11/17

My research paper actually focused on the ethics of clinical trials in HIV prevention, so the authors' casual dismissal of the subject was somewhat abrupt, in my opinion. However, their focus on treatment rather than prevention at this stage is a realistic perspective. Rationing has been accepted by bioethicists as an inevitability in HIV treatment, but how to implement it is obviously not an easy task. Recognizing that all rationing programs are politically, not simply medically, motivated. Preexisting social and economic disparities in this case have the possibility of being either minimized or further increased. Many disenfranchised propulsions are arguably more at risk for acquiring the infection, especially in developing countries. But the political inner workings of many NGOs and government-funded initiatives such as PEPFAR can often withhold treatment to those who need it as much as they help. PEPFAR appears to distribute aid either arbitrarily or based on political factors, skipping over clearly desperate countries like Zimbabwe because there is no derived political benefit from doing so. Rationing decisions on a lower level of bureaucracy are equally capable of altering the equity of treatment options, based on social standing, ethnic group, or often distance from treatment centers (establishment of "islands of treatment").
I was interested and alarmed by the authors' description of the disparity between developing an adequate healthcare infrastructure, limiting the brain drain and increasing the 'absorptive capacity' of these countries, and their ability to receive the IMF grants that are necessary to decrease the poverty level that causes healthcare disparities in the first place.
Ranking the "who" of treatment priorities is another interesting discussion treated in this article. Selecting pregnant women is a good idea as a means of preventing mother to child transmission, but is highly exclusive as a criterion. Selecting skilled workers is likely to improve human capital resources, which could by aiding the economy in turn help to improve treatment infrastructure overall, but this excludes most of the vulnerable populations in any society (women, children, etc.) Selecting sex workers may be a good means of eliminating one important vector of transmission, but this excludes the people who many would call the 'innocent victims' of HIV transmission.
Finally, the authors suggest that in treating AIDS comes the opportunity to expose and work to eliminate preexisting socioeconomic disparities, human rights violations, and basic inequalities in the developing world. In improving access to treatment, granting one of the most basic human rights and enabling previously vulnerable populations a more level playing field, the AIDS epidemic has the potential to have some positive effects.

Katie Nelson

AIDS care and Treatment in Sub- Saharan Africa; Implementation Ethis

Kesaobaka Modukanele

Global HIV/AIDS

Blog Post for Tuesday November, 17 2009

The impact of the IMF on health care in developing countries.

Along with the obvious geographical boundaries that separate the world today, there exist other boundaries: ‘First world’ and ‘Third world’; ‘Developed’ and ‘Developing’ etc. What bothers me the most, is the idea of a ‘developing world’, which implies that these countries are progressively improving, or rising to reach some basic level of ‘development’. However, with regards to global health – hope of somewhat improving the situation of ‘developing’ countries is based on falsities. The fate of these countries lies almost entirely on the organizations like the International Monetary Fund, whose concerns may sound genuine, but their actual policies are contradictory. For example, although “The IMF acknowledges that poverty reduction is itself a necessary condition for economic growth, and that investments in health and education are crucial to the reduction of poverty”, they insist that in order for ‘developing’ countries to receive aid from bilateral and multilateral donors, or have access to private investment by foreign entities that could help improve access to treatment of diseases like HIV/AIDS, these countries would have to keep their inflation rates low. To these governments, lowering inflation rates restricts national spending in the health sector. In this way, there is a clear shift in the country’s authority to govern its own economy, and in essence, be forced to rely completely on loans from the IMF. Furthermore, while the IMF compels the countries to lower their inflation rates by means of reducing health care expenditure, they also expect them to increase their “absorptive capacity”. This “absorptive capacity” apparently indicates that whatever AIDS treatment program the IMF would be funding will be sustainable. However, increasing absorptive capacity can only be achieved by a substantial amount of spending on health care, which in turn increases inflation! Such policies make me question what the motives of placing such a policy was –as they restricts these countries from making national efforts against diseases through health expenditure. The case of a Botswana is a good example of how this policy makes it difficult to combat HIV/AIDS. Because they complied with all the regulations of the IMF, they struggle to implement programs because of restricted health expenditure, such as hiring sufficient health personnel. Zambia faced a similar issue. By trying to become proactive at improving the national health care and discouraging doctors from leaving the country through monetary incentives, their increased expenditure lead to the IMF suspending them from funding! To me this is a control issue! It is one of the reasons that the term ‘developing’ is deceptive – a word that brings false hope that at some point developing countries will become developed and self sustaining, while organizations like the IMF impose policies that prevent self sustenance and innovation, but rather encourage dependence. Such organizations, whose policies are mostly determined by the leading industrialized countries, the G7 –limit the development of these so-called ‘developing’ countries simply because wealth is concentrated in the hands of the elitist countries only, and decisions that are made do not assimilate the interests of the developing countries.

Readings for 11/18

I was fascinated by the concept in this reading that as medical technology improves, treatment will improve however the challenges faced by the global health field in an ethical sense will keep pase with the trechnological improvements. I also found the quote "So much attention has been devoted to the standard of care in clinical trials that sometimes people living with HIVAIDS in the developing world seem insignificant to developed world bioethicists only when they are the subject of externally funded research." I think one of the key aspects of public health that is often lost in political and organizational decision making is the fact that the large numbers on a page or a computer screen are in fact human beings, who deserve the "best current" treatment, not the "best available." Perhaps this is idealistic in practice, but it should absolutely be the goal of any public health individual worker or organization.

Furthermore, I found the discussion of rationing particularly interesting, as it reprsents a difficult connection between the ideals of public health care system and the realities of limited resources. Limited resources often shape the field of economics as well as public health, thus rendering them closely linked topics.

11/18: The Ethics of Implementation

Frieda Behets and Stuart Rennie's article mentions a lot of important issues surrounding the interventions that have been put into practice to fight the HIV/AIDS pandemic. I especially appreciate that they address the effect international aid angencies like the IMF have on developing countries. One cynical but highly believeable way to look at this situation is that the IMF and other such organizations do not have the people's best interests at heart when they allow a country to sacrifice or reject outside aid money so as not to go above the ceiling income that they set for the country. It is extremely ironic that an organization whose claimed goal is to help poor countries pull themselves out of poverty, would limit how much money that country can earn when it comes to AIDS donations. It is important that we continue to examine the ethics behind AIDS intervention and treatment because AIDS affects other humans and especially with limited resources, it is extremely difficult to decide who or what country will receive money and what country won't. In the ideal world, triaging woundn't have to be a principle concept and there would be no ethical problems but since we don't live in the ideal world, we have to consider how to alleviate the problems in heavily afflicted countries while still respecting the rights of each individual. I personally think, money for treatment should be distributed based on the country with the highest prevalence and infection rates and not artibitrarily or politically which is sadly what happends. PEPFAR is a good example because there are some random coutries that were chosen that even though even a small number of HIV cases is bad, a larger one is worse and other countries with higher prevalences could have been chosen.

Reading Response for 11/18

I found the paradox of IMF "aid" discussed in this article very interesting and also shocking. The way the authors presented the conflict between IMF anti-inflation policies and investment in social services cast the IMF in a definite negative light. I would like to learn more about the justifications behind the IMF policies so that I can better understand the issue and make an informed judgment about this IMF/social services paradox. It does seem pretty ridiculous that a country would be in a position to lose aid by accepting aid!

It seems to me that the best, most moral way to approach all of this is to devote far more resources to the development of infrastructure and the overall health system in underdeveloped settings. I also firmly believe that citizens themselves must take ownership of reform and development of their own countries; impositions from outside continue power structures and colonialist legacies that are usually far from morally acceptable. It appears that powerful countries are still effectively tying the hands of those they are supposedly trying to help through stringent IMF policies and funds that come with strings attached. The complexity lies in what those strings are - the requirement of use of expensive, patented US drugs is an inappropriate imposition of US interests in my opinion, but there are other conditions such as the equitable use of the funds that are far more justifiable. It is due to nuances such as these that there is no rationing consensus, as the authors note.

One of the most interesting and telling ideas in this article was the authors' hope that healthcare providers are not "slaves to the rules." I found this statement slightly contradictory; if the authors are arguing for the necessity of rationing and a rationing ethic to accompany it, how can they advocate bending the very rules that they say must be in place? Though I would tend to agree with them in practice - as a doctor I certainly would not want to turn away a needy patient - I am cautious of their principles. They seem to be saying that the rules are unreasonable enough that it is permissible to disregard them. If this is the case, there should be a different set of rules! I think this hope that providers are not "slaves to the rules" demonstrates an underlying moral/ethical belief that care should be provided to all who truly need it. If that is the moral conclusion, we should be now be working to make that vision possible.

Reading for 11/18

The article “AIDS Care and Treatment in Sub-Saharan Africa: Implementation Ethics” by Stuart Rennie and Freida Behets points out the numerous conflicting issues that come in contact when determining how resources for fighting the AIDS pandemic should be allocated. Since there is a very limited amount of funding and treatment available for AIDS, there must be short term rationing. I was very shocked by Figure 1, the table with the estimated number of people needing treatment, the number on treatment, and the percentage covered. With the amount of funding that has gone into AIDS, I expected the percentages to be much higher. Due to the lack of available treatment, the treatment has to be rationed, but there are questions as to how this can be done. For instance, if everyone should be treated equally, then the people who are the most in need of treatment will have equal chances of receiving treatment compared to the people who may not need treatment so urgently. In a sense, this is also an unfair method of rationing AIDS treatment because some would argue that treatment should go to those who are most in need, just like a progressive tax rate is often used over a flat tax. In addition, there is controversy surrounding what the funds should be used for. PEPFAR was controversial because it went to fifteen seemingly arbitrary countries that may not have been most desperate for AIDS funding but perhaps the countries whose political beliefs were more aligned with the United States. It was also controversial because a large part of the fund was used for contraception and counseling for abstinence instead of for AIDS treatment. Some countries did not use the funds wisely to fight the AIDS epidemic, which leads to another problem of whether or not the people who are donating money should be able to dictate where the money goes and to what extent they should have control over how money is spent. Since funding is so limited, there are issues concerning what exactly the funding should be used for, whether to improve infrastructure, food so that AIDS treatment is more effective, or treatment and who qualifies for those treatment. I thought this article was interesting because it highlights the numerous problems that arise when we are trying to eliminate the AIDS epidemic. It brings up the different types of issues that must be considered when using and allocating limited funds for AIDS, and how different countries in sub-Saharan Africa have responded or can possibly respond to them.

17-11 AIDS implementation ethics -Vanessa Dang

Stuart Rennie and Frieda Behet’s report on implementation ethics reveals a multitude of dilemmas surrounding decision-making for AIDS treatment plans. While they mainly focus on the inevitable need to allot AIDS treatment in Sub-Saharan Africa, they first present opposition against treatment as the primary method for combating HIV/AIDS. Three areas question whether or not treatment is the best solution: first, prevention advocates cite cost-efficacy, arguing that prevention is better than treatment in this regard; second, some worry that intense focus on HIV/AIDS treatment will distract from other diseases, such as malaria and TB, that are also detrimental in developing countries; and third, there is the issue of small scale treatment vs. large-scale treatment: some worry that large-scale treatment plans - those that would be government funded – are more difficult to manage both financially and logistically, increasing the difficulty of adherence.

After establishing their focus on treatment implementation plans, Rennie and Behet provide further problems within providing treatment and the necessity for rationing. They underscore this inevitability with a variety of statistics and reasons, but the issue of what ‘treatment’ means is the most interesting. They point out how people seem to use this term loosely, without a clear definition of what they mean. Often, they say, people refer to ART and access to drugs when they use the word ‘treatment.’ However, we must broaden our meaning of this term, in order for ARVs to actually be successful in treating HIV/AIDS. This means that ‘treatment’ must include everything a person needs to successfully benefit from ART: medical personnel, a sufficient number of clinics so that every person is ‘close’ to one, a reliable drug supply to clinics/hospitals, diagnostic tests and monitoring equipment in clinics/hospitals, VCT and follow-up, counseling services, clean water, food, vitamins, etc. All of these factors further complicate the ability to provide wide-scale treatment plans – hence their argument that rationing is and will be necessary.

They continue the report by illuminating injustices within current programs that are supposed to help initiate and sustains AIDS treatment plans, (PEPFAR) as well as those that are supposed to help boost the economies of developing countries (IMF). These problems show that injustices exist at even the levels that we would expect the least from, and that these policies are, in many cases, actually a barrier to the implementation of treatment plans, such as in Uganda.

They conclude the report with two choices that have to be made: site selection (where treatment plans should be initiated) and who selection (within these sites, exactly who should receive treatment). They then discuss ‘fair process,’ a loose procedure for fairly making these two choices. By the end of the report, Rennie and Brehet have done a thorough job of identifying the obstacles one will encounter and the decisions that will have to be made in any treatment plan. They seem to conclude that someone will have to make these choices, and that no matter what someone decides, at least one group of people will be unhappy. But, as they say, ‘inequitable treatment programs are better than none at all.’ Plus, widespread, total coverage has to start off somewhere.

11/11 Reading

When reading this article about the difficulties associated with diagnosis in low-resource areas, I was particularly intrigued with the tuberculosis issue. Like many of the other diseases mentioned in the article, drug resistance is a factor that may limit the effectiveness of anti-TB campaigns and interventions. An accurate diagnostic measure would limit the impact of this by reducing the number of people treated with antibiotics due to misdiagnosis.

HIV infection is another cause of ineffective interventions. People with HIV may experience tuberculosis as an opportunistic infection, and diagnosing the TB without the HIV is not a long-term solution for infected individuals.

Modern diagnostic methods with regard to TB rely on chemical and molecular replication of sputum cultures. In most less-developed countries, direct sputum cultures are used to test for TB, but are less effective because of the unreliability of the culturing and difficulty in obtaining enough sputum to test. Chemical replication is necessary to magnify the samples, and these techniques are often beyond the scope of laboratory capabilities in low-income countries.

Some focus of the biomedical industry and public-health NGOs is on improving laboratory systems in developing countries, rather than working on the individual diagnostic tests themselves. Working to improve transportation infrastructure from field clinics to laboratory facilities requires the coordination of cold-storage transportation, bookkeeping and inter-clinic communication over potentially very long distances.

Ramsay, Andrew, and Anthony D. Harris. "The clinical value of new diagnostic tools for tuberculosis." F1000 Medicine Reports 1.36 (2009). Faculty of 1000 Medicine. Medicine Reports Ltd., 29 Apr. 2009. Web. 10 Nov. 2009. .

Reading 11/11

This article was really interesting to me as, although it looked through its lens, did not only talk about affects relevant to HIV AIDS. Instead it talked about how all healthcares is created from building blocks and directly pointed out the issues from the fundamental areas that need improvement. That’s not to say that this article didn’t talk about HIV AIDS directly. It did, about how very technical advances are helping get us one step closer to eradication. But, unlike other medical journals which only discuss the very specific areas of technological advances that help certain illness’ causes, this article discussed the lack of long standing infrastructure necessary to really eradicate HIV AIDS. In many ways, this article highlighted the importance of basic healthcare infrastructure. It argues that without this, the very technical improvements mean nothing. They are worthless without the fundaments because, for example, the new technologies can’t be delivered without them, or properly executed in other ways. This addressed a very important issue in healthcare today, which I do not believe is discussed enough.

Response to "Requirements for high impact diagnostics in the developing world", by Urdea

Kesaobaka Modukanele

Blog Post for November 10 readings

The common saying prevention is better than cure is often used in HIV/AIDS campaigns, to encourage people to avoid infection through behavior change. These two phenomena, prevention and treatment, are often used by epidemiologists to measure success at combating a virus. However, the paper “Requirements for high impact diagnostics in the developing world” by Mickey Urdea et al, shows a pitfall in the ‘prevention’ and ‘treatment’ indexes, and this pitfall lies in overlooking the issue of diagnosis. Diagnosis and treatment are complementary, which seems like an intuitive fact. However, it is amazing that even after the development of drugs that prevent mother to child transmission, “2.3 million children worldwide were living with HIV/acquired immunodeficiency syndrome (AIDS).” Diagnosis of a disease is obviously the first step toward treatment of diseases like HIV/AIDS, malaria and TB, however, it is also crucial because it helps reduce prevalence on different levels. Firstly, some diseases are not mutually exclusive of each other. Therefore, diagnosis of one disease could be a clue that the patient might have another disease. This is the case with HIV/AIDS and TB, and therefore, the paper discusses that “whenever TB is suspected, the HIV status needs to be considered simultaneously.” Similarly, STI’s like syphilis, gonorrhea or Chlamydia are clinically related and could be diagnosed in one test. This ability to multi-diagnose clinically related diseases is very important in decreasing prevalence, especially among high-risk populations. Secondly, diagnosis tests are very important because they could prevent misdiagnosis. For example, without such tests, children who have symptoms indicative of ARI are often given antimicrobials without any investigation, and this type of misdiagnosis could be deadly. Another importance of properly diagnosing diseases, are economical considerations. What a waste of resources it would be, if an individual not suffering from a disease was treated, while an infected person did not receive any treatment!

Although this paper does highlight the importance of diagnosis, and ways that different diseases could be diagnosed, it felt very stagnant while I was reading it. I kept wondering, what are the steps forward for resource poor countries? Unfortunately, the paper did not reach that point for me. It highlighted the problems, but offered very few if at all, any solutions to the problem of resource-limitation.

11/11: Informatics, Diagnostics, and Implementing ART in Africa

In this article about diagnostic tests and information, the authors illustrate a very intriguing and validated point: that not only do diagnostic tests save lives, they reduce the disease burden as a result of morbitity as opposed to sickness (measured as DALYs) and as a result of prevention and potential decrease of disease prevalence. It is only after reading an article like this that you realize how important effective diagnostic tests are especially in low resource areas where diseases are inevitably prevalent. These tests are also important because unlike most people in the developed world, residents of this low or no infrastructure areas do not have a primary doctor or even a trained clinician available to inform them of their illnesses: most of them learn about their illnesses at the onset of symptoms which for some diseases might be too late for people to be treated. And where there are diagnostic tests, they need to be effective as in highly sensitive and specific because in these areas and with these types of diseases, TB, malaria and others, a misdiagnosis can be the difference between life and death for a patient. But as the authors express, it is difficult to design a diagnostic test that can be this effective and yet so simple that it can be used in a low resource site but research continues and new methods have been found.
I am confused about how the authors came about with their results: they repeatedly say that they used mathematical models but it would be perhaps helpful if they should an example of the model and how or what kind of results it produced although they do have a thorough summary of what needs to be known.

Post for 11/11

What struck me when reading this article was the fact that good health does not exist in a vacuum. Even with the proper medications (and even some diagnostics!), there are obstacles to health care delivery. Clearly the development of better diagnostic testing is necessary, and it can make a huge impact on people's lives. However, medical technologies aren't going to bring clean water to the clinic or better educate clinic staff. So in some respects, technological advances (on their own) are just Band-Aids on larger infrastructural and societal problems.

That being said, it is encouraging to see the international health community trying to "meet people where they are at" and determine the user's needs in under-resourced settings. It seems to me that durability and flexibility of the diagnostic tests are the name of the game. The various cultural clashes that were mentioned toward the end of the article were interesting (for example, white malaria nets were not accepted in a culture where white is associated with the dead). It never would have occurred to me that something's color could have such an impact! Despite the research community's efforts to serve these under-served populations, profits and patents are inevitably involved. I hope that people/companies will be reasonable about how much money/royalties they require. It seems absurd to be making huge profits off of others' suffering. However, I do realize that at the same time, financial incentives are necessary to encourage the development of these technologies.

Reading for 11/11

"Requirements for High Impact Diagnostics in the Developing World" highlights the need for accurate, practical diagnostic tests for several widespread diseases, particularly in sub-Saharan Africa. While diagnostic tests may seem like a secondary priority to direct treatment, I was struck by the estimates based on modeling that predicted the number of lives saved by early, consistent diagnosis of various diseases. Further more, from an economic and health resources perspective, the level to which early diagnostic tests in developing countries could save later treatment costs is really significant. The authors predict that an accurate, widely used test for malaria in febrile young children could prevent 447 million unnecessary treatments per year, a number that represents a significant burden on health care services. Because health care systems in many developing countries, particularly in sub-Saharan Africa, are already so under-resourced, the burden of cost and services relieved by diagnostic testing would have a very significant impact on health care systems. Furthermore, diseases such as TB, STI's, and HIV/AIDS have been shown to exhibit correlations, and thus any reduction in the prevalence or later development of any one of these diseases could positively impact the treatment and prevention of the others. e.g. because STI's increase the risk for HIV infection, early diagnosis and thus treatment of STI's could reduce HIV incidence rates.

According to the authors' discussion, one of the greatest obstacles facing the development of effective diagnostic tests is the need for tests that can be used with limited laboratory facilities in developing countries. Thus the development of these tests and the strengthening of health care infrastructures, especially in rural areas, go hand in hand. As health care systems and facilities get stronger, diagnostic tests will be more accessible. The authors also discuss the issue of intellectual property and patent rights towards the end of the article. Although this may be somewhat unrealistic, I believe patent rights should be waved or partially bypassed in cases such as this, where the pooling of information could lead to more rapid development of high impact diagnostic tests for the developing world.

Reading for 11/11

Requirements for High Impact Diagnostics in the Developing World brings to attention the importance of developing accurate diagnostic tests to treat patients with infectious diseases. Prior to this reading, I often overlooked the importance of diagnostic tests, focusing mostly on the availability of treatments in reducing the number of preventable deaths due to infectious diseases like HIV/AIDS and Tuberculosis. According to this article, millions of lives can be saved if patients could be correctly diagnosed. For instance, since it is more common for children to have viral acute lower respiratory infection (ALRI) than bacterial ALRI, infants who do not need and will not benefit from antibiotics are still receiving them, reducing the amount of resources available for those who actually need it when resources are already limited. The article outlines the characteristics required for the most helpful diagnostic tests, specifically those designed for developing countries with limited laboratory infrastructure and equipment since those countries are usually the ones with the highest number of deaths due to incorrectly diagnosed, or not diagnosed at all, infectious diseases. According to their research, the authors have concluded that in order for a test to be successful, it has to be feasible for a setting with limited laboratory resources, the most common setting for a developing country. This means that the test has to be simple and easily done with minimal training, require minimal measurement since measuring devices are limited in number, test something such as blood and not sputum that is easily obtainable, and require a relatively short period of time to complete. I felt that most of the characteristics of a desirable diagnostic test outlined by the article were common knowledge, such as that tests have to be simple and done with minimal training. Since the article does not suggest different types of tests or explain what still needs to be done for testing each of the 6 most common infectious diseases that were discussed, it does not contribute very much other than bring to attention that better diagnostic tests for those infectious diseases need to be found.

11-11 Blog: high impact diagnostics - Vanessa

The reading this week on high impact diagnostics in the developing world was very interesting to me, since we often seem to focus on the need to provide treatment. However, this discussion reveals the importance of diagnostic tests in identifying who needs to receive treatment and who doesn’t – something I took for granted before reading this article. Not only are the tests important in identifying who needs treatment and for which specific disease, but also they help in protecting against over treatment. Along these lines, Urdea et al. bring up the connection between diagnostic tests and drug efficacy and availability: since diagnostic tests would be able to differentiate between individuals who need treatment and who do not, medicines would have an increased lifespan, and would be made available to those who actually need them by reducing the inappropriate use of medicines in individuals who do not need them.

The projected lives saved per year with such tests was astounding, and points to the importance of creating and distributing these tests in the developing world. At the same time, Urdea et al. also identify the potential problems with laboratory conditions, including a lack of personnel, equipment, electricity, and water, as well as the issue of climate. The team provided a comprehensive chart of requirements for the different levels of laboratory infrastructure in delivering these tests. It seems like, along with treatment, providing diagnostic tests are essential for establishing good health care to developing countries.

4-11-09 Vanessa Dang

From the onset, I was interested by the comment that ART increases the life expectancy of people living with HIV/AIDS, and therefore also increases the population size that is infected with HIV, resulting overall in an increased duration and prevalence of HIV in a community. Although the article didn’t go into more detail about this supposed problem, I was interested to learn from the table that drug-resistant strains were less transmissible than wild-type strains, but also that they could revert back to the wild-type strains. At the same time, the results of many of these studies conflict with each other. For example, while some considered drug resistance to be negligible, the study in Botswana and India projected that in 30 years, the accumulation of drug resistance would render ART useless. Overall, it seems that there is still much for us to research and discover, pointing to the complexity of HIV treatment and management.

11/2

It was interesting to see these authors try to take what is clearly a complex, multifaceted and amorphous issue and try to quantify it concretely in a mathematical model, Yet ironically, this attempt at pinning down the transmission of HIV merely served, in my opinion, to highlight the many variables that make dealing with the HIV epidemic such a Herculean task. The R0 value of the rate of transmission of the disease obviously varies greatly according to age, sex, and region (and therefore what usual method of transmission is most prevalent). The increased life expectancy resulting from ARV treatment, normally seen as a positive thing, is here in the 'pessimistic model' seen as merely a further mechanism of disease spread, since the prevalence of the disease is not decreasing due to death. This illustrates the importance of multi-pronged approach in dealing with the AIDS epidemic. ARV treatment alone is clearly not sufficient to reduce incidence of HIV (particularly as ARV's effectiveness decreases and toxicity increases over time)-- behavioral changes must occur as well. Prevention must be emphasized as much, if not more so, than treatment, whether that means preventative medications, behavior change, STD treatment or circumcision.

Modelling the Impact of Antiretroviral Use in Resource-Poor Settings Reading Response

Like most people, I’ve always heard of mathematical models being used in very practical science, such as medicine, but it was interesting to see it in action. At first I was really impressed with this article as it ventured to try and discover and if not just merely discuss the possibly of some sort of preventative drug for HIV AIDS. I was disappointed at the end, however. I know that studies and models like these are the stepping-stones for an answer in preventative medicine, but it was still frustrating to see how far we have to go.

Not only did they prove that some of the studies actually increased the prevalence of HIV AIDS, but even the so-called “positive” evidence was rocky at best. The pros to the medication was at a bare minimum and the negative response to many of them made the treatment not even worth it. A lot of the other data seemed so specific to certain circumstances that it didn’t even seem applicable to real world situations. I know that experimental studies such as these need to be as specific as possible, but at some point I thought it necessary to generalize some of their research and findings.

With all this in mind, I wasn’t so enchanted on the HIV AIDS aspect of the study. I was however, impressed in the use of mathematical models in medicine. I would love to see how correct some of these predictions are in order to gauge the accuracy and precision of models such as these, as, if proven correct, they could be of utmost importance in the medical community.

Epidemiological model of ART impact

The model of the effects of ARTs in affected AIDS communities was interesting. While it reaches some possibly previously know conclusions, there are a few new observations. First of all, as complex as this model was because it tried to incorporate as many possible dynamics that play a role in how ARTS and HIV affect the community but we have to remember that many assumptions were made to fit the model, some that may not be accurate but were the best fit. And we also have to take into consideration that some other dynamics, such as counseling along with therapy were not taken into account because of the complexity.

Yet, I think these models make sense, they are pessimistic because it seems like HIV infections will soon if they haven’t already start to increase due to ineffective or failed ARTs. Figure 2 was especially disturbing and is counterintuitive because while these ARTs are increasing everyone’s hope in the very deem possibility of curbing the epidemic at some point in the future, we see a significantly increased number of infections possibly as a result of ART and the effects it has on the patients. These effects being the patient’s naïve assumption that being on ART treatment, they can resume or continue their sexual behavior and other things. However, I am curious to see how accurate these models because its always difficult to apply numbers to such a situation especially that its a medical situation and is even more unpredictable.

These results would be really pessimistic if all the dynamics that go into HIV/AIDS prevention had been incorporated but this only considers ARTs so bottom line as the authors said is that ARTs cannot prevent HIV infections in resource poor countries. They might in industrious nations were the virus is diagnosed early in its stages before the immune system CD4 cell count has dropped below 200 cells/uL but that is not the case for resource constricted nations were the cases are diagnosed when the virus has already matured in the body. It would be interesting to see what the curves look like if other dynamics were incorporated such as counseling services, use of condoms, and possible even education.