Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America

OBJECTIVES: To describe temporal trends in baseline clinical characteristics, initial treatment regimens and monitoring of patients starting antiretroviral therapy (ART) in resource-limited settings. METHODS: We analysed data from 17 ART programmes in 12 countries in sub-Saharan Africa, South America and Asia. Patients aged 16 years or older with documented date of start of highly active ART (HAART) were included. Data were analysed by calculating medians, interquartile ranges (IQR) and percentages by regions and time periods. Not all centres provided data for 2006 and 2005 and 2006 were therefore combined. RESULTS: A total of 36,715 patients who started ART 1996-2006 were included in the analysis. Patient numbers increased substantially in sub-Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005-2006. In South America 20 regimes were used in 2005-2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/microl (IQR 53-194) in 2005-2006 in Africa, 134 cells/microl (IQR 72-191) in Asia, and 197 cells/microl (IQR 61-277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/microl in 2005-2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/microl in Africa, 65 cells/microl in Asia and 10 cells/microl in South America. In 2005-2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America. Corresponding figures for 6-month CD4 cell counts were 74%, 77% and 81%. CONCLUSIONS: The public health approach to providing ART proposed by the World Health Organization has been implemented in sub-Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV-infected men.

Major challenges in clinical management of TB/HIV co-infected patients in Eastern Europe compared with Western Europe and Latin America.

INTRODUCTION Rates of both TB/HIV co-infection and multi-drug-resistant (MDR) TB are increasing in Eastern Europe (EE). Data on the clinical management of TB/HIV co-infected patients are scarce. Our aim was to study the clinical characteristics of TB/HIV patients in Europe and Latin America (LA) at TB diagnosis, identify factors associated with MDR-TB and assess the activity of initial TB treatment regimens given the results of drug-susceptibility tests (DST). MATERIAL AND METHODS We enrolled 1413 TB/HIV patients from 62 clinics in 19 countries in EE, Western Europe (WE), Southern Europe (SE) and LA from January 2011 to December 2013. Among patients who completed DST within the first month of TB therapy, we linked initial TB treatment regimens to the DST results and calculated the distribution of patients receiving 0, 1, 2, 3 and ≥4 active drugs in each region. Risk factors for MDR-TB were identified in logistic regression models. RESULTS Significant differences were observed between EE (n=844), WE (n=152), SE (n=164) and LA (n=253) for use of combination antiretroviral therapy (cART) at TB diagnosis (17%, 40%, 44% and 35%, p<0.0001), a definite TB diagnosis (culture and/or PCR positive for Mycobacterium tuberculosis; 47%, 71%, 72% and 40%, p<0.0001) and MDR-TB prevalence (34%, 3%, 3% and 11%, p <0.0001 among those with DST results). The history of injecting drug use [adjusted OR (aOR) = 2.03, (95% CI 1.00-4.09)], prior TB treatment (aOR = 3.42, 95% CI 1.88-6.22) and living in EE (aOR = 7.19, 95% CI 3.28-15.78) were associated with MDR-TB. For 569 patients with available DST, the initial TB treatment contained ≥3 active drugs in 64% of patients in EE compared with 90-94% of patients in other regions (Figure 1a). Had the patients received initial therapy with standard therapy [Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (RHZE)], the corresponding proportions would have been 64% vs. 86-97%, respectively (Figure 1b). CONCLUSIONS In EE, TB/HIV patients had poorer exposure to cART, less often a definitive TB diagnosis and more often MDR-TB compared to other parts of Europe and LA. Initial TB therapy in EE was sub-optimal, with less than two-thirds of patients receiving at least three active drugs, and improved compliance with standard RHZE treatment does not seem to be the solution. Improved management of TB/HIV patients requires routine use of DST, initial TB therapy according to prevailing resistance patterns and more widespread use of cART.

Tuberculosis-related mortality in people living with HIV in Europe and Latin America: an international cohort study

BACKGROUND Management of tuberculosis in patients with HIV in eastern Europe is complicated by the high prevalence of multidrug-resistant tuberculosis, low rates of drug susceptibility testing, and poor access to antiretroviral therapy (ART). We report 1 year mortality estimates from a multiregional (eastern Europe, western Europe, and Latin America) prospective cohort study: the TB:HIV study. METHODS Consecutive HIV-positive patients aged 16 years or older with a diagnosis of tuberculosis between Jan 1, 2011, and Dec 31, 2013, were enrolled from 62 HIV and tuberculosis clinics in 19 countries in eastern Europe, western Europe, and Latin America. The primary endpoint was death within 12 months after starting tuberculosis treatment; all deaths were classified according to whether or not they were tuberculosis related. Follow-up was either until death, the final visit, or 12 months after baseline, whichever occurred first. Risk factors for all-cause and tuberculosis-related deaths were assessed using Kaplan-Meier estimates and Cox models. FINDINGS Of 1406 patients (834 in eastern Europe, 317 in western Europe, and 255 in Latin America), 264 (19%) died within 12 months. 188 (71%) of these deaths were tuberculosis related. The probability of all-cause death was 29% (95% CI 26-32) in eastern Europe, 4% (3-7) in western Europe, and 11% (8-16) in Latin America (p<0·0001) and the corresponding probabilities of tuberculosis-related death were 23% (20-26), 1% (0-3), and 4% (2-8), respectively (p<0·0001). Patients receiving care outside eastern Europe had a 77% decreased risk of death: adjusted hazard ratio (aHR) 0·23 (95% CI 0·16-0·31). In eastern Europe, compared with patients who started a regimen with at least three active antituberculosis drugs, those who started fewer than three active antituberculosis drugs were at a higher risk of tuberculosis-related death (aHR 3·17; 95% CI 1·83-5·49) as were those who did not have baseline drug-susceptibility tests (2·24; 1·31-3·83). Other prognostic factors for increased tuberculosis-related mortality were disseminated tuberculosis and a low CD4 cell count. 18% of patients were receiving ART at tuberculosis diagnosis in eastern Europe compared with 44% in western Europe and 39% in Latin America (p<0·0001); 12 months later the proportions were 67% in eastern Europe, 92% in western Europe, and 85% in Latin America (p<0·0001). INTERPRETATION Patients with HIV and tuberculosis in eastern Europe have a risk of death nearly four-times higher than that in patients from western Europe and Latin America. This increased mortality rate is associated with modifiable risk factors such as lack of drug susceptibility testing and suboptimal initial antituberculosis treatment in settings with a high prevalence of drug resistance. Urgent action is needed to improve tuberculosis care for patients living with HIV in eastern Europe. FUNDING EU Seventh Framework Programme.

Counselors' education in complex contexts with special reference to Latin America

This paper makes reference to the importance lying, at present, on the professional education of counselors. It goes through the history of the different pre-scientific and scientific stages of counseling, and it points out the main representatives in Latin America . It also shows the current state of the specialization, taking as an antecedent some in-depth, widely encompassing research carried out in the European Union in this area. Coincidences and differences are exposed here in terms of professional profiles, university degrees, institutional dependence, up-dating processes and modes of intervention. The current state of postgraduate studies at university is also touched upon, and the different proposals for further education in Latin America are analyzed as well as their dependence upon an undergraduate degree in Psychology, Educational Sciences or Psycho-pedagogy. Finally, this paper places counseling within the complexity and the need to provide all-encompassing and integrative answers which require a wide and deep enough education so as to answer all these issues and problems.

Counselors' education in complex contexts with special reference to Latin America

This paper makes reference to the importance lying, at present, on the professional education of counselors. It goes through the history of the different pre-scientific and scientific stages of counseling, and it points out the main representatives in Latin America . It also shows the current state of the specialization, taking as an antecedent some in-depth, widely encompassing research carried out in the European Union in this area. Coincidences and differences are exposed here in terms of professional profiles, university degrees, institutional dependence, up-dating processes and modes of intervention. The current state of postgraduate studies at university is also touched upon, and the different proposals for further education in Latin America are analyzed as well as their dependence upon an undergraduate degree in Psychology, Educational Sciences or Psycho-pedagogy. Finally, this paper places counseling within the complexity and the need to provide all-encompassing and integrative answers which require a wide and deep enough education so as to answer all these issues and problems.

Counselors' education in complex contexts with special reference to Latin America

This paper makes reference to the importance lying, at present, on the professional education of counselors. It goes through the history of the different pre-scientific and scientific stages of counseling, and it points out the main representatives in Latin America . It also shows the current state of the specialization, taking as an antecedent some in-depth, widely encompassing research carried out in the European Union in this area. Coincidences and differences are exposed here in terms of professional profiles, university degrees, institutional dependence, up-dating processes and modes of intervention. The current state of postgraduate studies at university is also touched upon, and the different proposals for further education in Latin America are analyzed as well as their dependence upon an undergraduate degree in Psychology, Educational Sciences or Psycho-pedagogy. Finally, this paper places counseling within the complexity and the need to provide all-encompassing and integrative answers which require a wide and deep enough education so as to answer all these issues and problems.

Constitutions around the world : A View from Latin America

This paper gives a global summary of the number of constitutions and the number of　articles in each constitution for many representative countries around the world. Several　works have already been written comparing different legal systems and different　constitutional traditions around the world; the purpose of this paper is just to compare the　numbers of constitutions and articles in the diverse regions of the world, namely: North　America, Latin America, Europe, Oceania, Middle East, Asia and Africa. Around the world, on average, Latin America has had the most convoluted constitutional history. The Dominican Republic has had a total of 32 constitutions, the largest number of constitutions of any country, since its independence in 1844. Three other countries have also had 20 or more constitutions throughout their history, all of them in Latin America: Venezuela (26), Haiti (24) and Ecuador (20). On the other hand, there are economies and societies that do not even have codified constitutions, like the United Kingdom in Europe, Hong Kong in Asia and New Zealand in Oceania. The United States has had only one constitution, even if it has been amended several times. There are also the special cases of Israel and Saudi Arabia, both in the Middle East, that do not have official written constitutions for historical and religious reasons. Comparative constitutional numbers and history help explain several things about the stability of political systems, but not necessarily about their quality.

Communism in Latin America. Hearings, Eighty-ninth Congress, first session.

Hearings held Feb. 16-Mar. 30, 1965.

Inventory of information basic to the planning of agricultural development in Latin America.

Bibliographical footnotes.

Report of the first session of the Regional Conference on Population and Development in Latin America and the Caribbean: full integration of population dynamics into rights-based sustainable development with equality: key to the Cairo programme of action beyond 2014

Includes as annex the Montevideo Consensus on Population and Development

The direct investments in Latin America and the Caribbean in the 1990s of multinational enterprises headquartered in Spain

This thesis explains why multinational enterprises (MNEs) headquartered in Spain made significant investments in Latin America in the 1990s. Two independent variables are considered: structural reforms in Latin America, and liberalization in Spain. The first independent variable concerns the ways in which Latin American governments adopted a series of reforms that made their economies attractive to foreign investors. The second variable explains how the prospects of liberalization and foreign competition led Spanish firms to invest abroad in order to expand their businesses. The study will also show the competitive advantage of Spanish MNEs, vis-a-vis other foreign and local competitors in Latin America. This thesis takes an international political economy approach. The core of the thesis shows the development of Spanish direct investment in Latin America and the Caribbean in the 1990s. The theoretical perspectives on MNEs are provided by theory of the firm, industrial organizations theory and alliance theory. ^

Latin America and the Caribbean in 2011 and Beyond: A conversation among Latin America and Caribbean Specialists.

For the first time in more than fifty years, the domestic and external conflicts in Latin America and the Caribbean (LAC) are not primarily ideological in nature. Democracy continues to thrive and its promise still inspires hope. In contrast, the illegal production, consumption, and trading of drugs – and its links to criminal gangs and organizations – represent major challenges to the region, undermining several States’ already weak capacity to govern. While LAC macroeconomic stability has remained resilient, illegal economies fill the region, often offering what some States have not historically been able to provide – elements of human security, opportunities for social mobility, and basic survival. Areas controlled by drug trafficking organizations (DTOs) are now found in Central America, Mexico, and the favelas of Rio de Janeiro and São Paulo, reflecting their competition for land routes and production areas. Cartels such as La Familia, Los Zetas, and Primeiro Comando da Capital (PCC-Brazil), among others, operate like trade and financial enterprises that manage millions of dollars and resources, demonstrating significant business skills in adapting to changing circumstances. They are also merciless in their application of violence to preserve their lucrative enterprises. The El Salvador-Guatemala-Honduras triangle in Central America is now the most violent region in the world, surpassing regions in Africa that have been torn by civil strife for years. In Brazil’s favelas and Guatemala’s Petén region, the military is leaving the barracks again; not to rule, however, but to supplement and even replace the law enforcement capacity of weak and discredited police forces. This will challenge the military to apply lessons learned during the course of their experience in government, or from the civil wars that plagued the region for nearly 50 years during the Cold War. Will they be able to conduct themselves according to the professional ethics that have been inculcated over the past 20 years without incurring violations of human rights? Belief in their potential to do good is high according to many polls as the Armed Forces still enjoy a favorable perception in most societies, despite frequent involvement in corruption. Calling them to fight DTOs, however, may bring them too close to the illegal activities they are being asked to resist, or even rekindle the view that only a “strong hand” can resolve national troubles. The challenge of governance is occurring as contrasts within the region are becoming sharper. There is an increasing gap between nations positioned to surpass their “developing nation” status and those that are practically imploding as the judicial, political and enforcement institutions fall further into the quagmire of illicit activities. Several South American nations are advancing their political and economic development. Brazil in particular has realized macro-economic stability, made impressive gains in poverty reduction, and is on track to potentially become a significant oil producer. It is also an increasingly influential power, much closer to the heralded “emerging power” category that it aspired to for most of the 20th century. In contrast, several Central American States have become so structurally deficient, and have garnered such limited legitimacy, that their countries have devolved into patches of State controlled and non-State-controlled territory, becoming increasingly vulnerable to DTO entrenchment. In the Caribbean, the drug and human trafficking business also thrives. Small and larger countries are experiencing the growing impact of illicit economies and accompanying crime and violence. Among these, Guyana and Suriname face greater uncertainty, as they juggle both their internal affairs and their relations with Brazil and Venezuela. Cuba also faces new challenges as it continues focusing on internal rather than external affairs and attempts to ensure a stable leadership succession while simultaneously trying to reform its economy. Loosening the regime’s tight grip on the economy while continuing to curtail citizen’s civil rights will test the leadership’s ability to manage change and prevent a potential socio-economic crisis from turning into an existential threat. Cuba’s past ideological zest is now in the hands of Venezuela’s President Hugo Chavez, who continues his attempts to bring the region together under Venezuelan leadership ideologically based on a “Bolivarian” anti-U.S. banner, without much success. The environment and natural disasters will merit more attention in the coming years. Natural events will produce increasing scales of destruction as the States in the region fail to maintain and expand existing infrastructure to withstand such calamities and respond to their effects. Prospects for earthquakes, tsunamis, and hurricanes are high, particularly in the Caribbean. In addition, there are growing rates of deforestation in nearly every country, along with a potential increase in cross-sector competition for resources. The losers might be small farmers, due to their inability to produce quantities commensurate to larger conglomerates. Regulations that could mitigate these types of situations are lacking or openly violated with near impunity. Indigenous and other vulnerable populations, including African descendants, in several Andean countries, are particularly affected by the increasing extraction of natural resources taking place amongst their terrain. This has led to protests against extraction activities that negatively affect their livelihoods, and in the process, these historically underprivileged groups have transitioned from agenda-based organization to one that is bringing its claims and grievances to the national political agenda, becoming more politically engaged. Symptomatic of these social issues is the region’s chronically poor quality of education that has consistently failed to reduce inequality and prepare new generations for jobs in the competitive global economy, particularly the more vulnerable populations. Simultaneously, the educational deficit is also exacerbated by the erosion of access to information and freedom of the press. The international panorama is also in flux. New security entities are challenging the old establishment. The Union of South American Nations, The South American Defense Council, the socialist Bolivarian Alliance, and other entities seem to be defying the Organization of American States and its own defense mechanisms, and excluding the U.S. And the U.S.’s attention to areas in conflict, namely Iraq, Afghanistan, and Pakistan – rather than to the more stable Latin America and Caribbean – has left ample room for other actors to elbow in. China is now the top trading partner for Brazil. Russian and Iran are also finding new partnerships in the region, yet their links appear more politically inclined than those of China. Finally, the aforementioned increasing commercial ties by LAC States with China have accelerated a return to the preponderance of commodities as sources of income for their economies. The increased extraction of raw material for export will produce greater concern over the environmental impact that is created by the exploitation of natural resources. These expanded trade opportunities may prove counterproductive economically for countries in the region, particularly for Brazil and Chile, two countries whose economic policies have long sought diversification from dependence on commodities to the development of service and technology based industries.

Two Decades Out of the Whirlpool: Past (and Possible Future) United States Interventions in Latin America [Student's Paper Series]

This paper examines the history of U.S. interventions in Latin America and attempts to explain their frequency by highlighting two factors – besides security and economic interests – that have made American interventions in Latin America so common. First, immense differences in size and influence between the United States and the States of Latin America have made interventions appear to be a low risk solution to crises that threaten American interests in the region. Second, when U.S government concerns and aspirations for Latin America converge with the general fears and aspirations of American foreign policy, interventions become much more likely. Such a convergence pushes Latin American issues high up the U.S. foreign policy agenda because of the region’s proximity to the United States and the perception that costs of intervening are low. The leads proponents of intervention to begin asking questions like “if we cannot stop communism/revolutions/drug-trafficking in Latin America, where can we stop it?” This article traces how these factors influenced the decision to intervene in Latin America during the era of Dollar Diplomacy and during the Cold War. It concludes with three possible scenarios that could lead to a reemergence of an American interventionist policy in Latin America. It makes the argument that even though the United Sates has not intervened in Latin America during the twenty-two years, it is far from clear that American interventions in Latin America will be consigned to the past.

Catholic student movements in Latin America: Cuba and Brazil, 1920s to 1960s

This dissertation examines the ideological development of the Catholic University Student (JUC) movements in Cuba and Brazil during the Cold War and their organizational predecessors and intellectual influences in interwar Europe. Transnational Catholicism prioritized the attempt to influence youth and in particular, university students, within the context of Catholic nations within Atlantic civilization in the middle of the twentieth century. This dissertation argues that the Catholic university movements achieved a relatively high level of social and political influence in a number of countries in Latin America and that the experience of the Catholic student activists led them to experience ideological conflict and in some cases, rupture, with the conservative ideology of the Catholic hierarchy. Catholic student movements flourished after World War II in the context of an emerging youth culture. The proliferation of student organizations became part of the ideological battlefield of the Cold War. Catholic university students also played key roles in the Cuban Revolution (1957-1959) and in the attempted political and social reforms in Brazil under President João Goulart (1961-1964). ^ The JUC, under the guidance of the Church hierarchy, attempted to avoid aligning itself with either ideological camp in the Cold War, but rather to chart a Third Way between materialistic capitalism and atheistic socialism. Thousands of students in over 70 nations were intensively trained to think critically about pressing social issues. This paper will to place the Catholic Student movement in Cuba in the larger context of transnational Catholic university movements using archival evidence, newspaper accounts and secondary sources. Despite the hierarchy's attempt to utilize students as a tool of influence, the actual lived experience of students equipped them to think critically about social issues, and helped lay a foundation for the progressive student politics of the late 1960s and the rise of liberation theology in the 1970s. ^