOur results show that relationships between viraemia, p24 antigenaemia and p24-antibody levels in HIV-1-infected Ethiopian patients differ from those found in comparable Swedish patients. This pattern may partly explain the differences seen in the natural course of HIV-1 infection in Ethiopia and Sweden.