Articles tagged as "Strengthen HIV integration"

Civil society responses

HIV-prevention interventions targeting men having sex with men in Africa: field experiences from Cameroon

Kalamar M, Maharaj P, Gresh A, Cult Health Sex. 2011 Nov;13(10):1135-49. Epub 2011 Sep 14

The HIV prevalence rate among men who have sex with men in Africa is high, yet a limited number of prevention interventions target this vulnerable group. The study aims to explore factors affecting the design and implementation of HIV-prevention interventions for men who have sex with men in Cameroon using Alternatives-Cameroun as a case study. It further examines the context in which these interventions are created and implemented. Operating in a repressive environment, facing criminalisation and stigmatisation, one organisation, Alternatives-Cameroun, has adopted an 'umbrella approach', using human rights as a platform from which to negotiate for greater recognition of men who have sex with men. Success has been achieved through a 'proximity approach to prevention', setting up a local Access Centre and using a base of volunteers to create interventions that venture into the community. The organisation faces many obstacles such as repressive legislation, stigmatisation, and volunteer fatigue. Findings reveal that understanding local realities and reinforcing multi-sectoral mobilisation around men who have sex with men issues are important first steps towards launching HIV-prevention interventions for men who have sex with men in sub-Saharan Africa.

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Editor’s note: Alternatives-Cameroun was launched in 2006 in Douala to serve primarily men who have sex with men (locally called nkouandengué) in an environment of denial, stigmatisation, and criminalisation that is not uncommon in other parts of Africa. This case study reveals that the widespread heterocentric perception of HIV in Cameroon influences the risk perception of men who have sex with men. Beliefs that anal sex cannot transmit HIV, a male partner is less risky for a man because there is no risk of pregnancy, and condoms are only for contraception are not uncommon among the men being reached by this community-based organisation. Men may try to camouflage their sexual orientation by having a girlfriend or by having multiple male partners so that they are not seen too often with the same man, which would arouse suspicion. Article 347bis of the Cameroon Penal Code, which criminalises homosexuality with a punishment of imprisonment from 6 months to 5 years and a fine of from 20,000 to 200,000 francs CFA, has created a climate of fear and repression reinforcing social marginalisation and constricting the methods that Alternatives-Cameroun can use to reach men who have sex with men. Based on ‘proximity approach’ principles, it conducts outreach to venues (both bars/clubs and virtual electronic networks), conducts educational workshops, refers men to gay-friendly physicians, and trains peer leaders to reach out to hidden men. The focus is on sexual practices and risk behaviours rather than on sexual orientation or identity. Although the experiences and sociolegal constraints of Alternatives-Cameroon are context-specific, they have resonance for countries across Africa that have not yet repealed similar repressive laws that contravene human rights principles.

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National Responses

Calculation of direct antiretroviral treatment costs and potential cost savings by using generics in the German HIV ClinSurv cohort

Stoll M, Kollan C, Bergmann F, Bogner J, Faetkenheuer G, Fritzsche C, Hoeper K, Horst HA, van Lunzen J, Plettenberg A, Reuter S, Rockstroh J, Stellbrink HJ, Hamouda O, Bartmeyer B; ClinSurv Study Group, PLoS One. 2011;6(9):e23946. Epub 2011 Sep 9

The study aimed to determine the cost impact of antiretroviral drugs by analysing a long-term follow-up of direct costs for combined antiretroviral therapy regimens in the nationwide long-term observational multi-centre German HIV ClinSurv Cohort. The second aim was to develop potential cost saving strategies by modelling different treatment scenarios. Antiretroviral regimens from 10,190 HIV-infected patients from 11 participating ClinSurv study centres have been investigated since 1996. Biannual data on antiretroviral therapy initiation, antiretroviral therapy changes, surrogate markers, clinical events, and the Centre of Disease Control (CDC) stage of HIV disease are reported. Treatment duration was calculated on a daily basis via the documented dates for the beginning and end of each antiretroviral drug treatment. Prices were calculated for each individual regimen based on actual office sales prices of the branded pharmaceuticals distributed by the license holder including German taxes. During the 13-year follow-up period, 21,387,427 treatment days were covered. Cumulative direct costs for antiretroviral drugs of €812,877,356 were determined according to an average of €42.08 per day (€7.52 to € 217.70). Since cART is widely used in Germany, the costs for an entire regimen increased by 13.5%. Regimens are more expensive in the advanced stages of HIV disease. The potential for cost savings was calculated using non-nucleotide-reverse-transcriptase-inhibitor, NNRTI, more frequently instead of ritonavir-boosted protease inhibitor, PI/r, in first line therapy. This calculation revealed cumulative savings of 10.9% to 19.8% of daily treatment costs (50% and 90% substitution of PI/r, respectively). Substituting certain branded drugs by generic drugs showed potential cost savings of between 1.6% and 31.8%. Analysis of the data of this nationwide study reflects disease-specific health services research and will give insights into the cost impacts of antiretroviral therapy, and might allow a more rational allocation of resources within the German health care system.

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Editor’s note: Using this huge data set, compiled since January 1999 and comprised of over 21 million antiretroviral treatment days, this study assessed trends in prescribing patterns and in the direct costs of various antiretroviral regimens to the German health care system. Among the interesting findings are the lower direct drug costs for women than for men because women in Germany tend to present earlier in their disease course, the historical evidence of treatment interruptions in 2003-2004 (12.1% per year) declining to 6.3% in 2008, and the large number of different drug regimens (197), although the top 10 account for 90% of treatment regimens. Colour graphs show the cumulative use of antiretroviral classes by year and mean daily treatment costs by class and by year, adjusting for the German consumer price index. With several drugs having come off patent or soon to do so, the authors calculate the cost savings that generic formulations could make at a time when German, European, and USA treatment guidelines recommend starting antiretroviral therapy at 500 CD/μl with 2 NRTI and a third drug which can be an NNRTI or a ritonavir-boosted protease inhibitor or an integrase inhibitor. This database of over 10,000 patients has the potential to provide the answers for national decision-making in Germany, whose health care system operates on an economic efficiency principle, on how best to allocate resources.

HIV Treatment
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