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Cambodia has experienced exponential economic growth in recent years and is expected to graduate from least developed country (LDC) status within the next decade. Membership of the World Trade Organization (WTO) will require Cambodia to grant product and process patents for pharmaceuticals upon LDC graduation. This study aims to measure the impact of the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) on the price of HIV and hepatitis C medicine in Cambodia once it graduates from LDC status and is obliged to make patents available for pharmaceutical products and processes. Using scenarios based on likely outcomes of accession to the TRIPS Agreement, it measures the impact on the price of the HIV treatment program and compares that impact with the hepatitis C treatment program. Graduation from LDC status would be expected to result in a modest increase in the cost of the antiretroviral (ARV) treatment program and very large increases in the cost of the direct acting antivirals (DAA) treatment program. If annual treatment budgets remain constant, patent protection could see 1,515 fewer people living with HIV able to access ARV treatment and 2,577 fewer people able to access DAA treatment (a drop in treatment coverage of 93%)., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Fluctuations in global health funding can significantly impact the lives of people who depend on donor-funded programs for life-long care. In this article, I examine shifting HIV policies that expanded antiretroviral therapy (ART) while reducing "care" services meant to improve ART access and adherence. I describe how these changes were experienced by HIV+ women accessing ART at a hospital in Tanzania in 2011-2012, highlighting their increasing precarity and uncertainty for care amidst donor instability and eroding program services. This research suggests that stable funding in support of long-term care services is important to help HIV+ people maintain life-long ART.

In 2019, only 14 European and Central Asian countries provided reimbursed HIV pre-exposure prophylaxis (PrEP). Using EMIS-2017 data, we present the difference between self-reported use and expressed need for PrEP in individual countries and the European Union (EU). We estimate that 500,000 men who have sex with men in the EU cannot access PrEP, although they would be very likely to use it. PrEP's potential to eliminate HIV is currently unrealised by national healthcare systems.

Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health plans (QHPs) for low-income people living with HIV. To date, little has been written about this from the client perspective. The study's objective was to gain information about the experience of Virginia ADAP-funded QHP enrollment and the impact of this change. English-speaking clients who were eligible for ADAP-funded QHPs were recruited at three HIV clinics in Virginia. The goal was to enroll ≥5% of those who were eligible for ADAP-funded QHPs in two Virginia Department of Health planning districts. Participants were surveyed about demographic characteristics, and semi-structured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort ( n  = 53) met our recruitment goal. Two-thirds gained their ACA knowledge at HIV clinics from case managers and social workers. Many barriers to enrollment were identified, including internet access/literacy. Almost 9 out of 10 participants had concerns about privacy, which centered on QHP's mandated use of mail-order pharmacies. Except for medication concerns, most participants had positive perceptions of the impact of QHP enrollment on their health care. HIV clinic case managers and social workers are often the primary source of knowledge for patients about insurance options and their assistance is crucial for QHP enrollment. Our findings indicate that reducing identified barriers and addressing privacy concerns by allowing people to opt out of mail order pharmacies may encourage QHP enrollment.

We discuss how corruption affects access to antiretroviral therapies (ARVs) globally. Recent cases of theft of ARVs, collusion, and manipulation in procurement found in countries such as Central African Republic, Bangladesh, Malawi, and Guinea, show there is still much work to be done to reduce the risk of corruption. This includes addressing the structural weaknesses in procurement mechanisms and supply chain management systems of health commodities and medicines., (© 2018 American Society for Clinical Pharmacology and Therapeutics.)

Linkage to HIV medical care and on-going engagement in HIV medical care are vital for ending the HIV epidemic. However, little is known about the cost-utility of HIV linkage, re-engagement and retention (LRC) in care programs. This paper presents the cost-utility analysis of Access to Care, a national HIV LRC program. Using standard methods from the US Panel on Cost-Effectiveness in Health and Medicine, we calculated the cost-utility ratio. Seven Access to Care programs were cost-effective and two were cost-saving. This study adds to a small but growing body of evidence to support the cost-effectiveness of LRC programs.

Introduction: Worldwide, 71 million people are infected with hepatitis C virus (HCV), which, without treatment, can lead to liver failure or hepatocellular carcinoma. HCV co-infection increases liver- and AIDS-related morbidity and mortality among HIV-positive people, despite ART. A 12-week course of HCV direct-acting antivirals (DAAs) usually cures HCV - regardless of HIV status. However, patents and high prices have created access barriers for people living with HCV, especially people who inject drugs (PWID). Inadequate access to and coverage of harm reduction interventions feed the co-epidemics of HIV and HCV; as a result, the highest prevalence of HCV is found among PWID, who face additional obstacles to treatment (including stigma, discrimination and other structural barriers). The HIV epidemic occurred during globalization of intellectual property rights, and highlighted the relationship between patents and the high prices that prevent access to medicines. Indian generic manufacturers produced affordable generic HIV treatment, enabling global scale-up. Unlike HIV, donors have yet to step forward to fund HCV programmes, although DAAs can be mass-produced at a low and sustainable cost. Unfortunately, although voluntary licensing agreements between originators and generic manufacturers enable low-income (and some lower-middle income countries) to buy generic versions of HIV and HCV medicines, most middle-income countries with large burdens of HCV infection and HIV/HCV co-infection are excluded from these agreements. Our commentary presents tactics from the HIV experience that treatment advocates can use to expand access to DAAs., Discussion: A number of practical actions can help increase access to DAAs, including new research and development (R&D) paradigms; compassionate use, named-patient and early access programmes; use of TRIPS flexibilities such as compulsory licences and patent oppositions; and parallel importation via buyers' clubs. Together, these approaches can increase access to antiviral therapy for people living with HIV and viral hepatitis in low-, middle- and high-income settings., Conclusions: The HIV example provides helpful parallels for addressing challenges to expanding access to HCV DAAs. HCV treatment access - and harm reduction - should be massively scaled-up to meet the needs of PWID, and efforts should be made to tackle stigma and discrimination, and stop criminalization of drug use and possession., (© 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.)

Background The aim of this study is to estimate the reduction in new HIV infections and resultant cost outcomes of providing antiretroviral treatment (ART) through Australia's 'universal access' health scheme to all temporary residents with HIV infection living legally in Australia, but currently deemed ineligible to access subsidised ART via this scheme., Methods: A mathematical model to estimate the number of new HIV infections averted and the associated lifetime costs over 5 years if all HIV-positive temporary residents in Australia had access to ART and subsidised medical care was developed. Input data came from a cohort of 180 HIV-positive temporary residents living in Australia who are receiving free ART donated by pharmaceutical companies for up to 4 years., Results: Expanding ART access to an estimated total 450 HIV+ temporary residents in Australia for 5 years could avert 80 new infections. The model estimated the total median discounted (5%) cost for ART and associated care to be A$36million, while the total savings in lifetime-discounted costs for the new infections averted was A$22million., Conclusions: It is estimated that expanded access to ART for all HIV-positive temporary residents in Australia will substantially reduce HIV transmission to their sexual partners at little additional cost. In the context of Australia's National HIV strategy and Australia's endorsement of global goals to provide universal access to ART for all people with HIV, this is an important measure to remove inequities in the provision of HIV-related treatment and care.

Antiretroviral (ARV) adherence has largely been considered from the perspective of an individual's behavior with less attention given to potential structural causes for lapses in treatment, such as the cost of medications and care. HIV medication expense is typically covered by third party payers. However, private insurance premiums and deductibles may rise, or policies terminated such as with a change in employment. Likewise, a patient's eligibility for publicly funded coverage like state AIDS Drug Assistance Programs (ADAP) or Medicaid can also be lost. We conducted a one-time survey of a sample of 300 patients receiving HIV care at a single large academic center in the south of United States to examine lapses in HIV therapy due to financial reasons. We found that during the prior year, financial issues including medication cost or coverage led to a lapse in ARVs in 10% (n = 31) of participants. However, of the 42% (n = 125) participants who had been enrolled in ADAP at any time during the prior year, 21% (n = 26) reported an ARV lapse due to problems with ADAP or medication cost. Respondents cited ADAP's required semi-annual renewal process and other administrative issues as the cause of ARV lapses. The median duration of missed ARVs was 2 weeks (range of <1-23 weeks). Non-HIV medication and transportation to and from clinic costs were also identified as financial burdens to care by respondents. In conclusion, although conducted at a single medical center and one state, this study suggests that a significant minority of HIV-infected patients encounter financial barriers to ARV access, and this is paradoxically more common among those enrolled in the state ADAP. Streamlining, supporting, and simplifying ADAP renewal procedures will likely reduce lapses in ARV adherence and persistence.

Background: Geographical and financial barriers hamper accessibility to HIV services for rural communities. The government has introduced the nurse initiated management of anti-retroviral therapy at primary health care level, in an effort to improve patient access and reduce patient loads on facilities further up the system., Objectives: To ascertain the perceptions and satisfaction of patients in terms of the decentralised anti-retroviral policy and the direct out-of-pocket expenses of patients accessing this care in a rural setting., Method: Using a cross-sectional study design, 117 patients from five different primary health care collection points and a hospital anti-retroviral clinic were interviewed using a standard questionnaire., Results: More clinic patients walked to their clinic to collect their medicines as compared to hospital patients (71.2% versus 14.6%). Hospital patients spent more than clinic patients on monthly transport costs (ZAR71.92 versus ZAR25.81, Anova F=12.42, p=0.0009). All clinic patients listed their respective clinic as their preferred medicine collection point despite recording lower levels of satisfaction with anti-retroviral services (89% compared to 95.5%)., Conclusion: Patients seem to indicate that they preferred decentralisation of HIV care to PHC level and that this might minimise out-of-pocket spending. Further studies are required to confirm these findings.

Purpose of Review: To discuss how aligning the collective power of scientists, regulators, drug companies, donors, implementers and advocates to achieve a single goal - accelerating access to simpler, safer, more robust and more affordable HIV treatment - can rapidly advance antiretroviral optimization efforts and enable scale-up., Recent Findings: Harmonization of traditionally sequential processes can address the delays commonly experienced in introducing new products to low-income and middle-income countries, by facilitating an 'end-to-end' approach that mitigates risk and encourages early planning for all aspects of product introduction., Summary: Planning with the 'end-in-mind' can facilitate healthy markets, benefit the application of new technologies, and accelerate the development of improved products in parallel (versus traditionally sequential efforts).

The Indian pharmaceutical industry has historically manufactured low-cost drugs for the global poor. Activist mobilizations at the height of the HIV/AIDS epidemic revealed a vast cost gap between global brands and Indian generics, much to the embarrassment of Euro-American corporations that were in the habit of pricing drugs for only the wealthy or well insured. As new drug access controversies focus on anticancer therapies, they reveal new flows of international capital, emergent genetic technologies, and increasingly coercive trade regimes. Together these favor multinational corporate oligopolies, which imperil the legacy of HIV/AIDS activism and the future availability of essential life-saving drugs for the work of global public health. In this essay, I describe how the future of the right to drug access rests uneasily, and potentially calamitously, on a shifting balance of power between global south interests and Euro-American pharmaceutical capital.

The introduction of generic antiretroviral medications in developing countries has resulted in significant CD4 cell restoration, HIV viral decline, and a noteworthy reduction in the time to initiation of therapy. Projection models have also predicted significant cost saving associated with the extensive diffusion of generic antiretrovirals in developed countries. However, some uncertainties on generics have recently been raised. These concerns mainly relate to the adequacy of the study design for bioequivalence testing, the potential for uncontrolled switching from one generic to another, and the loss of adherence if patients switched from fixed-dose coformulations to single components in order to incorporate the new generic drugs. In the present review, we deal with current evidence and potential controversial issues regarding generic antiretrovirals and their underlying economic implications and provide some proposals on how to favor the widespread diffusion of generics in HIV medicine. This may be particularly relevant considering that the safe, systematic switch from patented to generic antiretrovirals could potentially guarantee access to therapies for HIV-infected patients worldwide and lead to money savings that would compensate the expenditure increase resulting from new, innovative HIV drugs.
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Background: Sub-Saharan Africa is heavily dependent on global health initiatives (GHIs) for funding antiretroviral therapy (ART) scale-up. There are indications that global investments for ART scale-up are flattening. It is unclear what new funding channels can bridge the funding gap for ART service delivery. Many previous studies have focused on domestic government spending and international funding especially from GHIs. The objective of this study was to identify the funding strategies adopted by health facilities in Uganda to sustain ART programs between 2004 and 2014 and to explore variations in financing mechanisms by ownership of health facility., Methods: A mixed-methods approach was employed. A survey of health facilities (N = 195) across Uganda which commenced ART delivery between 2004 and 2009 was conducted. Six health facilities were purposively selected for in-depth examination. Semi-structured interviews (N = 18) were conducted with ART Clinic managers (three from each of the six health facilities). Statistical analyses were performed in STATA (Version 12.0) and qualitative data were analyzed by coding and thematic analysis., Results: Multiple funding sources for ART programs were common with 140 (72%) of the health facilities indicating at least two concurrent grants supporting ART service delivery between 2009 and 2014. Private philanthropic aid emerged as an important source of supplemental funding for ART service delivery. ART financing strategies were differentiated by ownership of health facility. Private not-for-profit providers were more externally-focused (multiple grants, philanthropic aid). For-profit providers were more client-oriented (fee-for-service, insurance schemes). Public facilities sought additional funding streams not dissimilar to other health facility ownership-types., Conclusion: Over the 10-year study period, health facilities in Uganda diversified funding sources for ART service delivery. The identified alternative funding mechanisms could reduce dependence on GHI funding and increase local ownership of HIV programs. Further research evaluating the potential contribution of the identified alternative financing mechanisms in bridging the global HIV funding gap is recommended.

The evolution of antiretroviral therapies (ART) has redefined HIV infection from a life-threatening disease to a chronic manageable condition. Despite ART, HIV infection remains a serious health burden in Zimbabwe, particularly among women of reproductive age. In this interpretive phenomenology study, we interviewed 17 women with advanced HIV infection to uncover and understand their experiences of living with HIV infection in the ART era. Two themes (knowing the restorative power of ART and the heavy burden of being infected with HIV) reflected the women's experiences. ART brought physical and mental relief, but did not change the sobering reality of poverty or the challenges posed by the infective nature of HIV. The heavily donor-funded Zimbabwean ART program has been a success story, but there is uncertainty over its long-term sustainability. In resource-limited countries, clinicians and other stakeholders should continue to focus on HIV prevention as the cornerstone of HIV programming., (Copyright © 2016 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

Whilst multi-lateral funding for HIV/AIDS dramatically increased from 2004 to 2008, it has largely plateaued in the last 8 years. Across sub-Saharan Africa, up to 20 % of total spending on health is used for HIV services, and of this over 85 % is estimated to come from international funding rather than in-country sources. In Uganda, the fiscal liability to maintain services for all those who are currently receiving it is estimated to be as much as 3 % of Gross Domestic Product (GDP). In order to meet the growing need of increased patient numbers and further ART coverage the projected costs of comprehensive HIV care and treatment services will increase substantially. Current access to HIV care includes free at point of delivery (provided by Ministry of Health clinics), as well as out-of-pocket financing and health insurance provided care at private for- and not for- profit facilities. The HIV response is funded through Ugandan Ministry of Health national budget allocations, as well as multilateral donations such as the President's Emergency Plan for AIDS in Africa (PEPFAR) and Global Fund (GF) and other international funders. We are concerned that current funding mechanism for HIV programs in Uganda may be difficult to sustain and as service providers we are keen to explore ways in which provide lifelong HIV care to as many people living with HIV (PLHIV) as possible. Until such time as the Ugandan economy can support universal, state-supported, comprehensive healthcare, bridging alternatives must be considered. We suggest that offering patients with the sufficient means to assume some of the financial burden for their care in return for more convenient services could be one component of increasing coverage and sustaining services for those living with HIV.

Linking and retaining people living with HIV in ongoing, HIV medical care is vital for ending the U.S. HIV epidemic. Yet, 41-44 % of HIV+ individuals are out of care. In response, AIDS United initiated Positive Charge, a series of five HIV linkage and re-engagement projects around the U.S. This paper investigates whether three Positive Charge programs were cost effective and calculates a return on investment for each program. It uses standard methods of cost utility analysis and WHO-CHOICE thresholds. All three projects were found to be cost effective, and two were highly cost effective. Cost utility ratios ranged from $4439 to $137,271. These results suggest that HIV linkage to care programs are a productive and efficient use of public health funds.

In Mali, where rates of attendance at healthcare facilities remain far below what is needed, three user fee exemption policies were instituted to promote access to care. These related to HIV/AIDS treatment, as of 2004, caesarean sections, since 2005, and treatment of malaria in children under five and pregnant women, since 2007. Our qualitative study compared these three policies, looking at their implementation provisions, functioning and outcomes. In each healthcare facility, we analysed documentation and carried out three months of on-site observations. We also conducted a total of 254 formal and informal interviews with health personnel and patients.

Tenofovir-emtricitabine (TDF-FTC) has demonstrated effectiveness as HIV preexposure prophylaxis (PrEP), but it is not commonly prescribed. Our study was designed to determine the barriers preventing utilization of PrEP among men who have sex with men (MSM), the group at greatest risk for HIV infection in the United States. A population-based sample of MSM presenting for HIV testing at 'Early Test' HIV testing and counseling sites in San Diego, California were offered PrEP and education about potential efficacy. Eligible individuals reported having unprotected sex within the past 12 months and who tested negative for HIV were offered study participation. Despite offering procedures for evaluation and prescription for PrEP to 416 eligible subjects, less than 0.5 % of participants received the drug. Surveys collected from 54 of those who declined study participation revealed multiple barriers to PrEP among MSM including cost, low perceived risk of infection and concerns about taking a daily medication and potential long-term side effects. Efforts should be made to address these barriers, especially lowering the cost of TDF-FTC, education about PrEP side effects and awareness of HIV risks.

In May 2011, the Brazilian Ministry of Health announced the distribution of the first batch of locally produced generic tenofovir disoproxil fumarate (TDF) to support its program of universal and free access for the treatment of HIV/AIDS. The inclusion of TDF in the public health program illustrates what has been considered the 'Brazilian model' of HIV/AIDS response, as it illustrates the current phase of the Brazilian pharmaceutical economy. Brazil is known for having managed to control the expansion of HIV/AIDS through a unique initiative combining the public health and the industrial production of generics. But, if at first local manufacturers could freely copy ARVs and produce cheaper generic versions that were delivered to the Ministry of Health, since the country started to grant patents on drugs in 1996, the sustainability of this policy has been challenged by the high cost of patented second-line HIV/AIDS treatments. In order to assure continuity of the local production of ARVs, and keep the program of public health alive, Brazilians are now forced to deal with conflicts of drugs' intellectual property rights in order to open the path to generic production. This article aims to describe the experiences surrounding TDF in Brazil and the unprecedented conflicts and challenges it has brought for our different interviewees. Blurring the frontier between the public and the private, the TDF case was driven at the same time by an ethic of drug access and regulation of drug quality, which has inspired Brazilians to intervene and transform the world they live in., (© 2014 John Wiley & Sons Ltd.)

Operational research to identify factors predicting poor clinical outcomes is critical to maximize patient care and prolong first-line regimens for those receiving free antiretroviral therapy (ART) in India. We sought to identify social or clinical factors amenable to intervention that predict virological outcomes after 12 months of ART. We examined a retrospective cohort of consecutive adults initiating free nonnucleoside reverse transcriptase inhibitor-based regimens. Individuals remaining in care 12 months post-ART initiation were tested for HIV viral load and surveyed to identify barriers and facilitators to adherence, and to determine clinic travel times and associated costs. Uni- and multivariate logistic regression identified factors predicting HIV viral load >200 copies/mL after 12 months of ART. Of 230 adults initiating ART, 10% of patients died, 8% transferred out, 5% were lost to follow-up, and 174/230 (76%) completed 12 months of ART, the questionnaire, and viral load testing. HIV viral load was <200 copies/mL in 140/174 (80%) patients. In multivariate models, being busy with work or caring for others (OR 2.9, p < 0.01), having clinic transport times ≥ 3 hours (OR 3.0, p = 0.02), and alcohol use (OR 4.8, p = 0.03) predicted viral load >200 copies/mL after 12 months of ART. Clinical outcomes following ART are related to programmatic factors such as prolonged travel time and individual factors such as being busy with family or using alcohol. Simple interventions that alter these factors should be evaluated to improve clinical outcomes for populations receiving free ART in similar settings.

With the Affordable Care Act set to expand insurance coverage to millions more Americans next year, existing discretionary health programs that receive federal support might find themselves competing for funds as the health reform law is fully implemented. To assess the implications the Affordable Care Act might have for discretionary health programs, we focused on state AIDS Drug Assistance Programs, which provide free medications to low-income HIV patients. We conducted semistructured interviews with program managers from twenty-two states. Many of the managers predicted that their programs will change focus to provide "wrap-around services," such as helping newly insured clients finance out-of-pocket expenses, including copayments, deductibles, and premiums. Although program managers acknowledged that they must adapt to a changing environment, many said that they were overwhelmed by the complexity of the Affordable Care Act, and some expressed fear that state AIDS Drug Assistance Programs would be eliminated entirely. To remain viable, such programs must identify and justify the need for services in the context of the Affordable Care Act and receive sufficient political support and funding.

Despite the unprecedented scale-up of treatment for HIV in low and middle-income countries over the past decade, 49% of adults and 77% of children in need of HIV treatment still do not have access to it. ART programmes that were initially set up as an emergency response now need to be adapted to ensure that they include all the essential components and are well integrated with other health services; meet the needs of special groups, including children, adolescents, pregnant women and older people; address the mental health needs of HIV-positive people; and monitor as well as report their impact in valid and comparable ways.This supplement is an output from the Evidence for Action on HIV Treatment and Care Systems research programme consortium. Evidence for Action was a 5-year, multidisciplinary research programme, which ran from 2006 to 2011, with partners in India, Malawi, Uganda, Zambia and the United Kingdom.The primary aim of this supplement is to stimulate reflection and provide guidance on what should be in the package of HIV treatment and care systems, as national programmes look to maintain the major advances of the past decade and scale-up treatment to the other 50% of people in need of it.

This article summarizes the conclusions and recommendations from the articles in this supplement. It presents a call for greater clarity of thinking related to projections of future need for HIV treatment and care. The demands placed on HIV treatment and care services will increase for the foreseeable future while the resources available for this are likely to remain constant or to decline. This highlights the need for realistic budgeting by national governments. The key strategies that should be employed to sustain HIV treatment and care programmes in high HIV-prevalence low and middle-income countries over the coming decade include further decentralization, task shifting, and integration of HIV services with other chronic disease treatment services. At the same time, greater attention will need to be given to the provision of mental healthcare for those living with HIV; to the specific treatment needs of children, adolescents, pregnant women and older people; and to the standard collection of validated indicators of treatment outcomes within national programmes. For the considerable gains that have been achieved to be sustained, funders--both internal and external to the country concerned--need to prioritize investment in operations research to maximise the efficiency of their other investments in HIV treatment and care services.

The unprecedented, successful collaborative international effort to provide universal access to HIV care, including effective antiretroviral therapy, has reached a crucial point. Global economic downturn, changing donor priorities, and competing priorities in the health sector threaten the target of provision of 15 million people with HIV/AIDS with treatment by 2015, as agreed by the UN General Assembly. This aspiration has received added impetus from the finding that treatment prevents transmission by reduction of infectiousness of patients. In this report we critically review success thus far and examine efforts to optimise delivery of HIV care including antiretroviral therapy in low-income and middle-income countries for four main domains: treatment strategy, drug dosing, monitoring, and service delivery., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: In Australia, temporary visa holders are ineligible for Medicare and subsidised antiretroviral drugs. Additionally, HIV testing is not mandatory for visas unless applicants seek work in the health sector. We sought to understand the impact of HIV and issues of access and adherence to antiretroviral therapy (ART) in people holding temporary visas and permanent residents., Methods: Data were gathered from interviews with 22 participants. Information concerning medication adherence, side effects, CD4 T-cell count, viral load and rate of response to generic drugs were collected., Results: The mean age was 33.4 years (±s.d.=6.0), 21 out of 22 were from HIV-prevalent areas in East Africa and Asia, 14 out of 22 were on temporary visas, 12 were ineligible for Medicare, 14 out of 22 were diagnosed during health screening, 19 out of 22 risk exposures were in country of origin, 8 out of 17 were taking generic ART at an average cost of $180 per month, adherence was excellent and self-reported side-effects were relatively infrequent. Participants applying for visa continuations and permanent residency were fearful, believing their HIV serostatus would prejudice their applications. Patients cited belief in ART efficacy, were motivated to maintain therapy and were anxious about lack of access to treatment in their countries of origin., Conclusion: Adherence to antiretroviral drugs in Medicare-ineligible HIV-infected individuals is excellent despite limited access to treatment. The threat of visa non-renewal and the likely failure of applications for permanent residency result in considerable anxiety and confidentiality concerns.

Objective: To characterize patient and programmatic factors associated with retention in care during the pre-antiretroviral therapy (ART) period and linkage to ART care., Design: Systematic literature review., Methods: An electronic search was conducted on MEDLINE, Global Health, Google Scholar and conference databases to identify studies reporting on predictors, barriers and facilitators of retention in care in the pre-ART period, and linkage to care at three steps: ART-eligibility assessment, pre-ART care and ART initiation. Factors associated with attrition were then divided into areas for intervention., Results: Seven hundred and sixty-eight citations were identified. Forty-two studies from 12 countries were included for review, with the majority from South Africa (16). The most commonly cited category of factors was transport costs and distance. Stigma and fear of disclosure comprised the second most commonly cited category of factors followed by staff shortages, long waiting times, fear of drug side effects, male sex, younger age and the need to take time off work., Conclusion: This review highlights the importance of investigating interventions that could reduce transport difficulties. Decentralization, task-shifting and integration of services need to be expedited to alleviate health system barriers. Patient support groups and strategic posttest counselling are essential to assist patients deal with stigma and disclosure. Moreover, well tolerated first-line drugs and treatment literacy programmes are needed to improve acceptance of ART. This review suggests a combination of interventions to retain specific groups at risk for attrition such as workplace programmes for employed patients, dedicated clinic and support programmes for men and younger individuals.

The immigrant population in Spain, whether legal or not, has been entitled to healthcare under the same conditions as the Spanish population since the year 2000. The entry into vigour of the Royal Decree-Law 12/2012 of 20 April has significantly restricted this right, so that unauthorized or non-resident foreigners may now only receive emergency care, if they are under 18 or pregnant women. Out of an estimated 459,909 illegal immigrants in our country, 2,700 to 4,600 are probably infected with HIV; 1,800 to 3,220 know that they are infected, and 80% of the latter could receive antiretroviral treatment. The Royal Decree-Law is likely to cause many undesirable consequences in this population infected with HIV: increasing mortality, promoting the emergence of opportunistic diseases, increasing hospital admissions, increasing infections in the population (by HIV and other pathogens), or contributing to mother to child transmission of HIV. The expected increase in morbidity and mortality will be a greater cost in patient care, a cost which will be significantly higher in the more immunosuppressed patients. Therefore, the enforcement of the Royal Decree-Law will be much less cost-effective in the short term than was expected, and will negatively affect our country's public health, especially for those patients infected with HIV who will not be covered, thus increasing healthcare medium to long term costs, and moving away from the international health goals that were established., (Copyright © 2012 Elsevier España, S.L. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Introduction: South Africa has the world's largest antiretroviral treatment (ART) programme. While services in the public sector are free at the point of use, little is known about overall access barriers. This paper explores these barriers from the perspective of ART users enrolled in services in two rural and two urban settings., Methods: Using a comprehensive framework of access, interviews were conducted with over 1200 ART users to assess barriers along three dimensions: availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between sites were explored using multivariate linear and logistic regressions., Results: While availability access barriers in rural settings were found to be mitigated through a more decentralised model of service provision in one site, affordability barriers were considerably higher in rural versus urban settings. 50% of respondents incurred catastrophic healthcare expenditure and 36% borrowed money to cover these expenses in one rural site. On acceptability, rural users were less likely to report feeling respected by health workers. Stigma was reported to be lowest in the two sites with the most decentralised services and the highest coverage of those in need., Conclusions: While results suggest inequitable access to ART for rural relative to urban users, nurse-led services offered through primary healthcare facilities mitigated these barriers in one rural site. This is an important finding given current policy emphasis on decentralised and nurse-led ART in South Africa. This study is one of the first to present comprehensive evidence on access barriers to assist in the design of policy solutions.

Objectives: Using the example of South Africa, this study aimed to examine and obtain a better understanding of the experiences and challenges of urban and rural patients on antiretroviral therapy (ART) in accessing this complex treatment in a resource-limited setting., Methods: Following a narrative approach, in-depth interviews were conducted with 20 patients successfully and unsuccessfully (ie, with interruptions) receiving ART in urban Johannesburg and rural Bushbuckridge, using a detailed interview guide structured to illuminate interviewees' life circumstances and contextualise illness and treatment trajectories. Participants were interviewed by trained fieldworkers in their local languages. The translated and transcribed interviews were coded by several team members. Codes were cross-examined and showed good congruence., Results: All interviewees emphasised the positive aspects of receiving ART, the lifeline and hope it provided by improving health, increasing their ability to live actively and reducing visible signs of (stigmatised) illness. Important factors supporting continuing adherence included social and economic support by individuals, role models and networks as well as positive experiences within the healthcare system and of the treatment itself. The main challenges were linked to patients' difficult life circumstances, especially those related to poverty (eg, transport and food costs) and health system constraints, including perceived lack of compassion and flexibility by healthcare workers., Conclusions: While there are many challenges for the sustainability of ART on an individual and health system level, this study emphasised the need for a patient-centric focus to continue to provide and increase the number of HIV-positive people receiving this lifeline, receiving hope.

Objectives: To investigate trends in official development assistance for health, HIV and non-HIV activities over time and to discuss the efficiency implications of these trends in the context of achieving universal access to treatment and health systems., Methods: Official development assistance for health, HIV programmes and non-HIV programmes were tracked using data from 2000 to 2009. A review of the literature on efficiency, treatment and health systems was conducted., Findings: The rate of growth of donor funding to HIV programmes has slowed in recent years at levels below those required to sustain programmes and to move towards universal access to treatment. These trends are likely due to increased pressure on foreign aid budgets and donor fatigue for HIV programmes., Conclusions: There is great need to consider how the limited resources available can be used most efficiently to increase the number of lives saved and to ensure that these resources also benefit health systems. Improving efficiency is much more than just improving the productive efficiency and also about ensuring that resources are going to where they will be the most beneficial and making investments that are the most efficient over time. These choices may be essential to achieving the goal of universal access to treatment as well as the sustainability of these programmes.

In resource-limited settings, successful HIV treatment scale-up has been tempered by reports of funding shortfalls. We aimed to determine the priorities, including ethical considerations, of decision makers for HIV antiretroviral programs. We conducted qualitative interviews with 12 decision makers, identified using purposive sampling. Respondents engaged in one-on-one, semi-structured interviews. We developed an interview guide to direct questions about key priorities and motivations for decision making about HIV antiretroviral programs. We evaluated textual data from the interviews to identify themes. Among 12 respondents, 10 (83%) lived and worked in South Africa. Respondents came from Western Cape, Gauteng, and KwaZulu-Natal provinces and worked primarily in urban settings. The respondents supported prioritizing individual patients based on treatment adherence, pregnancy status to prevent maternal-to-child HIV transmission and/or orphans, and severity of illness. However, priorities based on severity of illness varied, with first-come/first-serve, prioritization of the most severely ill, and prioritization of the least severely ill discussed. Respondents opposed prioritizing based on patient socioeconomic characteristics. Other priorities included the number of persons receiving treatment; how treated patients are distributed in the population (e.g., urban/rural); and treatment policy (e.g., number of antiretroviral regimens). Motivations included humanitarian concerns; personal responsibility for individual patients; and clinical outcomes (e.g., patient-level morbidity/mortality, saving lives) and/or social outcomes (e.g., restoring patients as functional family members). Decision makers have a wide range of priorities for antiretroviral provision in South Africa, and the motivations underlying these priorities suggest at times conflicting ethical considerations for providing HIV treatment when resources are limited.

Objectives: To develop projections of the resources required (person-years of drug supply and healthcare worker time) for universal access to antiretroviral treatment (ART) in Zimbabwe., Methods: A stochastic mathematical model of disease progression, diagnosis, clinical monitoring and survival in HIV infected individuals., Findings: The number of patients receiving ART is determined by many factors, including the strategy of the ART programme (method of initiation, frequency of patient monitoring, ability to include patients diagnosed before ART became available), other healthcare services (referral rates from antenatal clinics, uptake of HIV testing), demographic and epidemiological conditions (past and future trends in incidence rates and population growth) as well as the medical impact of ART (average survival and the relationship with CD4 count when initiated). The variations in these factors lead to substantial differences in long-term projections; with universal access by 2010 and no further prevention interventions, between 370 000 and almost 2 million patients could be receiving treatment in 2030-a fivefold difference. Under universal access, by 2010 each doctor will initiate ART for up to two patients every day and the case-load for nurses will at least triple as more patients enter care and start treatment., Conclusions: The resources required by ART programmes are great and depend on the healthcare systems and the demographic/epidemiological context. This leads to considerable uncertainty in long-term projections and large variation in the resources required in different countries and over time. Understanding how current practices relate to future resource requirements can help optimise ART programmes and inform long-term public health planning.

Global and local efforts have been devoted to increase the supply of antiretroviral therapy (ART) in sub-Saharan Africa. Recent qualitative studies suggest that even with free ART, patients may fail to adhere to medication because of socioeconomic barriers such as transportation costs to clinics. The aim of this study was to measure adherence in a population of patients receiving free ART and to examine barriers to adherence. Adherence was measured using the pill count and self-report methods among 140 HIV-positive patients at four PEPFAR-facilitated ART clinics in Kayunga, a rural district in Uganda. Self-report was also used to examine reasons for non-adherence. Pill count adherence estimates revealed that 86.4% of the patients were adherent (≥95%) in the past six months. Self-report estimates showed that all the patients were adherent in the past six months with average adherence of 99.7%±0.6. The main reasons for non-adherence were being away from medication at dose time (29.4%) and forgetting to take pills (27.5%). Lack of access to food and transportation costs accounted for 11.7% and 7.8% of non-adherence, respectively. Patients with 100% adherence reported lack of access to food as the main challenge they had to overcome to stay adherent. Patients attending the rural clinic were significantly less adherent to ART than patients at the Kayunga district capital [OR 0.046 (0.008-0.269)]. The study revealed that the greatest patient-perceived challenge to adherence in this population is the lack of access to food; however, the immediate reasons for non-adherence were found to be forgetfulness and being away from medication at dose's time. These results suggest that interventions tackling lack of access to food are necessary, but interventions addressing forgetfulness and being away from medication at dose's time would be the most effective in enhancing adherence inpatients receiving free ART.

If the 2010 CPHA conference is a bellwether of mainstream Canadian public and global health practice, its dearth of human rights papers suggests that, outside a small scholarly cohort, human rights remain marginal therein. This potential 'rights gap' conflicts with growing recognition of the relationship between health and human rights and ergo, the importance of human rights education for health professionals. This gap not only places Canadian health research outside the growing vanguard of academic research on health and human rights, but also ignores a potentially influential tool for achieving health equity. I suggest that human rights make a distinctive contribution to such efforts not replicated within other social justice and equity approaches, making human rights education a crucial complement to other ethical training. These contributions are evident in the normative specificity of the right to health in international law and its legally binding nature, in the success of litigation, the successful advocacy for AIDS treatment and the growing adoption of rights-based approaches to health. Canadian academic and research institutions should take up their rightful place within health and human rights research, education and practice globally, including by ramping up human rights-oriented education for health professionals within Canadian universities.

Researchers explored the barriers to AIDS care for rural women living with AIDS, and they investigated alternative delivery models to increase the women's adherence to antiretroviral therapy (ART). Community-based participatory research focus groups were conducted by the researchers with a convenience sample of 39 women living with AIDS from a primary health center (PHC) near Chennai, India, and with nurses, physicians, and Accredited Social Health Activists (Ashas), who are lay health care workers. The most prevalent barriers expressed by the women were sickness-related, psychological, financial issues with childcare, and distance, or transportation to the site. Women living with AIDS reviewed Ashas favorably.

"Access to medicines" is a broad concept. After a review of three authoritative frameworks that help to identify its constitutive components, this essay summarizes the actual situation on the ground in low- and middle-income countries on the basis of recent empirical work. An analysis of survey data from 36 countries concluded that developing countries should promote generic medicines as a key policy option for improving access to medicines. Taking an international perspective to that recommendation, this essay reviews the World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and, particularly, how this agreement has been applied in practice. As shown by the experience of Thailand, Brazil, and the Philippines, in order to deal effectively with international pressures for an excessive application of the TRIPS Agreement, some sort of conversion experience appears to be required, which then leads to a switch from a private enterprise, supply-driven approach to a public health vision that insists on universal and affordable access. But moral conviction is not sufficient. In order to muster and sustain the political will to face down international forces, civil society and government offices must be able and ready to show the costs and other adverse consequences of the TRIPS-based model for medicines. This calculation needs to reach beyond the health sector and calls for new alliances, nationally as well as internationally., (© 2010 American Society of Law, Medicine & Ethics, Inc.)