Gender and the Use of Antiretroviral Treatment in Resource ...

JOURNAL OF WOMEN’S HEALTH Volume 17, Number 1, 2008 © Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2007.0353

Gender and the Use of Antiretroviral Treatment in Resource-Constrained Settings: Findings from a Multicenter Collaboration PAULA BRAITSTEIN, Ph.D.,1 ANDREW BOULLE, M.D.,2 DENIS NASH, Ph.D.,3 MARTIN W.G. BRINKHOF, Ph.D.,4 FRANÇOIS DABIS, M.D., Ph.D.,5 CHRISTIAN LAURENT, M.D.,6 MAURO SCHECHTER, M.D.,7 SUELY H. TUBOI, M.D.,8 EDUARDO SPRINZ, M.D.,9 PAOLO MIOTTI, M.D.,10 MINA HOSSEINIPOUR, M.D.,11 MARGARET MAY, M.Sc.,12 MATTHIAS EGGER, M.D.,12 DAVID R. BANGSBERG, M.D.,13 and NICOLA LOW, M.D.4; THE ANTIRETROVIRAL THERAPY IN LOWER INCOME COUNTRIES (ART-LINC) STUDY GROUP

ABSTRACT Aims: To compare the gender distribution of HIV-infected adults receiving highly active antiretroviral treatment (HAART) in resource-constrained settings with estimates of the gender distribution of HIV infection; to describe the clinical characteristics of women and men receiving HAART. Methods: The Antiretroviral Therapy in Lower-Income Countries, ART-LINC Collaboration is a network of clinics providing HAART in Africa, Latin America, and Asia. We compared UNAIDS data on the gender distribution of HIV infection with the proportions of women and men receiving HAART in the ART-LINC Collaboration. Results: Twenty-nine centers in 13 countries participated. Among 33,164 individuals, 19,989 (60.3%) were women. Proportions of women receiving HAART in ART-LINC centers were similar to, or higher than, UNAIDS estimates of the proportions of HIV-infected women in all but two centers. There were fewer women receiving HAART than expected from UNAIDS 1Department

of Medicine, Indiana University, Indianapolis, Indiana, and School of Medicine, Moi University, Eldoret, Kenya. 2School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. 3International Center for AIDS Care and Treatment Programs, Columbia University, New York, New York. 4Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland. 5INSERM U593, Institut de Santé Publique Epidémiologie et Développement, Université Victor Segalen Bordeaux, Bordeaux, France. 6Institut de Recherche pour le Développement, UMR 145, Montpellier, France. 7Hospital Universitario Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. 8Hospital Escola S o Francisco de Assis, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. 9Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Brazil. 10Office of the Director, National Institutes of Health, Bethesda, Maryland. 11University of North Carolina Project, Lilongwe, Malawi. 12Department of Social Medicine, University of Bristol, Bristol, U.K. 13Epidemiology Prevention and Interventions Center, University of California at San Francisco, San Francisco, California. The ART-LINC Collaboration is funded by the U.S. National Institutes of Health (Office of AIDS Research) and the French Agence Nationale de Recherches sur le Sida (ANRS). The Canadian Institutes of Health Research supported this work through a postdoctoral fellowship to P.B.

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data in one center in Uganda and one center in India. Taking into account heterogeneity across cohorts, women were younger than men, less likely to have advanced HIV infection, and more likely to be anemic at HAART initiation. Conclusions: Women in resource-constrained settings are not necessarily disadvantaged in their access to HAART. More attention needs to be paid to ensuring that HIV-infected men are seeking care and starting HAART. INTRODUCTION

H

ALF OF THE 38.6 MILLION PEOPLE living with HIV/AIDS around the world are women, and about 59% of all HIV-infected adult women live in sub-Saharan Africa.1 In addition, women aged 15–24 years are on average three times more likely to be HIV-infected than men of the same age.1 The greater burden of HIV disease, especially among younger women, reflects the gender, social, and economic inequalities that are the stark reality of most women’s lives, particularly in many resource-constrained countries.2–4 The World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) have expressed concern that women might be being denied equitable and timely access to highly active antiretroviral treatment (HAART), which dramatically improves survival with HIV infection.2,5 The delivery of HAART is rapidly being scaled up worldwide.6,7 Women’s access to treatment could be reduced if existing gender attitudes prevent them from seeking testing or returning for results.2 Women who are receiving HAART might also have their adherence or response to treatment impaired by their disproportionate burden of caregiving and other responsibilities,2 difficulty in taking medicines openly at home,8 and clinical conditions, such as anemia. Gender inequities in health can affect men as well as women.9 Traditional masculine roles cast men as taking risks, being unconcerned about their health, and not needing help or healthcare.9 These ideas could present barriers for men in accessing prevention and treatment for HIV infection.10–12 There is a need for more sex-disaggregated data about the use of medicines in resource-constrained settings to investigate gender differences in healthcare in more detail.2 Here, we report findings from an international collaboration of HIV treatment programs in Africa, Asia, and Latin America. The objectives of this study were to: (1) compare the gender distribution of HIV-infected adults receiving

HAART in resource-constrained settings with UNAIDS estimates of the gender distribution of HIV infection and (2) investigate sociodemographic and clinical differences between women and men receiving HAART.

MATERIALS AND METHODS The ART-LINC Collaboration The Antiretroviral Therapy in Lower-Income Countries (ART-LINC) Collaboration is an international network of HIV/AIDS treatment programs. Details about the formation of the collaboration and baseline characteristics are described in detail elsewhere.13,14 Twenty-nine programs in 13 countries that collect prospective data systematically and electronically on patient characteristics and outcomes contributed data to this analysis. HAART was defined as receiving a minimum of three drugs. We categorized these into NNRTIbased regimens [two nucleoside reverse transcriptase inhibitors (NRTI) plus a nonnucleoside reverse transcriptase inhibitor (NNRTI)], protease inhibitor (PI)-based regimens (two NRTIs plus a PI), or other triple-drug combinations. Clinical stage was defined using either WHO or United States Centers for Disease Control and Prevention (CDC) criteria (asymptomatic, CDC stage A/WHO stage 1; symptomatic, CDC stage B/WHO stage II; AIDS, CDC stage C/WHO stage III–IV). We considered two categories of anemia: any anemia was defined as hemoglobin 13 g/dL for men or 12 g/dL for women;15 and severe anemia was defined as hemoglobin 8 g/dL in women and men.16

Statistical analysis We used UNAIDS country-level data from the 2004 AIDS Epidemic Update6 to estimate the percentage of female HIV-infected adults aged 15–49 years in the countries with cohorts participating in the ART-LINC Collaboration. The ART-LINC

GENDER AND HAART IN RESOURCE-LIMITED SETTINGS

database is regularly updated. The data used in the present analysis used data available on March 28, 2007. For each ART-LINC center, we calculated the percentage (95% confidence intervals [CI]) of patients receiving HAART who were women, including all individuals with complete data on gender, age, and HAART start date. We then compared UNAIDS and ART-LINC estimates. We categorized these as follows: similar, if the UNAIDS estimated proportion of women fell within the 95% CI of the ART-LINC percentage of adults receiving HAART who were women; overrepresentation of women receiving HAART, if the UNAIDS estimate was below the lower bound of the ART-LINC center estimate; and underrepresentation of women receiving HAART, if the UNAIDS estimate was above the upper bound of the ART-LINC center estimate. We used linear, logistic, or multinomial logistic models, as appropriate, to compare baseline differences in clinical and demographic characteristics between women and men. We used robust variance adjustment to calculate 95% CIs that take the clustered nature of the data (by cohort) into account.17 We used Stata software (version 9.1, College Station, TX) for all analyses.

RESULTS There were data available for 33,164 individuals (19,989 women and 13,175 men) participating in 29 centers in 13 countries (Table 1). There were four countries with single centers in Africa (Botswana, Malawi, Rwanda, Morocco) and two African countries with two centers (Kenya, Zambia). There were also three centers in Ivory Coast, five in Uganda, and seven in South Africa. Brazil (two centers) and Argentina were the only countries in Latin America and India and Thailand (two centers) were the only Asian countries contributing data. The majority of patients were treated in centers that provided free treatment (Table 1). These comprised 12 general public clinics (26,509 people), 9 public, and 2 faith-based clinics providing care for pregnant women, their partners and children (family clinics, 2552 people), and 3 cohorts (650 people) derived from clinical trials. Most family clinics were part of the MTCT-Plus Initiative, which links efforts to prevent mother-tochild transmission of HIV with programs focused on the health of mothers and their families.18

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There were 3 private clinics that charged user fees for treatment, covering 3,453 (10%) patients in Botswana, Zambia, and India. Table 1 shows the proportions (95% CI) of people receiving treatment in ART-LINC centers who were women and the UNAIDS estimated proportion of HIV-infected adults in the same countries who are female. The estimated proportion of female HIV-infected adults was 50% in all subSaharan African countries. In the other countries with cohorts in the ART-LINC Collaboration, women comprised from 20% of all HIV-infected adults in Argentina to 38% in India. Of 22 centers in sub-Saharan Africa, the proportions of women receiving HAART were similar to the UNAIDS estimate of the proportion of HIV-infected adults who are women in 8 centers (Botswana, Malawi, Zambia, Kenya, Rwanda, 2 clinics in Uganda, Ivory Coast); women were overrepresented in comparison with the UNAIDS country estimate in 13 centers (all 7 centers in South Africa, Zambia, Kenya, 2 centers in Uganda, and 2 centers in Ivory Coast); in 1 center in Uganda, women were underrepresented (Table 1). There was no UNAIDS estimate about the number of HIV-infected women in Morocco, but 48% of HAART recipients in the ART-LINC center were women. In centers in Thailand and Argentina, women were overrepresented. In both programs in Brazil, UNAIDS and ART-LINC estimates were similar. In the center in India, women were underrepresented. Of 16 centers where women were overrepresented, 9 were antenatal clinics that mainly saw pregnant women, 6 were general public clinics, and 1 was a research cohort (Table 1). Of the 2 clinics where women were underrepresented, 1 was a general public clinic in Uganda, and 1 was a private clinic in India. In the other 2 private clinics the proportion of women was similar to the UNAIDS estimate. The 6 largest programs, in Malawi, South Africa, Kenya, Ivory Coast, and India, all involved more than 2,000 patients each and covered 71% (23,408 of 33,164) of all participants. In 4 centers, women were overrepresented, in 1, women were underrepresented, and in the other, the proportion of women was similar to the UNAIDS country estimate. Figure 1 shows trends in the proportion of women over time. There was strong evidence for an increase in the proportion of women treated in centers in sub-Saharan Africa (p 0.0001, test for trend) and Asia (p 0.001) but not in Latin Amer-

Country

aN/A,

January 2003 March 2001 April 2005 July 2004 November 2003 September 2003 July 2004 April 2001 October 1999 April 2004

Public, free treatment Research cohort, free treatment Public, free treatment Public, free treatment, antenatal clinic

Private, user fees for treatment Clinical trial, free treatment Public, free treatment, antenatal clinic

Public, free treatment Public, free treatment Public, free treatment

No data available.

February 2005 January 2005 May 2004 September 2004 June 2004 June 2003 March 2005 September 2004

clinic clinic clinic clinic

clinic

September 2005 March 2004 December 2004 April 2005 May 2005 May 2005 September 2004 November 2004 February 2004

October 2002 February 2005

Public, free treatment Public, free treatment, antenatal clinic Faith-based, free treatment, antenatal clinic Public, free treatment, antenatal clinic Faith-based, free treatment, antenatal clinic Research cohort, user fees for treatment Public, free treatment Public, free treatment

Private, user fees for treatment Public, initially user fees, free treatment from June 2004 Public, free treatment Public, free treatment Public, free treatment, antenatal Public, free treatment Public, free treatment, antenatal Public, free treatment, antenatal Public, free treatment, antenatal Public, free treatment, antenatal Private, user fees for treatment

Clinic characteristics

Median start of HAART date

Receiving antiretrovirals (Data from ART-LINC Collaboration)

158/426 404/1083 115/390

526/2625 116/160 148/221

261/548 215/393 1837/2502 239/276

5065/7428 104/149 86/130 176/244 140/196 62/97 582/1337 116/215

1408/2061 1208/1727 531/716 3051/4457 92/94 92/114 183/213 154/199 28/56

440/772 2452/4335

Number of women/total

(43–52) (50–60) (72–75) (82–90)

(67–69) (62–77) (57–74) (66–78) (65–78) (57–73) (40–46) (47–61)

(66–70) (68–72) (71–77) (67–70) (93–100) (72–87) (81–90) (71–83) (36–64)

37 (32–42) 37 (34–40) 29 (25–34)

20 (19–22) 73 (65–79) 67 (60–73)

48 55 73 87

68 70 66 72 71 64 44 54

68 70 74 68 98 81 86 77 50

57 (53–60) 57 (55–58)

% (95% CI)

15 (5–30) 530 (370–750)

N/Aa 57

650 (320–1,100) 120 (61–200)

37 20

5,000 (2,500–8,200) 560 (310–1,000)

230 (150–350) 450 (300–730)

57 60

38 36

1,100 (760–1,600)

830 (680–1,000)

5,100 (4,300–5,900)

330 (310–340) 810 (650–1,000)

65

57

57

58 57

% women

Estimated total in thousands (low–high estimates)

Estimated number of HIV-infected adults (Data from UNAIDS)

PERCENTAGE OF WOMEN RECEIVING HAART AT 29 SITES PARTICIPATING IN THE ANTIRETROVIRAL THERAPY IN LOWER INCOME COUNTRIES (ART-LINC) COLLABORATION, BY COUNTRY, COMPARED TO UNAIDS ESTIMATED PERCENTAGE OF HIV-INFECTED ADULTS WHO ARE WOMEN

3 South Africa 4 South Africa 5 South Africa 6 South Africa 7 South Africa 8 South Africa 9 South Africa 10 Zambia 11 Zambia Central and East Africa 12 Kenya 13 Kenya 14 Rwanda 15 Uganda 16 Uganda 17 Uganda 18 Uganda 19 Uganda North and West Africa 20 Morocco 21 Ivory Coast 22 Ivory Coast 23 Ivory Coast Asia 24 India 25 Thailand 26 Thailand South America 27 Brazil 28 Brazil 29 Argentina

Southern Africa 1 Botswana 2 Malawi

Site

TABLE 1.

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FIG. 1. Percentage (with 95% CIs) of women among patients starting HAART in ART-LINC centers in different regions, by year.

ica (p 0.78). Table 2 shows that at HAART initiation, women were younger than men (median 33 vs. 37 years, p 0.001) and were less likely to have AIDS (55% vs. 67%, p 0.001). Among individuals who had a hemoglobin measurement (10,014, 50% of women; 6,422, 49% of men), the odds of having any anemia or severe anemia were 1.43 (95% CI 1.05-1.94) and 1.75 (95% CI 1.32-2.32) times higher, respectively, in women than in men, after taking between-cohort differences into account. Initial treatment regimens in women and men were similar. NNRTI, such as nevirapine and efavirenz, were used in 90% of participants. PIs were used in 10% of people, most of whom were in treatment programs in Brazil. In clinics that provide care for families, including pregnant women and their partners, such

TABLE 2. DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF WOMEN AND MEN STARTING HAART AT 29 SITES IN AFRICA, ASIA, AND LATIN AMERICA (N 33,164)

Variable Age at HAART,b years Median (IQR) Treatment naïve Disease status at baseline (n 26429) Asymptomatic Symptomatic AIDS Any anemia at baselinec (n 16436) Severe anemia at baselinec (n 16436) Baseline CD4 count available Baseline CD4 Median (IQR) (n 28095) Baseline log10 HIV RNA Median (IQR) (n 6964) Initial ART regimen (n 33,164) 2 NRTI NNRTI 2 NRTI PI Other Unknown Most common ART regimens 3TC D4T NVP 3TC D4T EFV 3TC AZT NVP 3TC AZT EFV Other NNRTI or PI ap

Women n 19,989 (60.3%)

Men n 13,175 (39.7%)

p valuea

33 (29–40)

37 (32–44)

0.001

18919 (95%) 4950 2761 9464 7645

(29%) (16%) (55%) (76%)

1130 (11%) 16985 (85%) 119 (51–189) 4.91 (4.29–5.40)

12353 (94%) 1891 1160 6203 4453

(20%) (13%) (67%) (70%)

436 (7%) 11109 (84%) 96 (37–174) 5.06 (4.54–5.53)

18274 1041 259 415

(92%) (5%) (1%) (2%)

11830 955 152 238

(90%) (7%) (1%) (2%)

9571 4906 1754 1668 1416

(50%) (25%) (9%) (9%) (7%)

6026 2950 942 1544 1323

(47%) (23%) (8%) (12%) (10%)

0.53

0.001 0.023 0.001 0.72 0.001 0.001

0.80

0.14

values are adjusted for between-cohort differences. antiretroviral therapy; HAART, highly active antiretroviral therapy IQR, interquartile range; NRTI, nucleoside reverse transcriptase inhibitor; NNRTI, nonnucleoside reverse transcriptase inhibitor; PI, protease inhibitor; 3TC, zalcitabine; D4T, stavudine; EFV, efavirenz; NVP, nevirapine. cAny anemia was defined as hemoglobin 13 g/dL for men or 12 g/dL for women15; severe anemia was defined for both men and women as 8 g/dL.16 Hemoglobin data were available for 16 cohorts. bART,

52

BRAITSTEIN ET AL. TABLE 3.

CLINICAL CHARACTERISTICS

OF

WOMEN

AND

MEN STARTING HAART ACCORDING

TO

Women Variable

614 588 743 149

(32%) (30%) (38%) (84–195)

Other

4,336 2,173 8,721 115

4.71 (4.20–5.21)

as the MTCT-Plus Initiative, both women and men had earlier HIV disease than those seen in other settings (Table 3). The differences were more marked for men than women (p value for interaction 0.012). Among men attending family clinics, 43% had AIDS when they started HAART, compared with 69% of men in other types of clinic. In family clinics, women and men also had higher CD4 counts and lower viral loads than patients treated in other clinics, although the difference was less marked.

DISCUSSION In this large international collaboration, the proportion of female HAART recipients was similar to or higher than the UNAIDS estimated proportion of HIV-infected adults who are women in 20 of 22 programs in sub-Saharan countries, 3 programs in Brazil and Argentina, and 2 in Thailand. In one program in Uganda and the center in India, women accounted for a lower proportion of HAART recipients than would be expected from the estimated number of HIV-infected women. Women were more likely to be asymptomatic and more likely to be anemic than men at baseline. There were no differences in antiretroviral regimens received by women and men. The main strength of this study is its coverage, which allowed us to compare standardized, detailed, contemporaneous data among 13 low-income and middle-income countries on three continents. As a convenience sample, the included centers might not be fully representative of the rapidly evolving situation of antiretroviral treatment programs in resource-constrained areas. For example, few ART-LINC centers are in rural areas, and the need for electronic data collection

OF

TREATMENT

Men

Family clinic

Disease status at baseline (n 26,429) Asymptomatic Symptomatic AIDS Baseline CD4 Median (IQR) (n 28,095) Baseline log10 HIV RNA Median (IQR) (n 6,964)

SITE

(28%) (14%) (57%) (48–189)

4.93 (4.30–5.43)

Family clinic

181 167 259 133

(30%) (27%) (43%) (63–189)

4.81 (4.38–5.29)

Other

1,710 993 5,944 94

(20%) (11%) (69%) (36–173)

5.08 (4.55–5.54)

means that centers of excellence might be overrepresented. However, the ART-LINC Collaboration is, to our knowledge, the largest and most international dataset on HAART use available in resource-constrained settings.13 The range of administrative and fiscal structures (40% public, 40% nongovernmental organization, 20% private for profit) reflects the diversity of centers and settings in which HAART is being used. The longitudinal nature of the study means that, in future, we will be able to monitor changes in the gender distribution of adults receiving HAART in the Collaboration. Furthermore, our statistical analyses took between-center differences into account, and we had complete information on age, sex, and HAART start date for the majority of patients. There are some limitations to this analysis. First, the comparison of local data about HAART use with country-level HIV burden in women is limited because national estimates might mask regional or local variations and because of uncertainties inherent in the UNAIDS estimates.6 Second, the gender distribution of those eligible for HAART might not be the same as that of all prevalent HIV cases, but data on eligibility are not available. Our findings on the proportion of people receiving HAART who are women are supported by a systematic review, which found a female/male ratio of recipients of HAART of 1 in all but 2 of 21 published studies in seven countries in Southern Africa.19 Our study also includes data from unpublished studies, from other areas of Africa, and from Asia and Latin America. We show that the proportion of women starting HAART in ART-LINC centers in Central and East Africa, Ivory Coast, Argentina, Brazil, and Thailand is also similar to or higher than the proportion of women with HIV estimated by UNAIDS.


Women in this study were younger and started treatment at an earlier clinical stage of HIV than men. The disease stage profile of men who attended family clinics was, however, more similar to that of women than of men attending other settings. In this study, we found a higher prevalence of anemia and severe anemia in women than in men. This might be expected to worsen the survival of women starting HAART because anemia has been shown to be associated with disease progression, independent of CD4 cell, count in Africa20 and in Europe.21 In resource-constrained settings, anemia might be due to poor nutrition, chronic malaria, intestinal infestations, and childbearing, as well as factors related to HIV.21 We were unable to examine this in detail because hemoglobin values were available for about half of participants, who are likely to be a selected group. In previous analyses from this collaboration, survival in the first year of HAART was similar in women and men (hazard ratio 0.84, 95% CI 0.581.23).13 UNAIDS, the WHO, patient advocacy groups, and researchers are right to be concerned about gender inequalities and the inferior power, social, and economic status2,23,24 that place women at risk of death from childbirth, unsafe abortion, gender-related violence, and sexually transmitted infections (STIs) and infectious diseases other than HIV.23–26 The only ART-LINC center in India, and one of the largest in the Collaboration, was one of those requiring patients to pay for treatment. Women’s inferior economic position is a well-documented barrier to healthcare in India.24 This might help explain why women comprised only 20% of patients in the ART-LINC clinic in India and were underrepresented when compared with the UNAIDS estimate that 38% of HIV-infected adults in India are women. Of note, the percentage of women in the Indian center was 30% in more recent years. Gender inequalities that inhibit men’s use of healthcare have received less attention.9 Women’s and men’s health-seeking behaviors are known to differ.9 In addition, traditional gender roles give men the power to deny women access to healthcare.27 The physical and emotional strength associated with masculinity and power can, however, also make it unacceptable for men to seek healthcare.9 Studies of men’s sexual health have tended to focus on their roles and responsibility for improving outcomes for their partners rather than on their own needs.11 Women are of-

53

ten more likely than men to attend health services because of dedicated provision of reproductive and child health clinics. Health services that address the needs of men, therefore, remain underdeveloped, and men are more likely to seek care in the informal sector, such as pharmacies.10,28 Paradoxically, conventional views of gender inequality might have made it relatively easier for women than men in some settings to become engaged with HIV diagnosis and treatment services. In addition, the stigma attached to HIV infection, work or family responsibilities, homophobia, and masculine responses to health and disease might make it more difficult for men to accept an HIV diagnosis and seek treatment.12 The family-based approach to the delivery of HIV care and treatment, such as that provided by the MTCT-Plus Initiative, might be particularly beneficial for men.29 Our study shows that gender equity in access to care and treatment for HIV infection is a complex issue. Women are more vulnerable than men to becoming infected with HIV, but in almost all ART-LINC programs, they were equally or more likely than men to start HAART. Continued efforts are needed to empower women and secure their rights to treatment and care for HIV infection. More attention needs to be paid to HIV-infected men to ensure that gender stereotypes do not prevent them from protecting their health.

ACKNOWLEDGMENTS We are grateful to all the patients, and collaborating center staff who made this project possible, as well as to Lotti Senn, Raffaele Battaglia, Gian Töny, and Sophie Lamarque for their ongoing help and advice.

The Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration Principal Investigators: François Dabis, Matthias Egger, Mauro Schechter Central Team: Eric Balestre, Martin Brinkhof, Claire Graber, Olivia Keiser, Catherine Seyler Steering Group: Kathy Anastos (Kigali); FranckOlivier Ba-Gomis (Abidjan); David Bangsberg (Mbarara/Kampala); Andrew Boulle (Cape Town); Jennipher Chisanga (Lusaka); Eric Dela-

54

porte (Dakar); Diana Dickinson (Gaborone); Ernest Ekong (Lagos); Kamal Marhoum El Filali (Casablanca); Mina Hosseinipour (Lilongwe); Charles Kabugo (Kampala); Silvester Kimaiyo (Eldoret); Mana Khongphatthanayothin (Bangkok); N Kumarasamy (Chennai); Christian Laurent (Yaounde); Ruedi Luthy (Harare); James McIntyre (Johannesburg); Timothy Meade (Lusaka); Eugene Messou (Abidjan); Denis Nash (New York); Adama Ndir (Dakar); Winstone Nyandiko Mokaya (Eldoret); Margaret Pascoe (Harare); Larry Pepper (Mbarara); Papa Salif Sow (Dakar); Sam Phiri (Lilongwe); Mauro Schechter (Rio de Janeiro); John Sidle (Eldoret); Eduardo Sprinz (Porto Alegre); Besigin Tonwe-Gold (Abidjan); Siaka Toure (Abidjan); Stefaan Van der Borght (Amsterdam); Ralf Weigel (Lilongwe); Robin Wood (Cape Town) Advisory Committee: Zackie Achmat, Chris Bailey, Kevin de Cock, Wafaa El-Sadr, Ken Freedberg, Helene Gayle, Charlie Gilks, Catherine Hankins, Tony Harries, Elly Katabira, Jonathan Sterne, Mark Wainberg Funders: National Institutes of Health Office of AIDS Research (Paolo Miotti, Jack Whitescarver); Agence Nationale de Recherche sur le Sida (ANRS) (Brigitte Bazin); Canadian Institutes of Health Research (CIHR) Collaborating Centers: CEPREF / ANRS COTRAME (Abidjan, Côte d’Ivoire); Center Hospitalier Universitaire (Casablanca, Morocco); CORPMED (Lusaka, Zambia); HIVNAT (Bangkok, Thailand); Gugulethu (Cape Town, South Africa); Hospital de Clinicas / SOBRHIV (Porto Alegre, Brazil); Hospital Universitario Clementino Fraga Filho (Rio de Janeiro, Brazil); Independence Surgery Clinic (Gaborone, Botswana); ISS (Mbarara, Uganda); Kamuzu Central Hospital / Lighthouse Trust (Lilongwe, Malawi); Makerere-UCSF / Generic Antiretroviral Therapy Project (Kampala, Uganda); Moi University College of Health Sciences / University of Indiana (Eldoret, Kenya); MTCT (Cape Town; Cato Manor, Durban; Soweto, Johannesburg, South Africa; Lusaka, Zambia; Kisumu, Kenya; Rwanda; Mulago, Uganda; Nsambya, Uganda; Abidjan, Ivory Coast; Bangkok, Thailand); Nsambya Hospital (Kampala, Uganda); PHRU / Opera (Soweto, South Africa); PUMA (Buenos Aires, Argentina); Themba Lethu / WITS (Johannesburg, South Africa); University of Cape Town / Khayelitsha (Cape Town South Africa); YRG Care (Chennai, India).

BRAITSTEIN ET AL.

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