EDITORIAL (pp 1–2)
Extended to two pages per issue covering two or three topics. The first editorial this week (HIV/AIDS: not one epidemic but many) comments that localised solutions to differing HIV/AIDS epidemics will be the key to future success: 'We need to know as much as possible about each epidemic, tracking it in each community, and monitoring the effectiveness of interventions. And we must keep in mind that each epidemic, though interrelated with other epidemics, is essentially a local battle that will be lost or won by people within each community. Community workers must be given the training and resources and independence to devise interventions tailored to their situation. While grand global initiatives are needed to raise funds and to develop new drugs, it will be local people in the field who will defeat the epidemic. As the world's HIV community focuses its attention and enthusiasm next week on the international AIDS conference being held in Bangkok, this lesson must not be forgotten.'
The second editorial discusses the new design changes to the journal and restates our new publication policy: 'The Lancet's editors now encourage authors to post electronic documents of their peer-reviewed and edited papers on personal websites and in institutional archive repositories. Authors do not need our permission to do so. All we ask is that they link their article to The Lancet, which will remain the secure site for the pdf version of their work. This change in policy has been described as a "breakthrough" by open-access advocates. While The Lancet remains a subscription (user-pays) journal, our enthusiastic support for institutional repositories, which can be linked and searched independently of the journal, means that in any ordinary meaning of the phrase, The Lancet's content is now openly and freely accessible. We hope authors will make use of this new facility for open access to their work.'
COMMENT (pp 3–14)
Expanded to 12 pages each week, this section provides analysis of topical issues in medical science and continues to provide context and perspective to key journal content. This week's topics:
Generic antiretroviral drugs--WILL THEY BE THE ANSWER to HIV in the
developing world
* Linked to research article, see research section of press release.
Concurrent sexual partnerships help to explain Africa's high HIV prevalence: implications for prevention
Daniel Halperin and Helen Epstein propose that concurrent sexual partner networks, less male circumcision, and lower condom use associated with longer-term ongoing partnerships are the main reasons why the HIV/AIDS pandemic is having a more devastating effect in east and southern Africa compared with other world regions.
Contact: Dr Daniel Halperin, Office of HIV-AIDS, US Agency for International Development,
Washington, DC 20523, USA;
202-712-4529; or cell 240-535-3327
E)
dhalperin@usaid.gov ; dhalp@worldwidedialup.net
Seizing the opportunity to capitalise on the growing access to HIV treatment to expand HIV prevention
Helene Gayle and Joep Lange outline how expanded access to antiretroviral treatment in resource-poor settings also offers new opportunities to simultaneously strengthen HIV prevention efforts.
Contact: Dr Helene Gale, HIV, TB & Reproductive Health, Bill & Melinda Gates Foundation,
Seattle, WA 98102, USA;
T) 206-709-3400;
E) media@gatesfoundation.org
Unexpected drug interactions and adverse events with antiretroviral drugs
* Linked to research letter, see research section of press release.
HIV escape from cytotoxic T lymphocytes: a potential hurdle for vaccines?
An analysis of recent research about HIV mutation and the possible implications for the development of HIV vaccine strategies.
Contact: Dr Dan H Barouch, Beth Israel Deaconess Medical Center, Harvard Medical
School, Boston, MA 02215, USA;
T) 617-667-4434;
E) dbarouch@bidmc.harvard.edu
The Global Fund to Fight AIDS, Tuberculosis and Malaria: funding for unpopular public-health programmes
An outline of the challenges facing the global fund and individual countries in determining priorities for the funding of HIV programmes.
Contact: Dr Thomas Kerr, Canadian HIV/AIDS Legal Network, Montreal, Quebec H2Y 2M4,
Canada;
T) 514-397-6828 x222;
E) tkerr@aidslaw.ca
Social marketing of condoms is great, but we need more free condoms
A call for the distribution of free condoms as a global HIV prevention strategy.
Contact: Dr Deborah A Cohen, RAND Corporation, Santa Monica, CA 90405, USA;
T)
310-393-0411 ext 6023;
E) dcohen@rand.org
WORLD REPORT (pp 15–18)
A new four-page World Report section will contain one or more in-depth news features each week. The first World Report (An opportunity lost) discusses how a lack of publichealth strategy is undermining the recovery of Iraq's health system.
PERSPECTIVES (pp 19–22)
A four-page section covering reviews (books, the arts), profiles, and obituaries. This week's highlights: a revealing interview with Chinese HIV activist Wan Yanhai, Director of the Aizhixing Institute of Health Education in China; three book reviews, and the obituary of Tim Cullinan ('Tireless champion of community medicine and of the poor in Malawi, the UK, and around the world'). '
CORRESPONDENCE (pp 23–28)
6 pages of lively correspondence from Lancet readers conclude the front section of the journal.
Primary Research
EVIDENCE FOR USE OF TRIPLE COMBINATION GENERIC DRUGS IN LESSDEVELOPED COUNTRIES (p 3, 29)
Results of a trial from Cameroon lend support to the use and funding of a generic fixeddose combination of nevirapine, stavudine and lamivudine as first-line antiretroviral treatment in developing countries.
The lack of clinical evidence from trials is an obstacle for the funding of generic combination antiretrovirals. Christian Laurent and colleagues report how 80% of people given a twice-daily dose of nevirapine, stavudine and lamivudine had no detectable viral load after 6 months of treatment. Authors of an accompanying Commentary conclude: 'there is no question about safety and efficacy of generic antiretrovirals. Generic antiretrovirals will have a major role in WHO's scaling-up of antiretroviral delivery in their 3-by-5 plan in resource-constrained settings. Because of patents by proprietary companies, newer antiretrovirals may not be manufactured by the generic companies, which might be a major obstacle to patients getting drugs in such settings.'
Contact: Marie-Christine Simon, ANRS (The national agency for AIDS research, France) ; T) 33-153-946-030 ; E) marie-christine.simon@anrs.fr
Professer Eric Delaporte, IRD (Institut de Recherche pour le Developpement) / University
of Montpellier, France ;
T) 33-467-416-297 ;
E) eric.delaporte@mpl.ird.fr
(Commentary) Dr N Kumarasamy, YRG Centre for AIDS Research and Education, IACTU/NIH Chennai Site, Voluntary Health Services, Tharamani, Chennai – 600113, India ; T) 91-442-254-2929 ; e) kumarasamy@yrgcare.org
NO DECLINE AND LARGE SUB-REGIONAL DIFFERENCES IN HIV PREVALENCE AND TRENDS IN SUB-SAHARAN AFRICA (p 35)
Only the analysis of surveillance data from the same populations over time can provide insight into trends of HIV prevalence. J Ties Boerma and colleagues compared HIV prevalence in sub-Saharan Africa between 1997 and 2003; this was based on data from 140,000 pregnant women attending over 350 antenatal clinics. Data were also available from 57 urban and regional areas.
HIV prevalence increased by 2.5% to 23.8% in 2003 in 148 of the clinics assessed. At more than half the sites (58%) an increase of at least one-tenth was noted, but at a fifth of sites, prevalence dropped by at least one-tenth; prevalence decreased from around 13% in eastern Africa in 1997 to 8.5% in 2003 on average, although 7% of sites studied showed an increase during this time. Prevalence remained similar in west Africa at around 3.5%. Data from urban areas suggest a stabilisation in HHIV prevalence over the past 2--3 years compared with the previous decade.
Contact: Dr J Ties Boerma, Research, Monitoring, & Evaluation, HIV/AIDS Department,
World Health Organization, CH1211 Geneva, Switzerland;
T) 41-22-791-1481;
E)
boermat@who.int
BEHAVIOURAL INTERVENTIONS COULD PREVENT HIV TRANSMISSION AMONG MEN WHO HAVE SEX WITH MEN (p 41)
To date, no behavioural interventions specifically for men who have sex with men have been tested with HIV infection as the primary outcome. The EXPLORE Study Team did a randomised trial among 4295 participants; half received 10 sessions of one-to-one counselling aimed at reducing risky sexual behaviour (the intervention group), the other half received counselling twice a year.
Men in the intervention group had an 18% slower rate of HIV infection than men in the standard treatment group. Intensive counselling reduced the risky practice of unprotected anal intercourse by around 20%. The investigators comment that the prevention of HIV infection among men who have sex with men by a behavioural intervention is feasible. Further work should be done to develop more effective interventions.
Contact: Dr Beryl A Koblin, Laboratory of Infectious Disease Prevention, The New York
Blood Center, 31O E 67th Street, New York NY 1OO21, USA;
T) 212-570-3000;
E)
bkoblin@nybloodcenter.org or
Professor Thomas Coates, Department of Medicine,
Division of Infectious Diseases, David Geffen School of Medicine, University of California,
Los Angeles 37-121 CHS MC-168817 Los Angeles, CA 90095, USA;
T) 310-794-3580 or
310-367-9044;
E) TCoates@mednet.ucla.edu
WHAT ARE THE TREATMENT PRIORITIES FOR PEOPLE WHO FAIL COMBINATION THERAPY? (p 51)
A CD4-cell count above 200/mL is the goal of combination therapy in patients no longer able to suppress viral replication. In these patients, a positive CD4 response is maintained as long as the viral load remains below 10,000 copies/mL. However, once the viral load increases substantially above this threshold, the CD4 count starts to decrease and patients become at risk of death. These are the main conclusions of a collaborative study from Europe, North America, and Australia.
Author Jens D Lundgren comments: "In patients no longer able to fully suppress viral replication, viral replication remains fairly constant and substantially below the rates seen in untreated patients. Patients in this situation still gain significant clinical benefit from the therapy, but this benefit is likely to be limited in duration. It is crucial that better strategies are developed for the treatment of patients in this situation ".
Contact: Dr Jens D Lundgren, Copenhagen HIV Program, Section 044, Hvidovre University
Hospital, 2650 Copenhagen, Denmark;
T) 45-3632-3015 or 45-4087-9303;
E)
jdl@cphiv.dk
ACHIEVING THE WHO/UNAIDS ANTIRETROVIRAL TREATMENT 3 BY 5 GOAL: WHAT WILL IT COST? (p 63)
The "3 by 5" initiative aims to provide antiretroviral therapy to 3 million people by the end of 2005. Juan Gutierrez and colleagues aimed to estimate the financial costs needed to implement WHO-recommended treatment protocols, by use of countryspecific estimates for 34 countries that account for 90% of the need for antiretroviral therapy in resource-poor settings. The researchers estimate that between US$5·1 billion and US$5·9 billion will be needed by the end of 2005 to provide antiretroviral therapy, support programmes, and cover country-level administrative and logistic costs for 3 by 5.
Contact: Dr Benjamin Johns, Health System Financing, Expenditure and Resource
Allocation (EIP/FER), World Health Organization, CH-1211 Geneva 27, Switzerland;
T) 41-22-791-4582;
E) johnsb@who.int
INCREASED RISK OF PANCREATITIS FROM CO-ADMINISTRATION OF DIDANOSINE AND TENOFIVIR (pp 8, 65)
Authors of a research letter highlight how the taking of two common antiretroviral drugs increases the risk of pancreatitis. Esteban Martínez and colleagues found that 5 out of 185 (2·7%) of patients receiving didanosine plus tenofovir developed pancreatitis compared with 1 patient out of 182 (0·5%) taking only didanosine. No patients taking only tenofovir developed pancreatitis. Graeme Moyle states in an accompanying commentary: "Wherever feasible, novel antiretroviral combinations should be tested in drug-interaction studies and in adequately powered and carefully monitored clinical trials before becoming widely used in clinical practice".
Contact: Dr Esteban Martínez, Infectious Diseases Unit, Hospital Clinic, C/ Villarroel 170,
08036 Barcelona, Spain;
T) 34-93-227-5430;
E) esteban@intercom.es
Dr Graeme Moyle, Chelsea and Westminster Hospital, London SW10 9NH, UK;
T) 44-208-746-8000;
E) gm@moyleg.demon.co.uk
Review and Opinion
HIV/AIDS IN ASIA (p 69)
Praphan Phanuphak and colleagues outline in a seminar how HIV/AIDS epidemics in Asia are far from over, and how several countries--including China, Indonesia, and Vietnam--have growing epidemics.
The authors outline two important factors influencing the scale of the problem: the size of the sex worker population and the frequency with which commercial sex occurs. Issues relevant to developing appropriate highly active antiretroviral treatment programmes in the region are discussed. Although access to antiretroviral therapy is increasing globally, making it work effectively while simultaneously expanding prevention programmes to stem the flow of new infections remains a real challenge in Asia. The authors conclude that 'genuine political interest and commitment are essential foundations for success, demanding advocacy at all levels to drive policy, mobilise sufficient resources, and take effective action'.
Contact: Professor Praphan Phanuphak, The Thai Red Cross AIDS Research Centre,104
Rajdamri Road, Bangkok 10330, Thailand;
E) ppraphan@chula.ac.th
THE CHANGING FACE OF THE HIV EPIDEMIC IN WESTERN EUROPE (p 83)
Authors of a review article comment how, despite substantial reductions in HIV-related illness and death since the introduction of highly active antiretroviral treatment, HIV continues to pose a major public-health problem in western Europe. More than half a million people are living with an infection which remains incurable and requires costly lifelong treatment; many people remain unaware of their infection, and thousands of new infections continue to occur every year.
Emphasis is given on how HIV prevention, treatment, and care must be adapted to reach the most vulnerable groups (such as migrant populations), and that renewed public-health campaigns are needed to counter the increase in risky sexual behaviour among men who have sex with men in Europe.
Contact: Dr Françoise Hamers, c/o Ms Elsa Vidal, Press Officer, Institut de Veille Sanitaire,
12 rue du Val d'Osne, 94415 Saint-Maurice Cedex, France;
T) 33-141-796-959;
E)
e.vidal@invs.sante.fr
THE GLOBAL FUND : MANAGING GREAT EXPECTATIONS (p 95)
A public-health article gives a preliminary assessment on how four countries in sub- Saharan Africa (Mozambique, Tanzania, Uganda, and Zambia) and the Global Fund are collaborating to ensure that funds for HIV programmes are disbursed as effectively as possible. The authors comment that 'new and existing donors need to coordinate assistance to developing countries by bringing together funding, planning, management, and reporting systems if global goals for disease control are to be achieved.'
Contact: Dr Ruairi F Brugha, Health Policy Unit, Department of Public Health & Policy,
London School of Hygiene & Tropical Medicine, London WC1E 7HT;
T) 44-208-809-3793 or 44-795-763-0275;
E) Ruairi.brugha@lshtm.ac.uk
CREATION OF A DRUG FUND FOR POST-CLINICAL TRIAL ACCESS TO ANTIRETROVIRALS (p 101)
Ethical issues concerning ongoing HIV treatment after patients have participated in clinical trials are discussed in a Viewpoint article. Jintanat Ananworanich and colleagues also discuss the success of the HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), established in 1996 to help patients access drug treatment after participation in drug trials. However the authors comment that 'this is not a complete solution. For any developing country, long-term drug supply for patients at the end of a trial can only realistically be sustained if the government provides it. We hope that in the future, our HIV-NAT drug fund will be needed by only a few patients who might need antiretrovirals that are not provided by the government. A drug fund should be a temporary solution until the ultimate goal of access for all is achieved. In the meantime, allocation of institutional income for this purpose should be a priority.'
Contact: Dr Jintanat Ananworanich, HIV-NAT The Red Cross AIDS Research Centre, 104
Rajdumri Road, Pathumwan, Bangkok, 10330 Thailand;
T) 66-2-255-7335 EXT 129;
E)
jintanat.a@chula.ac.th
SCALING UP ACCESS TO ANTIRETROVIRAL TREATMENT IN SOUTHERN AFRICA: WHO WILL DO THE JOB? (p 103)
Reportage from Malawi, Mozambique, Swaziland, and South Africa emphasizes the lack of human resources (predominantly health workers) preventing access to antiretroviral drugs in sub-Saharan Africa.
Author Katharina Kober comments: "In hospitals in South Africa, Malawi, Mozambique, and Swaziland, we have met and talked with health workers who are exhausted from their daily confrontation with AIDS-related suffering and death. It is for these remaining carers and their millions of patients that the international donor community must find solutions for the human resource crisis today rather than tomorrow.'
Contact: Dr Katharina Kober, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium; T) 32-3-247-6478; E) kkober@itg.be or
Dr
Wim Van Damme, Department of Public Health, Institute of Tropical Medicine,
Nationalestraat 155, 2000 Antwerp, Belgium,
T) 32-247-6478;
E) wvdamme@itg.be
HIV AND SEXUAL HEALTH IN THE UK: POLITICS AND PUBLIC HEALTH (p 108)
A Health and Human Rights article comments on the UK's poor sexual health compared with other European countries (such as the 20% year-on-year increase in HIV incidence between 1997 and 2002). Author Lisa Power comments that current government initiatives targeted at immigrant communities and asylum seekers will have little effect on the cost and scale of the UK HIV problem. She comments: "The growing epidemics of HIV and sexual ill-health in the UK are a tragedy, albeit a much smaller one than that of Africa or Asia. They are a tragedy because we have the knowledge and the skills to stop them growing and to reduce them. But as long as sexual health is not a local NHS priority, and as long as the government of the UK prefers politically popular and superficial measures to those that are proven to reduce onward transmission, the UK will continue to lag behind other western countries".
Contact: Ms Lisa Power, Terrence Higgins Trust, c/o Samantha Reddin, press Officer 1117
Lancaster Road, London W11 1QT;
T 44-207-816-8622;
E) samantha.reddin@tht.org.uk
Journal
The Lancet