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HATIP #55, 20th September 2005

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Main article: Revised WHO guidelines on prevention of mother-to-child transmission

By Theo Smart

Earlier this month, the World Health Organization issued proposed revisions to its recommendations on the use of antiretroviral drugs for the prevention of mother-to-child transmission (PMTCT) (see http://www.who.int/entity/3by5/PMTCTreport_June2005.pdf and http://www.who.int/entity/3by5/PMTCTtable_June2005.pdf).

The recommendations were the product of a panel of experts convened by WHO at the end of June, 2005 to discuss important new concerning the development of resistance in women and children using single dose nevirapine (sdNVP) for PMTCT, as well as new clinical findings on strategies that might help reduce the development of that resistance. The panel had the unenviable task of proposing simple, practical evidence-based recommendations that would work in the variety of differently resourced environments and clinical situations that confront healthcare workers trying to help mothers protect their infants from HIV-infection in the developing world.

HATIP published a couple of issues on the subject of sdNVP resistance last year. Since that time, several studies have produced important data.

More resistance

Initial reports suggested that resistance only occurred in 20-30% of the women exposed to sdNVP-exposed women in HIVNET and other trials and in a higher proportion of women exposed to two doses of the drug in the Saint study.

But recent studies using more sensitive techniques to screen for resistance suggest that it is much more common (see http://www.aidsmap.com/en/news/379A4719-2FBD-49F8-8353-E3FDFF72F567.asp, http://www.aidsmap.com/en/news/A3C49CD6-6951-4B70-B872-887600D5C1D3.asp). The methods used in some of these studies can detect very small minority populations of drug-resistant virus — which appears to occur in as many as 60-75% of the women who take it, depending on the study and perhaps the viral subtype.

But most of this resistance seems to diminish over time. In one of the studies, nevirapine resistance one year after delivery was seen in only 25% of the women. Encouragingly, HIV DNA in the women’s white blood cells did not show any evidence of nevirapine resistance, despite use of the more sensitive lab test. This suggests that archiving of the nevirapine-resistance mutations may be a rare event (HIV DNA represents viral material that has been incorporated into cells that will lie dormant until that cell is activated, at which point new HIV particles are produced. This HIV DNA provides a reservoir that allows drug resistant viruses to persist in the body for long periods).

So it’s not clear whether low frequency mutations have much of an impact. It appears to have little impact on the effectiveness of subsequent use of sdNVP, at least for PMTCT in a second pregnancy (see http://www.aidsmap.com/en/news/0507DD7B-0FD6-4A3F-BB67-5E71638EE5EC.asp).

But the potential effect on the mothers' treatment outcomes is more troublesome. Prior exposure to sdNVP did compromise at least some mother's subsequent responses to NNRTI-based antiretroviral therapy in a substudy of the Thai Perinatal HIV Prevention Trial-2 (PHPT-2) (previously reported here http://www.aidsmap.com/en/news/94EC3850-D045-4420-A7BB-6EE22D9B70AB.asp). However most of the mothers exposed to sdNVP in that study went onto ART only six months after labour (median).

Virologic responses might not be as impaired in women who have more time to wait until they need antiretroviral therapy for their own health. Yet no subsequent clinical trial has really addressed this.

One study presented at the 3rd International AIDS Society Conference on HIV Pathogenesis and Treatment in Rio de Janeiro last just July, did report on CD4 cell responses to ART in women who waited a median of 17 months after being exposed to sdNVP before starting antiretroviral therapy. (see http://www.aidsmap.com/en/news/D15A2763-C672-42C2-BE78-34CF7AD207F6.asp). There were no virologic data from this study but investigators could find no difference in CD4 cell responses between those who were exposed to sdNVP and those who were not. However, these women were drawn from the Ditrame-plus cohort (http://www.aidsmap.com/en/news/819CD092-3764-4C00-9C68-66E9BA35AA9D.asp) and also took AZT/3TC for a few days after childbirth.

Covering nevirapine's tail - sdNVP plus AZT/3TC or AZT

Those few days of combination therapy when AZT/3TC is given to women who have taken sdNVP may make a big difference. The selective pressure on the virus to mutate and become resistant is probably greatest the first few days after dosing (while nevirapine is at its most potent). And the rate of resistance reported by the researchers in the Ditrame Plus study seems almost impossibly low (~1.14%).

The question of whether adding AZT/3TC reduces nevirapine resistance was addressed prospectively in a controlled setting by Dr. James McIntyre, who presented the most recent data from the Treatments Options Preservation Study (TOPS) in Rio. In short, TOPS found that adding four to seven days of AZT/3TC after birth to mothers who have received sdNVP during labour significantly reduces the risk that they will develop resistance to nevirapine, and may preserve their future treatment options.

The study had three treatment arms 1) sdNVP, or 2) sdNVP plus four days of Combivir (AZT/3TC combination tablet), or 3) sdNVP plus seven days of Combivir. Twice-daily Combivir was started in the mothers during labour and in their babies as soon as possible after birth.

The sdNVP arm was discontinued after an interim analysis of HIV resistance data at weeks two and six showed that nine of the 18 women (50%) randomised to receive single dose nevirapine alone had NNRTI resistance compared to 4 out of 43 (10%).

Data on the remaining 226 mothers and 228 infants who were enrolled at the time of the closure of the sdNVP arm are in the table below.

	sdNVP	sdNVP plus 4 days AZT/3TC	sdNVP plus 7 days AZT/3TC
Number who developed resistance /number in treatment arm (%)	41/68(60)	8/67(12)	7/68(10)
Baseline viral load (median)	23,200	24,700	35,000
Viral load at nadir (median)	8,300	< 400	436

No resistance to AZT/3TC was detected in the study. However, adding AZT/3TC significantly reduced the rate of NNRTI resistance among mothers from 60% to 12% (4 days) and 10% (7 days). It also greatly reduced the viral load which could be of critical importance. Among the mothers who took only sdNVP, the median viral load (at baseline and nadir) was higher in the mothers who developed resistance, (43,650 and 16,600 copies/ml) than in those who did not, (10,600 and 4,160 copies/ml).

The total infection rate at 6 weeks was 10.5% (24/228) however all but three of these cases were determined to be from in utero transmission.

Two infants had NNRTI mutations at birth, one in the sdNVP and another in the 4-day arm but no new NNRTI mutations emerged in any of the 13 infants who received AZT/3TC. However, 6 out of 9 (66.7%) of the infected infants in the sdNVP only arm developed new NNRTI mutations.

sdNVP in the infant - but not the mother

Another way to keep a mother’s treatment options open would be to simply skip the maternal nevirapine dose, and just give sdNVP to the infant. This idea has been explored in Botswana, where treatment realities are somewhat different than in the rest of Africa.

The Botswana ‘Mashi’ study has been adjusted several times to reflect changes in the standard of care. Originally, the trial gave all mothers AZT from 34 weeks to delivery, and to the babies from birth to one month. It then randomised participants to sdNVP as per the HIVNET 012 protocol, or a placebo to both mother and infant. Then the placebo was judged unethical due to revisions in Botswana’s national protocol. The revised protocol gave nevirapine to all babies as soon as possible (an average of 24 minutes) after birth. Nevertheless, half of the mothers were still placed on placebo. (see http://www.aidsmap.com/en/news/819CD092-3764-4C00-9C68-66E9BA35AA9D.asp).

The transmission rates at birth were 2.3% for mother/baby pairs who both received sdNVP and 3.8% where the mother received a placebo. Transmission increased from 3.7% and 4.3% respectively a month after birth.

A resistance sub-study found that 44% of women given sdNVP developed resistance mutations.

The consequences of nevirapine resistance to women in Botswana may be more immediate than in much of the rest of the developing world. In Botswana, a woman with HIV who needs antiretroviral therapy for her own health can access it. For various reasons, though, pregnant women do not always present to an antenatal clinic or have an HIV test result in time before their child is due to start combination antiretroviral therapy. Consequently, women in countries with good treatment access like Botswana who receive single dose nevirapine and who then start treatment shortly afterwards may be at higher risk of a compromised treatment outcome than women in other, less well-resourced settings.

Fortunately, there are also increasing data showing that ART can be successfully given to pregnant women in resource limited settings (see section on Dream study in http://www.aidsmap.com/en/news/819CD092-3764-4C00-9C68-66E9BA35AA9D.asp), and from an antenatal clinic in one Pepfar-funded study in South Africa (http://www.aidsmap.com/en/news/0B7338AE-5DBB-43CC-9ABA-9D37F516F012.asp

Some thoughts on the WHO revised recommendations

The revised WHO PMTCT recommendations clearly try to take into account improvements in treatment access, tailoring their recommendations to situations where there is access to the full complement of antiretrovirals and where there is not. When the original PMTCT guidelines were written, such access seemed a remote possibility. Increasing availability to antiretroviral therapy has changed the equation completely — and made continued sdNVP in mothers who can access ART more risky.

Unfortunately, it’s not clear what revising the guidelines can do for the vast majority of women who live somewhere in the middle, those who may be able to access nevirapine through the antenatal clinic but not ART.

However, is it wise, especially in a breastfeeding population, to continue recommending the same postnatal treatment regimen (eg, AZT plus sdNVP or AZT/3TC) for the mother and the child? This would seem to be a recipe for the transmission of resistance when it occurs in the mother.

Although there is no reliable well-controlled study demonstrating that the treatments should be switched to decrease the chance of resistant virus being transmitted, do we really need to wait three years for another large trial to tell us that one week of AZT/3TC in the mother, and sdNVP in the child makes more sense?

Finally, WHO should be lauded for their increased emphasis on CD4 cell monitoring in people with HIV — and for recommending the consideration of treatment for pregnant women with 200-350 CD4 cells.

According to Dr. Siobhan Crowley, of WHO’s HIV/AIDS Department: “Clearly it is not OK to wait for AIDS before starting ART — this is way too late. Criteria for initiation of ART need to be clinical and immunological and may well change with time and advancing knowledge and experience. Unfortunately in many countries waiting for ART, AIDS-defining conditions (CDC or WHO defined ) is how people are recognised as eligible for ART.”

News Headlines

Common vaginal infection may double HIV acquisition risk

http://www.aidsmap.com/en/news/1767E991-8D37-4337-8308-4512E2CA3C8E.asp

Bacterial vaginosis (BV), the most common vaginal infection in women of childbearing age, may double a woman's susceptibility to HIV infection, according to the results of a South African study published in the October 15th edition of The Journal of Infectious Diseases, and now available online. If more effective diagnosis and treatment were available, argues an accompanying editorial, HIV infection rates in the developing world could be substantially reduced.

Free ARVs should not be restricted to treatment-naïve, say Ugandan doctors

http://www.aidsmap.com/en/news/2A787F9B-98B6-416C-9C36-8243EBBD3F7C.asp

A group of Ugandan doctors closely involved with their country’s efforts to scale up antirertroviral treatment say that national treatment programmes should not discriminate against people who have been using their own money to buy ARVs when it comes to enrolling future patients.

Nevirapine paediatric dosing: adult tablets can be split, Thai study reports

http://www.aidsmap.com/en/news/27D5459B-000F-4A6D-9102-7AF115D43474.asp

Dosing of children with fractions of adult fixed dose combination tablets that contain nevirapine can provide the appropriate nevirapine exposure for children of varying ages, a Thai study reports this month in the journal AIDS.

Condom promotion in Uganda not reducing HIV risk, study shows

http://www.aidsmap.com/en/news/4E172283-15D5-446A-8CF7-97BCD5B7C8C1.asp

A study of condom distribution and promotion in Uganda has found that whilst education in condom use increased uptake, it did not lead to consistent use in the following six months. Men in the intervention group went on to have a larger number of sexual partners and were somewhat less likely to use condoms with casual sex partners than the control group. The findings are published in the September 1st edition of the Journal of Acquired Immune Deficiency Syndromes.

Malaria more frequent in HIV-positives in Malawi

http://www.aidsmap.com/en/news/FD8F1F2F-66C7-4713-8765-17CD76EAEE7D.asp

Malaria was more frequent in people with HIV in Malawi and a first episode more likely to occur in HIV-positive people with low CD4 cell counts or high viral load, according to findings from a study published in the September 15th edition of the Journal of Infectious Diseases. Malaria prophylaxis for people with HIV should be considered as a routine intervention, the authors suggest, in order to reduce the malaria burden in countries where both HIV and malaria are common.

Efavirenz and rifampicin: UK doctors caution on higher EFV doses in Africans

http://www.aidsmap.com/en/news/E0929D96-C96B-412D-9C8E-1035DFB87268.asp

Clinicians at St George's Hospital in London report that patients are much more likely to experience efavirenz-related side-effects when 800mg efavirenz (Sustiva) is co-administered with the anti-tuberculosis (TB) drug, rifampicin. In a research letter published in the September 23rd issue of the journal, AIDS, they argue that using the higher dose of efavirenz with concomitant anti-TB therapy should not be practised universally, particularly in patients of black African origin who are more likely to carry a genetic polymorphism that slows efavirenz clearance.

HIV disproportionately affecting young women in South Africa

http://www.aidsmap.com/en/news/7A4645D5-6C27-4B6F-B647-AAF5FEA4547A.asp

Fifteen percent of young South African women, aged between 15 and 24 are HIV-positive, compared to only 5% of South African males in the same age group, according to a study published in the September 23rd edition of AIDS. The investigators found that older sexual partners, sexually transmitted infections and inconsistent condom use were amongst the risk factors for HIV infection, but they also found that young people who had participated in South Africa’s loveLife HIV prevention activities were less likely to be HIV-infected.

Drug-using MSM and transgendered Katoey in Thailand require culturally appropriate HIV and Hepatitis C targeted prevention

http://www.aidsmap.com/en/news/D338BF8C-F9E2-4B66-8ACA-D2F77E809255.asp

Men who have sex with men (MSM) in Thailand, who often do so with transgendered men known as Katoey, do not perceive themselves to be engaging in sex between men, and are consequently requiring culturally appropriate targeted prevention, according to a study published in the the September 23rd issue of the journal, AIDS. The study also found that substance-using MSM are at high risk of both HIV and hepatitis C infection.

IAS: Prevention is the new 'treatment'

http://www.aidsmap.com/en/news/A858524A-0D6B-4FDE-ABAD-F9413A5C7B77.asp

For the first time in over a decade, a major scientific HIV conference was not dominated by news and debate on HIV treatments or access to them, but on HIV prevention.

Global Fund: donors meeting fails to unleash cash for further scale-up

http://www.aidsmap.com/en/news/3ADEFC3B-AD1A-497C-AEC2-BBA648DDAFD8.asp

An international meeting of donor countries designed to replenish the reserves of the Global Fund to Fight AIDS, TB and Malaria has failed to generate the cash necessary to further expand treatment programmes in 2006 and 2007, according to advocacy groups.

Nevirapine-resistant HIV present in breastmilk of a third of women exposed to single dose

http://www.aidsmap.com/en/news/702AA7B5-1347-408C-84DE-4A3FB5A4A072.asp

A third of women who take single-dose nevirapine (Viramune) to prevent mother-to-child transmission of HIV have virus resistant to non-nucleoside reverse transcriptase inhibitors (NNRTIs) present in their breastmilk eight weeks after giving birth, according to a study published in the October 1st edition of Clinical Infectious Diseases (now online). The investigators also found that almost three quarters of women had detectable HIV in their breastmilk and that women with mastitis – breast tissue inflammation – had significantly higher levels of HIV shedding, leading the researchers to recommend that “interventions to reduce mastitis…are warranted, to increase the safety of breast-feeding and prevent breastmilk transmission of HIV.”

Detectable viral loads in patients on antiretroviral therapy causes slow development of resistance

http://www.aidsmap.com/en/news/5B43E629-07C7-4769-90B0-623FF2AFD589.asp

HIV-infected patients taking antiretroviral therapy but with detectable levels of HIV in the blood acquire drug resistance mutations relatively slowly, according to a prospective observational cohort study presented in the 1st September edition of The Journal of Acquired Immune Deficiency Syndromes.

Does buprenorphine have a role in preventing HIV transmission and treating HIV-infected IDUs

http://www.aidsmap.com/en/news/E564BB83-A1AD-4F98-A976-A9A7002CB789.asp

A review article published in the 15th September edition of Clinical Infectious Diseases has outlined the benefits of buprenorphine (Subutex) in the treatment of intravenous drug use. The drug, which was added to the World Health Organization’s (WHO's) list of essential drugs in July 2005, may be beneficial in reducing HIV transmission through injection practices, as well as treating HIV-infected drug users.

Risk of 5% weight loss increased in HAART era, not linked to lipodystrophy

http://www.aidsmap.com/en/news/253F1E5A-12E9-467A-A406-A60CF4B1FF02.asp

The proportion of HIV-positive patients who experienced an unintentional loss in body weight of 5% or more increased significantly between 1995 and 2003, according to an American study published in the September 1st edition of the Journal of Acquired Immune Deficiency Syndromes. The investigators found that this weight loss was not connected with lipodystrophy and express concern that weight loss of 5% or more has been shown to markedly increase the risk of death in HIV-positive patients.

HIV treatment dramatically cuts risk of HIV transmission in steady heterosexual couples

http://www.aidsmap.com/en/news/11D0BCF6-B93A-4FDA-9436-7279344CD363.asp

Effective anti-HIV treatment has significantly reduced the sexual transmission of HIV amongst steady heterosexual couples, according to the results of a Spanish study published in the September 1st edition of the Journal of Acquired Immune Deficiency Syndromes. The investigators found that HIV prevalence amongst the initially HIV-negative partners fell from 10% before potent HIV therapy became available to 2% after the introduction of effective antiretroviral treatment. In addition, the investigators also noted that not a single case of HIV transmission occurred in a couple where the HIV-positive partner was taking a powerful combination of anti-HIV drugs.

Very low rate of liver problems seen with Kaletra

http://www.aidsmap.com/en/news/C4A19B52-359D-4E8B-95BF-47327B9A17AD.asp

Treatment with Kaletra (lopinavir/ritonavir) does not involve a high rate of major liver side-effects, according to an Italian study published in the September 2nd edition of AIDS. The investigators found that, even though over 40% of the patients enrolled in their study were coinfected with hepatitis B or C virus, the incidence of a grade III or IV liver abnormality was less than one per 100 person years of follow-up.

CD4 percentage could help decide when to start treatment

http://www.aidsmap.com/en/news/F731C054-1B9C-4A8B-BB54-052E27C113DE.asp

CD4 percentages, along with CD4 cell counts, could be of benefit in helping patients decide when to start antiretroviral therapy, according to a study published in the 15th September edition of The Journal of Infectious Diseases. In particular, they suggest that patients with a CD4 cell count above 350 cells/mm3 but a low CD4 percentage could benefit from starting HIV treatment earlier than recommended in current guidelines.

NNRTIs have a greater risk of resistance than PIs when used in regimens after treatment break

http://www.aidsmap.com/en/news/24591AF0-90FC-4FD1-96F0-657307860915.asp

Patients who take a non-nucleoside reverse transcriptase inhibitor (NNRTI) -based regimen after a break from HIV treatment are significantly less likely to achieve an undetectable viral load than patients reinitiating HIV therapy with a protease inhibitor-containing combination, according to the results of a retrospective Spanish study published in the September 15th edition of Clinical Infectious Diseases. The investigators believe that the resistance barriers and pharmacokinetics of NNRTIs could explain these findings and suggest that resistance tests should be performed before a patient recommences NNRTI treatment after a break from HIV therapy.

Hepatitis C co-infection blunts response to antiretroviral therapy

http://www.aidsmap.com/en/news/6B6EC4F2-C5C6-43AB-93C1-A9836498851F.asp

Co-infection with the hepatitis C virus (HCV) reduces CD4 cell count gains by an average of 33 cells/mm3 after a year of antiretroviral therapy in HIV-positive patients, according to the results of a meta-analysis published in the 1st September edition of Clinical Infectious Diseases.

South Africa: Erratic infant formula supply puts PMTCT at risk

http://www.aidsmap.com/en/news/0624EC9F-F6EE-4624-982C-D14E43B0A984.asp

International food and beverage company Nestlé is to provide a full report to the South African government on how it is addressing the erratic supply of infant formula to public health facilities.

Co-trimoxazole in Malawi: risks may outweigh benefits

http://www.aidsmap.com/en/news/FDC11E07-6146-4944-9F1C-FDAEA5F2C614.asp

A study in Malawi has found that whilst most of the opportunistic infections prevented by the drug co-trimoxazole are rare in people with HIV, bacterial infections and malarial infection that already have reduced sensitivity to co-trimoxazole are widespread, calling into question the global recommendation that all people with HIV with CD4 cell counts below 500 should receive prophylactic treatment with co-trimoxazole. Its use in settings where resistance is high in the general population has been controversial.

Antiretroviral therapy reduces HIV transmission through breast milk

http://www.aidsmap.com/en/news/37FAC18C-BBF2-42F0-AD8F-5F48C16EB2AE.asp

Treatment of HIV-positive breast-feeding mothers with antiretroviral therapy results in reduced viral loads in breast milk and anti-HIV drug levels sufficient to prevent HIV transmission, according to findings published in the 1st September edition of The Journal of Infectious Diseases.

Flagship mother-to-child transmission prevention programme in Lusaka only 30% effective

http://www.aidsmap.com/en/news/E65D7DEE-FF48-47E8-956A-4C0530BE54BA.asp

A free city-wide programme to prevent mother-to-child transmission (MTCT) in Lusaka, Zambia is only effectively reaching 30% of mother-child pairs, according to the results of a paper published in the September 1st issue of the journal Clinical Infectious Diseases. The most striking findings were that anonymously identified HIV-positive women were significantly less likely to accept an HIV test than their HIV-negative counterparts, and that almost one-in-three of the women who knew they were HIV-positive (32%) did not actually take the single dose of nevirapine (Viramune) during labour.

Mother-to-child transmission may be more common with subtype D than A

http://www.aidsmap.com/en/news/DF66F343-556F-4B6B-98A1-1DEF35D61CF7.asp

There is a trend for higher rates of mother-to-child transmission of HIV for women infected with sub-type D versus sub-type A, according to data from the HIV Network for Prevention Trials (HIVNET) 012 study published in the August 15th edition of The Journal of Acquired Immune Deficiency Syndromes.

Lower CD4 cell count in Ethiopians doesn't mean shorter survival

http://www.aidsmap.com/en/news/B2E7B1DA-9C31-4355-B7DC-9530E75CF357.asp

A low baseline CD4 cell count does not mean that HIV-positive Ethiopians have poorer survival, according to a study published in the September 1st edition of the Journal of Infectious Diseases. The investigators found that median survival time for Ethiopians was comparable to that of Dutch gay men and injecting drug users before effective anti-HIV treatment became available, because the Ethiopians lost CD4 cells at a slower rate than the Dutch.

Ranbaxy says seven ARV products are back on WHO list

http://www.aidsmap.com/en/news/804BE0D7-EB7F-407E-81BB-FCAB755ED864.asp

India’s Ranbaxy Laboratories has announced that seven of its antiretroviral products have been reinstated to the World Health Organization’s list of prequalified antiretrovirals (ARVs) after new bioequivalence tests carried out by `globally recognised` contract research laboratories.

Race does not affect effectiveness of HAART: US women's study

http://www.aidsmap.com/en/news/C2EBA871-6F74-4591-B9F8-3254A9F285CA.asp

Race does not affect virological, immunological, or clinical response to antiretroviral therapy amongst women who continue taking HIV therapy after initiating highly active antiretroviral therapy (HAART), according to a study conducted in the United States and published in the August 15th edition of the Journal of Acquired Immune Deficiency Syndromes. The investigators, from the Women’s Interagency HIV Study (WIHS), found however, that discontinuing HAART and to a lesser extent, depression, were both associated with a poorer response to antiretroviral therapy.

New publications from the International HIV/AIDS Alliance

Setting up and managing sexual health clinical services in resource-poor settings: A comprehensive programmatic guide for NGOs (Volume I)

http://www.aidsalliance.org/sw28653.asp

This manual was developed to support the provision of clinical services to key populations (men who have sex with men, people living with HIV/AIDS, sex workers and injecting drug users) in Andhra Pradesh as part of the India AIDS Initiative-Avahan programme and the Frontiers Prevention Project.

Clinical management of sexually transmitted infections in resource-poor settings: A comprehensive guide for clinicians (Volume II)

http://www.aidsalliance.org/sw28656.asp

This volume is primarily intended as a manual for clinical staff who will oversee and manage a variety of interventions, including the diagnosis and treatment of STIs, within the specialised NGO clinics.

It features a comprehensive approach for the effective management of STIs, including taking a patient’s sexual history, the management and treatment of STIs, tools which may be useful in implementing clinical services, and participatory exercises for those who wish to use this manual to assist in training.

Other Alliance publications on HIV treatment and care

The Alliance is committed to making access to care, treatment, and prevention a reality for all, including HIV testing and counselling, treatment, palliative care, support and prevention. These should be available and accessible to everyone living with and affected by HIV/AIDS, including children and others who have to face the effects of the epidemic – caring for or losing parents or siblings, for example. To this end, the Alliance has developed a range of publications and resources, including toolkits, fact sheets and reports on lessons learnt.

The titles below are listed by date of publication.

Community education and referral: Supporting adherence to ARV treatment and prevention for people with HIV in Zambia

http://www.aidsalliance.org/sw23263.asp

Human resources for health exist in communities

http://www.aidsalliance.org/sw23323.asp

ARV treatment fact sheets

http://www.aidsalliance.org/sw19588.asp

Access to rights and services of people living with HIV in Ukraine: social research results

http://www.aidsalliance.org/sw21036.asp

What is community engagement for ARV treatment?

http://www.aidsalliance.org/sw7427.asp

Voices from Zambian communities – Experiences of HIV/AIDS-related treatment in urban and rural settings

http://www.aidsalliance.org/sw7434.asp

Scaling up testing and counselling services – Toolkit

http://www.aidsalliance.org/sw7420.asp

A public health approach for scaling up ARV treatment – A toolkit for programme managers

http://www.aidsalliance.org/sw7419.asp

Movilizar ONGs, OBCs y Grupos de PVVs Para Mejorar el Acceso a Tratamientos Relacionados al VIH/SIDA

http://www.aidsalliance.org/sw8143.asp

Voluntary counselling and testing – Emerging approaches from Asia and Eastern Europe

http://www.aidsalliance.org/sw7433.asp

Antiretroviral treatment in Zambia – A study of the experiences of treatment users and health care workers

http://www.aidsalliance.org/sw7422.asp

Improving Access to Antiretroviral Treatment in Cambodia

http://www.aidsalliance.org/sw7405.asp

Linking HIV and TB – underlying issues to consider when scaling up integration of HIV and TB services in Cambodia

http://www.aidsalliance.org/sw7424.asp

Guide sur l’accès aux traitements liés au VIH/SIDA – Recueil d’informations, d’outils et de references à l’intention des ONG, des organisations communautaires (OC) et des groupes de PVS

http://www.aidsalliance.org/sw7438.asp

The care and support cellule – an integrated and decentralised approach to care and support for people living with HIV/AIDS in developing countries

http://www.aidsalliance.org/sw8152.asp

Handbook on access to HIV/AIDS treatment – A collection of information, tools and resources for NGOs, CBOs and PLWHA groups

http://www.aidsalliance.org/sw7421.asp

Integrating HIV/AIDS and TB services – A practical resource

http://www.aidsalliance.org/sw7435.asp

Improving access to HIV/AIDS-related treatment – A report sharing experiences and lessons learned on improving access to HIV/AIDS-related treatment

http://www.aidsalliance.org/sw7423.asp

Care, involvement and action: Mobilising and supporting community responses to HIV/AIDS care and support in developing countries

http://www.aidsalliance.org/sw7425.asp

An evaluation of the MoH/NGO home care programme for people with HIV/AIDS in Cambodia

http://www.aidsalliance.org/sw7426.asp

About HATIP

A regular electronic newsletter for health care workers and community-based organisations on HIV treatment in resource-limited settings.

Its publication is supported by the UK government's Department for International Development (DfID), the Diana, Princess of Wales Memorial Fund and the Stop TB Department of the World Health Organization.

Other supporters include Positive Action GlaxoSmithKline (founding sponsor); Abbott Fund; Abbott Molecular; Cavidi; Elton John AIDS Foundation; Merck & Co., Inc.; Pfizer Ltd; F Hoffmann La Roche; Schering Plough; and Tibotec, a division of Janssen Cilag.