Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review

Paper published in PLoS Medicine in 2007.

Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Efficiency, Equity, and Reality

Background: Rationing of access to antiretroviral therapy already exists in sub-Saharan Africa and will intensify as national treatment programs develop. The number of people who are medically eligible for therapy will far exceed the human, infrastructural, and financial resources available, making rationing of public treatment services inevitable. Methods: We identified 15 criteria by which antiretroviral therapy could be rationed in African countries and analyzed the resulting rationing systems across 5 domains: clinical effectiveness, implementation feasibility, cost, economic efficiency, and social equity. Findings: Rationing can be explicit or implicit. Access to treatment can be explicitly targeted to priority subpopulations such as mothers of newborns, skilled workers, students, or poor people. Explicit conditions can also be set that cause differential access, such as residence in a designated geographic area, co-payment, access to testing, or a demonstrated commitment to adhere to therapy. Implicit rationing on the basis of first-come, first-served or queuing will arise when no explicit system is enforced; implicit systems almost always allow a high degree of queue-jumping by the elite. There is a direct tradeoff between economic efficiency and social equity. Interpretation: Rationing is inevitable in most countries for some period of time. Without deliberate social policy decisions, implicit rationing systems that are neither efficient nor equitable will prevail. Governments that make deliberate choices, and then explain and defend those choices to their constituencies, are more likely to achieve a socially desirable outcome from the large investments now being made than are those that allow queuing and queue-jumping to dominate.

How Much Does It Cost to Provide Antiretroviral Therapy for HIV/AIDS in Africa?

Background: Many African countries are rapidly expanding HIV/AIDS treatment programs. Empirical information on the cost of delivering antiretroviral therapy (ART) for HIV/AIDS is needed for program planning and budgeting. Methods: We searched published and gray sources for estimates of the cost of providing ART in service delivery (non-research) settings in sub-Saharan Africa. Estimates were included if they were based on primary local data for input prices. Results: 17 eligible cost estimates were found. Of these, 10 were from South Africa. The cost per patient per year ranged from $396 to $2,761. It averaged approximately $850/patient/year in countries outside South Africa and $1,700/patient/year in South Africa. The most recent estimates for South Africa averaged $1,200/patient/year. Specific cost items included in the average cost per patient per year varied, making comparison across studies problematic. All estimates included the cost of antiretroviral drugs and laboratory tests, but many excluded the cost of inpatient care, treatment of opportunistic infections, and/or clinic infrastructure. Antiretroviral drugs comprised an average of one third of the cost of treatment in South Africa and one half to three quarters of the cost in other countries. Conclusions: There is very little empirical information available about the cost of providing antiretroviral therapy in non-research settings in Africa. Methods for estimating costs are inconsistent, and many estimates combine data drawn from disparate sources. Cost analysis should become a routine part of operational research on the treatment rollout in Africa.

Non-clinical outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review

The impacts of antiretroviral therapy on quality of life, mental health, labor productivity, and economic wellbeing for people living with HIV/AIDS in developing countries are only beginning to be measured. We conducted a systematic literature review to analyze the effect of antiretroviral therapy (ART) on these non-clinical indicators in developing countries and assess the state of research on these topics. Both qualitative and quantitative studies were included, as were peer-reviewed articles, gray literature, and conference abstracts and presentations. Findings are reported from 12 full-length articles, 7 abstracts, and 1 presentation (representing 16 studies). Compared to HIV-positive patients not yet on treatment, patients on ART reported significant improvements in physical, emotional and mental health and daily function. Work performance improved and absenteeism decreased, with the most dramatic changes occurring in the first three months of treatment and then leveling off. Little research has been done on the impact of ART on household wellbeing, with modest changes in child and family wellbeing within households where adults are receiving ART reported so far. Studies from developing countries have not yet assessed non-clinical outcomes of therapy beyond the first year; therefore, longitudinal outcomes are still unknown. As ART roll out extends throughout high HIV prevalence, low-resource countries and is sustained over years and decades, both positive and adverse non-clinical outcomes need to be empirically measured and qualitatively explored in order to support patient adherence and maximize treatment benefits.

Biologically Inspired Approaches to Automated Feature Extraction and Target Recognition

Ongoing research at Boston University has produced computational models of biological vision and learning that embody a growing corpus of scientific data and predictions. Vision models perform long-range grouping and figure/ground segmentation, and memory models create attentionally controlled recognition codes that intrinsically cornbine botton-up activation and top-down learned expectations. These two streams of research form the foundation of novel dynamically integrated systems for image understanding. Simulations using multispectral images illustrate road completion across occlusions in a cluttered scene and information fusion from incorrect labels that are simultaneously inconsistent and correct. The CNS Vision and Technology Labs (cns.bu.edulvisionlab and cns.bu.edu/techlab) are further integrating science and technology through analysis, testing, and development of cognitive and neural models for large-scale applications, complemented by software specification and code distribution.

Target Selection by Frontal Cortex During Coordinated Saccadic and Smooth Pursuit Eye Movement

Oculomotor tracking of moving objects is an important component of visually based cognition and planning. Such tracking is achieved by a combination of saccades and smooth pursuit eye movements. In particular, the saccadic and smooth pursuit systems interact to often choose the same target, and to maximize its visibility through time. How do multiple brain regions interact, including frontal cortical areas, to decide the choice of a target among several competing moving stimuli? How is target selection information that is created by a bias (e.g., electrical stimulation) transferred from one movement system to another? These saccade-pursuit interactions are clarified by a new computational neural model, which describes interactions among motion processing areas MT, MST, FPA, DLPN; saccade specification, selection, and planning areas LIP, FEF, SNr, SC; the saccadic generator in the brain stem; and the cerebellum. Model simulations explain a broad range of neuroanatomical and neurophysiological data. These results are in contrast with the simplest parallel model with no interactions between saccades and pursuit than common-target selection and recruitment of shared motoneurons. Actual tracking episodes in primates reveal multiple systematic deviations from predictions of the simplest parallel model, which are explained by the current model.

A Self-Organizing Neural Network for Learning a Body-Centered Invariant Representation of 3-D Target Position

This paper describes a self-organizing neural network that rapidly learns a body-centered representation of 3-D target positions. This representation remains invariant under head and eye movements, and is a key component of sensory-motor systems for producing motor equivalent reaches to targets (Bullock, Grossberg, and Guenther, 1993).

Neural Representations for Sensory-Motor Control, III: Learning a Body-Centered Representation of 3-D Target Position

A neural model is described of how the brain may autonomously learn a body-centered representation of 3-D target position by combining information about retinal target position, eye position, and head position in real time. Such a body-centered spatial representation enables accurate movement commands to the limbs to be generated despite changes in the spatial relationships between the eyes, head, body, and limbs through time. The model learns a vector representation--otherwise known as a parcellated distributed representation--of target vergence with respect to the two eyes, and of the horizontal and vertical spherical angles of the target with respect to a cyclopean egocenter. Such a vergence-spherical representation has been reported in the caudal midbrain and medulla of the frog, as well as in psychophysical movement studies in humans. A head-centered vergence-spherical representation of foveated target position can be generated by two stages of opponent processing that combine corollary discharges of outflow movement signals to the two eyes. Sums and differences of opponent signals define angular and vergence coordinates, respectively. The head-centered representation interacts with a binocular visual representation of non-foveated target position to learn a visuomotor representation of both foveated and non-foveated target position that is capable of commanding yoked eye movementes. This head-centered vector representation also interacts with representations of neck movement commands to learn a body-centered estimate of target position that is capable of commanding coordinated arm movements. Learning occurs during head movements made while gaze remains fixed on a foveated target. An initial estimate is stored and a VOR-mediated gating signal prevents the stored estimate from being reset during a gaze-maintaining head movement. As the head moves, new estimates arc compared with the stored estimate to compute difference vectors which act as error signals that drive the learning process, as well as control the on-line merging of multimodal information.

Neural Representations for Sensory-Motor Control I: Head-Centered 3-D Target Positions from Opponent Eye Commands

This article describes how corollary discharges from outflow eye movement commands can be transformed by two stages of opponent neural processing into a head-centered representation of 3-D target position. This representation implicitly defines a cyclopean coordinate system whose variables approximate the binocular vergence and spherical horizontal and vertical angles with respect to the observer's head. Various psychophysical data concerning binocular distance perception and reaching behavior are clarified by this representation. The representation provides a foundation for learning head-centered and body-centered invariant representations of both foveated and non-foveated 3-D target positions. It also enables a solution to be developed of the classical motor equivalence problem, whereby many different joint configurations of a redundant manipulator can all be used to realize a desired trajectory in 3-D space.