Non-AIDS conditions such as cardiovascular disease and non-AIDS defining cancers dominate causes of morbidity and mortality among persons with HIV on suppressive combination antiretroviral therapy. Accurate estimates of disease incidence and of risk factors for these conditions are important in planning preventative efforts.+ cell count ≥300 cells/mm3 who were taking antiretroviral therapy and had an HIV RNA level ≤500 copies/mL. Cox models were used to examine the effect of age and other baseline factors on risk of a composite outcome of all-cause mortality, AIDS, or serious non-AIDS.With use of medical records, serious non-AIDS events, AIDS events, and causes of death were adjudicated using pre-specified criteria by an Endpoint Review Committee in two large international trials. Rates of serious non-AIDS which include cardiovascular disease, end-stage renal disease, decompensated liver disease, and non-AIDS cancer, and other serious (grade 4) adverse events were determined, overall and by age, over a median follow-up of 4.3 years for 3,570 participants with CD4Five-year Kaplan-Meier estimates of the composite outcome, overall and by age were 8.3% , 3.6% (<40), 8.7% (40–49) and 16.1% (≥50), respectively (p<0.001). In addition to age, smoking and higher levels of interleukin-6 and D-dimer were significant predictors of the composite outcome. The composite outcome was dominated by serious non-AIDS events . Most serious non-AIDS events were due to cardiovascular disease and non-AIDS cancers.To date, few large studies have carefully collected data on serious non-AIDS outcomes. Thus, reliable estimates of event rates are scarce. Data cited here, from a geographically diverse cohort, will be useful for planning studies of interventions aimed at reducing rates of serious non-AIDS events among people with HIV. Potent combination antiretroviral therapy (cART) has improved life expectancy for people with HIV. AIDS-related events are now less common among patients taking suppressive cART Future intervention trials will require accurate estimates of SNA event rates and of patient risk factors that could be used to select study participants. In this report, we take advantage of the long-term follow-up and centrally adjudicated clinical outcomes of participants in the control arms of two large international randomized clinical trials who received continuous cART aimed at viral suppression to estimate rates of a composite outcome of all-cause mortality, SNA, or AIDS, and rates for each component of this composite outcome. Results are given overall and by age since risk of SNA increase with age and, therefore, age is an obvious factor to consider as an inclusion criterion in future trials. Furthermore, the number of people aged ≥50 years living with HIV-1 (HIV) has been increasing worldwide + cell counts >350 cells/mm3 were randomized to either the Drug Conservation group, which received CD4+ cell count-guided episodic cART or the Viral Suppression control group, which received continuous cART + cell counts ≥300 cells/mm3 were randomized to receive cART alone (control group) or cART with interleukin-2 Outcomes for the participants in the control arms of the Strategies for Management of Anti-Retroviral Therapy (SMART) trial and the Evaluation of Subcutaneous Proleukin in a Randomized International Trial (ESPRIT) are the subject of this report. Both studies were carried out by the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT). The study design and methods of both studies have been reported previously For this study, we included participants in the control arms of SMART and ESPRIT who were on cART at study entry with an HIV RNA level ≤500 copies/mL  to focus on participants who were being successfully treated with cART. This now represents the great majority of patients taking ART and is likely to be the target population for adjunctive interventions aimed at reducing SNA since the first goal of treatment is maximal and durable suppression of plasma HIV viral load Written informed consent was obtained from all participants. The institutional review board (IRB) or institutional ethics committee (IEC) at each site and the University of Minnesota, which served as the Statistical and Data Management Center, approved the protocols of SMART and ESPRIT and the analysis of stored specimens for consenting participants. The University of Minnesota institutional review board also approved plans for the continued analysis of SMART and ESPRIT datasets utilized in this study. Copies of all IRB/IEC approval letters are filed with the Statistical and Data Management Center at the University of Minnesota.The INSIGHT Endpoint Review Committee (ERC) reviewed AIDS and SNA non-fatal events and deaths using pre-specified criteria Serious non-AIDS (SNA) events included CVD, end-stage renal disease, decompensated liver disease, and non-AIDS cancer . Myocardial infarction, cerebrovascular strokes, coronary artery disease requiring an invasive procedure, and CVD death were classified as CVD events.2 from study entry.In addition to AIDS and SNA events, rates of grade 4 events and estimated glomerular filtration (eGFR) are also reported. Grade 4 events are potentially life-threatening symptomatic events requiring medical intervention according to the toxicity table of the Division of AIDS of the National Institute of Allergy and Infectious Diseases (NIAID). In each study grade 4 events were classified using System Organ Classes (SOC) defined by the Medical Dictionary for Regulatory Activities (MedDRA). eGFR was calculated using the Chronic Kidney Disease-Epidemiology Collaboration equation Medical and treatment histories, including AIDS and non-AIDS diagnoses, HIV and SNA risk factors, and use of concomitant medications, were ascertained prior to randomization. Interleukin-6 (IL-6), an inflammatory marker, and D-dimer, a coagulation marker, were measured at baseline on stored specimens in both studies for consenting participants + cell count and HIV RNA levels were measured locally at each follow-up visit. For consenting individuals, stored specimens were used to measure creatinine levels annually with additional measurements at four and eight months in SMART.In ESPRIT, follow-up visits for data collection were conducted every four months; in SMART, participants were seen one month and two months after enrollment, then in two-month intervals until year one, and in four-month intervals in subsequent years. CD4Participant characteristics at enrollment and outcomes during follow-up are presented overall and for three age groups: <40, 40–49, and ≥50 years of age. Cross-sectional associations of demographic and health factors with age were assessed using logistic and general linear models for categorical and continuous variables, respectively. Event rates per 100 person-years are cited and cumulative three, four and five-year event probabilities are calculated using the Kaplan-Meier method with 95% log-log confidence intervals (CIs). Cox proportional hazards models were used to examine the relationship between age and major clinical outcomes, and to investigate determinants of a composite outcome of all-cause mortality, SNA, or AIDS; adjusted hazard ratios (aHRs) for ten years increase in age and 95% CIs are cited. For each event considered, time at risk was defined as the time from randomization to the first event, death, loss to follow-up, or study closure.P-values are two-sided and unadjusted for multiple comparisons.Data were analyzed using SAS version 9.3 and R version 2.15.1. Among 4792 participants in the control arms of SMART (n = 2752) and ESPRIT (n = 2040), 3570 (74.5%) were taking cART and had an HIV RNA level ≤500 copies/mL at study entry. Of these participants from 35 countries, 1327 (37.2%) were enrolled by sites in Europe; 1319 (36.9%) by sites in North America; 489 (13.7%) by sites in South America; 257 (7.2%) by sites in Asia; 146 (4.1%) by sites in Australia; and 32 (0.9%) by sites in Africa. Median follow-up time was 4.3 years (interquartile range [IQR]: 2.1 and 6.7 years). Vital status was known for 96.5% of participants at the completion of both studies.P<0.001) and had acquired HIV through homosexual contact (P<0.001). As expected, older participants were more likely to have had a history of CVD or diabetes (both P<0.001), and were more likely to be on medications for hypertension, hyperlipidemia, osteoporosis, diabetes, or CVD . Among participants ≥50 years old, 14.6% were taking two or more of these types of medication in addition to cART. Overall, the median time on ART was 4.0 years (IQR: 2.6–5.0). Older participants were more likely to have been on ART longer and have a history of use of protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). Older participants also were more likely to have been prescribed abacavir, tenofovir, stavudine, zalicitabine, and lamivudine.P<0.001).Total/HDL cholesterol, IL-6, and D-dimer levels were higher and eGFR was lower among older participants . In each age group, SNA events were the dominant component of this composite outcome. Overall, the most common SNA events were non-AIDS cancers and CVD (79 participants each). The most common cancers were lung cancer (n = 16), prostate cancer (n = 11), anal cancer (n = 8), breast cancer (n = 7), skin cancer (n = 7), and colon cancer (n = 4). For the 79 participants with at least one CVD event, the individual CVD events were acute myocardial infarction (n = 40), coronary artery disease with surgery (n = 21), stroke (n = 10), and other causes (n = 8). Decompensated liver disease (n = 14) and end stage renal disease (n = 4) were much less common.Rates of all-cause mortality , SNA events , CVD events , non-AIDS cancers , CKD , and all-cause hospitalization , increased with older age as expected . AIDS evP<0.001). With regard to the composite endpoint, five-year event rates were 3.6%, 8.7% and 16.1% for the respective age groups (P<0.001). We examined determinants of the composite outcome of all-cause mortality, SNA, or AIDS in unadjusted and adjusted Cox models . The fol+ cell counts were followed for several years and fatal and non-fatal AIDS, SNA and other causes of deaths were centrally adjudicated against standard event criteria. In this report we estimate rates of these major causes of morbidity and mortality overall and by age. Such information is critical for planning future research aimed at improving the long-term health among a growing number of older persons with HIV.In SMART and ESPRIT, HIV-positive participants taking suppressive cART with high CD4Over 90% of major clinical events among participants aged ≥50 years at enrollment were attributable to conditions other than AIDS, primarily CVD and non-AIDS cancers. This emphasizes the importance of prevention and control of established major CVD risk factors for an aging population with HIV Consistent with previous studies + counts may be different in developing countries. An additional limitation is that older participants had different cART exposure than younger participants, both duration and type of drugs. However, in a sensitivity analysis, adjusting for these different cART exposures, duration of cART use, and other covariates did not change the associations of other covariates with the composite outcome.Strengths of the current study include the large geographically diverse population, long follow-up with little missing data, and use of standardized event definitions. The SMART and ESPRIT studies were among the earliest to carefully adjudicate non-AIDS conditions. A limitation is that participants were enrolled in clinical trials and may therefore be healthier than the general HIV population. However, our primary goal is to provide information useful for planning trials of future interventions, therefore data presented here are considered very relevant for that purpose. Another limitation is that the cohort largely consists of participants in developed countries and causes of morbidity and mortality for participants on suppressive cART with high CD4In summary, the patterns of risk with age identified in this report highlight that major morbidity and mortality will be increasingly dominated by non-AIDS conditions and grade 4 events as individuals with HIV age. The age spectrum of persons with HIV is shifting older worldwide, largely as a consequence of effective treatment with cART. In the United States, the CDC estimates that half of all HIV-infected individuals will be aged 50 or older by 2015. Thus, event rates presented here will be useful for planning intervention studies aimed at interventions to treat or prevent non-AIDS diseases among persons with HIV taking suppressive cART.


There is controversy over whether traditional intermittent bolus dosing or continuous infusion of beta-lactam antibiotics is preferable in critically ill patients. No significant difference between these two dosing strategies in terms of patient outcomes has been shown yet. This is despite compelling in vitro and in vivo pharmacokinetic/pharmacodynamic (PK/PD) data. A lack of significance in clinical outcome studies may be due to several methodological flaws potentially masking the benefits of continuous infusion observed in preclinical studies. In this review, we explore the methodological shortcomings of the published clinical studies and describe the criteria that should be considered for performing a definitive clinical trial. We found that most trials utilized inconsistent antibiotic doses and recruited only small numbers of heterogeneous patient groups. The results of these trials suggest that continuous infusion of beta-lactam antibiotics may have variable efficacy in different patient groups. Patients who may benefit from continuous infusion are critically ill patients with a high level of illness severity. Thus, future trials should test the potential clinical advantages of continuous infusion in this patient population. To further ascertain whether benefits of continuous infusion in critically ill patients do exist, a large-scale, prospective, multinational trial with a robust design is required. The mortality rate of severe sepsis and septic shock in critically ill patients remains high despite recent therapeutic advances. Swift and judicious antibiotic use in these patients is vital and any delays are associated with increases in mortality ,2. Beta-max) to minimum inhibitory concentration  [0-24) to MIC (AUC0-24/MIC). Therefore, increasing the dose or/and concentration for these antibiotics can be logically expected to enhance the rate and extent of bacterial killing [Antibiotic pharmacodynamics (PD) is the discipline that attempts to relate PK parameters to the ability of an antibiotic to kill or inhibit the growth of bacterial pathogens . Antibiomax/MIC) ,11. Some killing ,13. In c killing -17.fT>MIC) best describes its bacterial kill characteristics [The debate persists about whether traditional intermittent bolus dosing (IB) or continuous infusion (CI) is clinically preferable for administration of beta-lactam antibiotics. This is despite the fact that beta-lactam PD data suggest advantages for CI compared with IB -24, showeristics   during a dosing interval is regarded as the optimal PD index for beta-lactam antibiotics, and as such, maintaining effective drug concentration above the MIC should be the priority when this antibiotic class is used. Specifically, the % fT>MIC needed for bacteriostasis and bactericidal is 35-40% and 60-70% for cephalosporins, 30% and 50% for penicillins, 20% and 40% for carbapenems, respectively [fT>MIC for this antibiotic class without some of the CI-associated drawbacks outlined in Table The percentage (%) of ectively ,33,41,42ectively . Furtherectively ,45. Thusectively . Combiniss) that is at least 4 x MIC [min) greater than the 4 x MIC of the offending pathogen for 40–70% of a dosing interval and for CI, a Css greater than 4 x MIC to prevent biased comparisons. It follows that the real challenge for IB is to obtain a Cmin greater than 4 x MIC in a severely ill patient who is infected with a pathogen with high MIC.Different PD endpoints have been used in published studies, which make comparison between CI and IB difficult. However, several reviews have suggested that prolonged antibiotic exposures will achieve better PD profile ,49,50. A 4 x MIC . Thus, ffT>MIC required for carbapenems bacteriostatic (20%) and bactericidal (40%) activity may relate to the antibiotics PAE [Another consideration for optimizing antibiotic pharmacokinetic exposure is the postantibiotic effect (PAE), i.e., the suppression of bacterial growth even with antibiotic concentrations below the MIC . Althougtics PAE -61. Therhttp://www.eucast.org/clinical_breakpoints/) and Clinical and Laboratory Standards Institute  have had an impact on how clinicians view and manage infections worldwide. These new rules also are applicable for interpretation of antibiotic PK/PD studies. Due to these changes, future studies need to be interpreted in light of the new susceptibility breakpoints [The recent revision in antibiotic breakpoints to indicate if an organism is susceptible or resistant to different antibiotics, as classified by the European Committee on Antimicrobial Susceptibility Testing  critically ill patients; 2) patients with higher level of illness severity ; 3) patients infected with less susceptible microorganisms; and 4) patients with gram-negative infections.Several reviews have suggested the importance of designing and conducting a methodologically sound clinical trial in the investigation of CI versus IB antibiotic administration benefits in critically ill patients ,38-40. TMost studies did not address the methods for allocation sequence generation and concealment further increasing the chance for selection bias ,76,78-88Ideally, the antibiotic dosing regimen in each treatment arm  should be comparable in terms of the provision of an initial loading dose with an equal daily antibiotic dose. Alternatively, a suitable surrogate endpoint, such as a cost-effective analysis, may be used to compare these two dosing approaches when unequal antibiotic doses are used between them. Concomitant administration of other non-beta-lactam antibiotics, such as the aminoglycosides or fluoroquinolones, in the setting of a study is appropriate considering that a single empirical therapy is unlikely to occur during antibiotic initiation in ICU patients ,4. Furthss) greater than 4 x MIC to be microbiologically more effective than IB. On the other hand, IB has to achieve an antibiotic concentration (Cmin) greater than 4 x MIC during the typical 40–70% of the dosing interval [Only a number of studies measured the antibiotic concentrations and included a concurrent PK/PD evaluation to confirm whether the dosing approaches were actually meeting their respective PK/PD endpoints Table  52,76-7,86. Hencinterval ,87,103. P. aeruginosa compared with 50% who received the conventional imipenem dosing. This is one of the few recent studies to evaluate the relative ability of the two dosing approaches in the prevention of resistance; similar studies, particularly involving critically ill patients, should ensue. Although there are not enough prior clinical data to power a study in the ICU and describe the appropriate methodology, data collection on the observed resistance should be performed in future clinical trials investigating the two dosing approaches.Considering the rampant development of bacterial resistance, the exact role of altered dosing approaches to reduce the problem should be addressed. To date, studies investigating the impact of various beta-lactams dosing approaches and their associated risk of bacterial resistance are scarce . HoweverPreviously published studies have mostly been single-center in design. To our knowledge, only three studies were conducted as a multicenter study, and only two of the three studies were able to include more than 200 patients ,79,83. Tp = 0.001), thus supporting the notion of PK/PD superiority associated with continuous administration. Clinical cure also was superior in the CI group . Other relevant findings include the feasibility of the proposed randomization and blinding process used by the BLING I investigators and the suggestion of appropriate surrogate endpoints for survival to be utilized in a multicenter study. Thus, based on the findings from BLING I, BLING II was designed with rigorous and stringent methods to answer the ultimate question of whether administration of beta-lactam antibiotics by CI will result in improved outcomes for patients with severe sepsis. BLING II is a phase II, multicenter, double-blinded, randomized, controlled trial that will recruit critically ill patients with severe sepsis in several ICUs in New Zealand as well as Australia and Hong Kong. The Australian National Health and Medical Research Council (NHMRC)-funded clinical trial aims to compare the effects of two approaches to the administration of beta-lactam antibiotics  on ICU-free days up to day 28.Because of the cost of large-scale trials, a step-wise approach to consider potential problems and feasibility is desirable. An initial pilot study before proceeding with a larger multicenter trial is beneficial. In this regard, the Beta-lactam Infusion Group’s feasibility study (BLING I) has now led to the design of large clinical outcome study, BLING II. BLING I  was a prospective, multicenter, double-blind, double dummy, pilot, randomized, controlled trial enrolling 60 critically ill patients from 5 ICUs across Australia and Hong Kong. The primary endpoint of the study was to establish the PK separation between CI and IB in terms of achieving plasma antibiotic concentrations above the MIC of causative pathogens. The PK findings in BLING I demonstrated significant differences in plasma antibiotic concentrations above MIC favoring the CI group (CI; 81.8% vs. IB; 28.6%, Although numerous PK/PD data from various in vitro and in vivo experimental studies favor the use of continuous infusion, the current clinical data are less convincing and insufficient to instigate a global shift from conventional bolus dosing. However, this lack of convincing data may be due to several methodological flaws and inconsistencies among the available studies, thus contributing toward insufficient power to detect any significant differences between CI and IB, if they exist. Based on the published literature, it can be concluded that CI of beta-lactams will not be beneficial to all patients but may potentially be beneficial to specific subsets of patients. If any patient group is likely to benefit from CI, it may be critically ill patients with severe infections. If benefits from CI do exist in critically ill patients, a large-scale, prospective, multinational trial with a robust design is required. A step-wise approach to conduct such clinical trials has begun and already shows promise. A phase II study involving 420 patients is about to start and will provide high-quality information to confirm or refute the need for a pivotal phase III double-blinded RCT of CI vs. beta-lactam dosing in critically ill patients with sepsis.PK, Pharmacokinetics; PD, Pharmacodynamics; ICU, Intensive care unit; MIC, Minimal inhibitory concentration; Cmax, Maximal concentration; AUC0-24, Area under the concentration time curve during a 24-hour period; AUC0-24/MIC, Ratio of area under the concentration time curve during a 24-hour period; PAE, Post antibiotic effect; CI, Continuous infusion; IB, Intermittent bolus; EI, Extended infusion; Cmin, Lowest concentration; APACHE II, Acute Physiological and Chronic Health Evaluation II; T, Time; Css, Steady-state concentration; BLING, Beta-lactam Infusion Group; NHMRC, Australian National Health and Medical Research Council; RCT, Randomized controlled trial; ISF, Interstitial fluid.Mohd Abdul Aziz, Dr. Joel Dulhunty, and Prof Rinaldo Bellomo have no conflicts of interest. Dr. Jason Roberts has served for a consultant for Astra Zeneca, Pfizer, Gilead, and Janssen-Cilag. Prof. Jeffrey Lipman has received research grants from Astra Zeneca and has attended Advisory Boards, acted as a consultant to, or given lectures with honoraria from Astra-Zeneca, Janssen-Cilag, Merck Sharp & Dohme, Pfizer, and Wyeth Australia.JD and RB conceived the topic review idea and proposal. MA-A, JD, JL, and JR performed the literature search and selected the relevant articles to be discussed. All authors participated in design, coordination, and writing of the manuscript. All authors read and approved the final manuscript.


Nitric oxide (NO) emerged as one of the major signaling molecules operating during plant development and plant responses to its environment. Beyond the identification of the direct molecular targets of NO, a series of studies considered its interplay with other actors of signal transduction and the integration of NO into complex signaling networks. Beside the close relationships between NO and calcium or phosphatidic acid signaling pathways that are now well-established, recent reports paved the way for interplays between NO and sphingolipids (SLs). This mini-review summarizes our current knowledge of the influence NO and SLs might exert on each other in plant physiology. Based on comparisons with examples from the animal field, it further indicates that, although SL–NO interplays are common features in signaling networks of eukaryotic cells, the underlying mechanisms and molecular targets significantly differ. De facto cardinal questions such as the origin, mode of action, or integration of NO signal into regulatory networks became of broad interest for plant biologists  are crucial to convert NO signal into proper physiological responses , or reactive oxygen species (ROS), that trigger, mediate and/or modulate NO signal in response to specific stimuli  is a pleiotropic actor of signaling cascades in eukaryotes . The lasologists . The comologists . In partesponses . This asesponses . Beyond  stimuli . A recench other . Althougch other .Recently, sphingolipids (SLs), another class of well-known signaling lipids in mammal cells, were ascribed important signaling functions in plants . NumerouThe generic term SLs designate both membrane-located complex SL  and their metabolic precursors, i.e., long chain bases (LCB) and ceramides Cer; . They th2+, heterotrimeric G proteins, ROS, and the MAP kinase AtMPK6. Recent data also suggest that PtdOH signaling can act in a coordinated way with SL . Rafts are not only enriched in SL and sterols, but also present a particular protein composition . Indeed,Figures B). First, NO can regulate sphingomyelinases (SMase) that generate the formation of Cer from sphingomyelin (SM), a major membrane SL in mammal cells , NO promotes (i) the activation of SMases that generate Cer and (ii) represses Cer degradation via the inhibition of ceramidase activities  physiological situations  mediated by S1P . Fusarium sp IFB-121 induce NO formation in Taxus yunnanensis and Artemisia annua. Cerebrosides are complex membrane SL widely found in soilborne fungi and are considered as pathogen-associated molecular patterns  from Fusarium moniliforme. Although the formation of NO in response to these toxins has not been directly evidenced, AAL-triggered cell death was blocked by an inhibitor of mammalian NOS suggesting that NO was required for AAL response . Nevertheless, several lines of evidence indicate the existence of similar interplays between SL and NO signaling in plants. First, studies have reported the capacity of SL-related molecules to trigger NO synthesis . In particular it may participate in the fine-tuning of the equilibrium between LCB/Cer and LCB-P/Cer-P. This was evidenced for Arabidopsis response to cold where two phosphorylated SL species  are rapidly and transiently formed (Arabidopsis mutant line over-expressing a non-symbiotic hemoglobin, and thereby exhibiting low NO levels, over-accumulates phytosphingosine. The levels of phytosphingosine were further increased after cold exposure and might afford for the highest rate of phytosphingosine-P formation observed in this mutant (Conversely to the regulation of NO formation by SL, recent data indicate that NO regulates specific aspects of SL metabolism in plants (y formed . In thisy formed . How NO y formed . So far y formed . The regs mutant . Interess mutant . These dArabidopsis and the phytopathogenic bacteria Pseudomonas syringae is another context where NO–SL interactions are likely. On the one hand studies carried out on this pathosystem led to the pioneering demonstration of NO as a signal in plants (As for SL-triggered NO formation, the example presented above questions about the ubiquity of SL–NO interplay in diverse physiological contexts and the underlying mechanisms at work. Although direct connections have not been established yet, it is likely that SL–NO crosstalks participate in ABA signaling . In thisn plants . On the n plants . Althougn plants . Besidesn plants . Due to n plants , furtherIncreasing evidence plead for functional interplays between NO and lipid signaling and indirectly bring to forestage the role of biological membranes in NO biology. As exemplified in mammals and plants, SL signals generated by the catabolism or as intermediates of the synthesis of complex membrane SL, constitute new elements of the NO signaling network in a variety of physiological processes. The rising interest for SL and NO signaling in plants will undoubtedly provide soon new examples of this interplay. Future investigations should help unravel the mechanisms underlying such NO–SL signaling crosstalks. In particular a direct regulation of enzymes of the NO and SL pathway by SL and NO, respectively should be evaluated. As observed in mammals, this might include modulation of activity but also regulation of protein targeting. Finally it is likely that NO, which is liposoluble, does not only interplay with SL signaling within the cytosol, but also within the biological membranes. As it might deeply affect the activity and/or targeting of membrane-located proteins and the overall membrane structure, attention should now be paid to NO signaling within the lipid phase.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We describe temporal trends in the mortality rates and factors associated with AIDS and non-AIDS related mortality at the Evandro Chagas Clinical Research Institute (IPEC), Oswaldo Cruz Foundation (FIOCRUZ).Adult patients enrolling from 1986 through 2009 with a minimum follow up of 60 days were included. Vital status was exhaustively checked using patients’ medical charts, through active contact with individuals and family members and by linkage with the Rio de Janeiro Mortality database using a previously validated algorithm. The CoDe protocol was used to establish the cause of death. Extended Cox proportional hazards models were used for multivariate modeling.A total of 3530 individuals met the inclusion criteria, out of which 868 (24.6%) deceased; median follow up per patient was 3.9 years (interquartile range 1.7–9.2 years). The dramatic decrease in the overall mortality rates was driven by AIDS-related causes that decreased from 9.19 deaths/100PYs n 1986–1991 to 1.35/100PYs in 2007–2009. Non-AIDS related mortality rates remained stable overtime, at around 1 death/100PYs. Immunodeficiency significantly increased the hazard of both AIDS-related and non-AIDS-related causes of death, while HAART use was strongly associated with a lower hazard of death from either cause.Our results confirm the remarkable decrease in AIDS-related mortality as the HIV epidemic evolved and alerts to the conditions not traditionally related to HIV/AIDS which are now becoming more frequent, needing careful monitoring. Highly-active antiretroviral therapy (HAART) had a dramatic impact on the AIDS epidemic; in particular, it has greatly changed the mortality profile for human immunodeficiency virus (HIV)-infected individuals. In the pre-HAART era there was a clear predominance of AIDS-related conditions whereas, currently, the mortality profile is more diverse, including cardiovascular diseases, non-AIDS-related-malignancies and other end-organ diseases such as end-stage liver and renal diseases In Brazil, mono and dual antiretroviral therapy started being provided in the early 1990s and HAART has been made available since 1996. Local studies have shown an increased survival of HIV-infected individuals and, more recently, an increased frequency of non-AIDS-related causes of death among HIV-infected individuals IPEC is a national reference center for infectious diseases and has been a reference center for care, research, and training related to HIV/AIDS since 1986. The AIDS program at IPEC is one of the largest providers of primary, specialty, and tertiary care for HIV infected individuals and AIDS patients in Rio de Janeiro State.A longitudinal observational clinical database has been maintained on patients receiving HIV care at IPEC. Cohort procedures have been described and results published The study population included adult patients (age ≥18 years) who enrolled in the IPEC cohort and had a minimum follow up of 60 days, from September 12, 1986 (the date of the first enrollee) through October 30, 2009 . End of follow up was defined as the earlier of death or December 31 2009 when administrative censoring was applied. Information regarding vital status was exhaustively checked up until December 31 2009 using the patients’ medical charts, through active contact with individuals and family members and by linkage with the Rio de Janeiro Mortality database using a previously validated algorithm http://www.cphiv.dk/CoDe/) was used to revise near death patient information. The CoDe method is a uniform coding system that includes detailed data collection on the causes of death and contributing factors and a centralized review process of the collected data. The Portuguese translated CoDe case report forms were completed by two physicians specialized in HIV care. The central review process followed the CoDe guidelines and was performed independently by two qualified reviewers also specialized in HIV care. If agreement on the immediate and underlying causes of death was reached, the cause of death was established. If there was disagreement between the two reviewers, the specific case was referred to one additional reviewer who reviewed the CoDe case report and the CoDe review forms and then established the cause of death.For all deaths that occurred in the study period, the CoDe (“Coding of Death in HIV”) method (The cause of death was given by the underlying cause of death. Groups of causes of death were defined based on the categories present in the CoDe review form as follows: AIDS-infection (CoDe 01.1), AIDS-malignancy (CoDe 01.2), AIDS-not specified (CoDe 01), non-AIDS infection (CoDe 02), liver-related (CoDe 03), non-AIDS malignancy (CoDe 04), diabetes mellitus (CoDe 05), pancreatitis (CoDe 06), toxicity , cardiovascular , primary pulmonary hypertension (CoDe 11), lung embolus (CoDe 12), respiratory disease , renal failure (CoDe 15), violence (CoDe 16), psychiatric , substance abuse (CoDe 19), hematological disease (CoDe 20), endocrine disease (CoDe 21), central nervous system (CNS) disease (CoDe 23), digestive system disease , skin and motor system disease (CoDe 27), urogenital disease (CoDe 28), obstetric complication (CoDe 29), congenital disorders (CoDe 30) and unknown . Of the above mentioned causes of death, those with two deaths or less were combined in the “Other causes” group.Age at enrolment was calculated as the difference between date of birth and date of enrolment. Age at the end of follow up was calculated as the difference between date of birth and end of follow up as defined above. Race/ethnicity was based on the provider’s report and was categorized into white and non-white. Education was self-reported and categorized according to the number of years in school into three groups: ≤5 years, 6–9 years, and ≥10 years. Presumed HIV exposure category were self-reported and categorized hierarchically into injection drug use , men who have sex with men , heterosexual and other/unknown. Baseline CD4 cell count was defined within a window of 180 days of enrolment, and, if more than one measurement was available, the value closest to the date of enrolment was chosen. HAART use was defined as the use of at least three antiretroviral drugs: two nucleoside reverse transcriptase inhibitor and either one protease inhibitor or one non-nucleoside reverse transcriptase inhibitor, and categorized into those who, at any given point in time, used HAART for more than 12 weeks, and those who never used HAART (never used or used for 12 weeks or less). AIDS-diagnosis (CDC 1993 definition) at baseline was defined by the occurrence of an AIDS-defining illness at or before cohort enrolment.Descriptive statistics for demographic and clinical variables were compared for four groups defined as a function of vital status and category of underlying cause of death . Kruskal-Wallis and Chi-squared tests were used to access differences among groups for continuous and categorical variables, respectively. Incidence rates of death per 100 person-years were calculated for all causes, and for AIDS-related and non-AIDS-related causes of death. For the calculation of the rates, the study period was divided into three-year periods, except for the first period, to allow for a more precise description and assessment of temporal trends. Temporal trends over periods were tested by exact mid-P values calculation.To explore the factors associated with AIDS or non-AIDS related causes of death, we used extended Cox proportional hazards models, accounting for competing risks, as described elsewhere This study was conducted according to the principles expressed in the Declaration of Helsinki. This study was approved by the ethics committee of the Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation. Participants provided written informed consent.During the study period, a total of 3530 individuals met the inclusion criteria, out of which 868 (24.6%) deceased. Some demographic and clinical characteristics were significantly different across the groups alive, death due to non-AIDS related and death due to AIDS-related causes of deaths , such asThe remarkable changes in the relative frequency of causes of death are shown in Among the specific causes, the percentage of deaths due to AIDS-infection decreased from 66.4% in 1986–1991 to 34.9% in 2007–2009. The top three causes of death within the AIDS-infection group were tuberculosis , cytomegalovirus , and cryptococcosis . In contrast, the percentage of deaths due to AIDS-malignancy increased from 1.8% in 1986–1991 to 10.7% in 2007–2009. The top two causes of death within the AIDS-malignancy group were Kaposi’s sarcoma  and non-Hodgkin lymphoma .Non-AIDS infection was the most frequent non-AIDS cause of death with 5.2% (45/868) of all deaths . Sepsis Mortality rates from all causes decreased remarkably from over 10 deaths/100 person-years (PYs), to almost 2/100PYs during the study period . This deThe cumulative incidence functions for AIDS-related, non-AIDS related and unknown causes of death are shown in the figure for the entire cohort  and for We retrospectively assigned a defined cause of death to 97.7% of the 868 deaths occurring among the 3530 individuals followed at IPEC from 1986 to 2009. We showed that mortality rates from AIDS-related causes of death dramatically decreased over time from 9.19 deaths/100 PYs in 1986–1991 to 1.35 deaths/100 PYs in 2007–2009. In contrast, mortality rates from non-AIDS-related causes showed no trend over time, oscillating at 1 death/100 PYs. Moreover, remarkable changes in the relative frequency of AIDS-related and non-AIDS-related causes of death were observed with AIDS-related causes decreasing from 87% to 62%  in the periods 1986–1991 and 2007–2009, respectively. These results are in agreement with reports from Brazil and other countries that show a remarkable decrease in AIDS-related causes of death as the HIV epidemic progressed through time and corroborates the observation that conditions that are not traditionally related to HIV/AIDS are now becoming relatively more frequent, as reflected in our findings We found that patients who died from AIDS-related causes of death had poorer immunological profile at cohort enrollment compared to those who remained alive or died of non-AIDS-related causes of death. Median CD4 cell counts at baseline for patients who died of AIDS-related infections and AIDS-related malignancies were, respectively, 117 and 146 cells/mm3, as opposed to 296 cells/mm3 for patients who died of non-AIDS related causes. Additionally, a significantly higher percentage of those who died of AIDS related causes had AIDS diagnosis at enrollment. Indeed, AIDS diagnosis at enrollment and lower CD4 cell count were significantly associated with a higher hazard of death from AIDS-related causes in the multivariate analysis. In previous analyses, we have shown that late presentation to care is a major problem in our setting We also found that HAART use was significantly associated with a lower hazard of death from AIDS-related and non-AIDS related causes. In a scenario where antiretroviral treatment has been shown to dramatically reduce mortality rates attributable to HIV-infection and where improvements in antiretroviral treatment have further reduced mortality rates among HIV-infected individuals, the significant association of lower CD4 cell counts with higher rates of death due to AIDS and non-AIDS related causes supports the numerous arguments for earlier initiation of antiretroviral treatment AIDS-infection remained the most frequent cause of death throughout the 25 years evaluated in the present study. This finding has also been reported in several other cohorts from the developed and developing world In the adjusted analysis, we found that older age, lower education, and lower CD4 cell counts significantly increased the hazard of death from non-AIDS related causes. Compared to those who died from AIDS-related conditions, patients who died of non-AIDS-related causes of death were older at cohort enrolment and at the time of death. An aging HIV-infected population presents new challenges that include the monitoring and handling of drug interactions resulting from the treatment of chronic co-morbid conditions and HIV infection.Among non-AIDS-related deaths, non-AIDS-infections were the most frequent cause of death. We have previously shown that infections play a major role in early mortality Cardiovascular disease was the second most frequent cause of death among non-AIDS related causes. Similar to several other HIV-associated co-morbidities, cardiovascular disease stems from the interplay of multiple risk factors, including both traditional risk factors and those specific to HIV infection, such as impaired immune function disease Our results also show that the proportion of deaths attributable to both AIDS-malignancy and non-AIDS-malignancy increased over time. The most common AIDS-related malignancies were Kaposi’s sarcoma and non-Hodgkin lymphoma while the most frequent non-AIDS malignancy was lung cancer. Malignancies are important causes of morbidity and mortality among HIV infected individuals. Due to declining mortality from AIDS-related infections, malignancies account for a growing fraction of deaths Our study has strengths and limitations that are worth mentioning. A strength was to the use of a standardized method of assessing the causal link between a disease or condition and death, namely the CoDe method Our results show a dramatic decreasing trend in the mortality rates from AIDS-related causes of death among HIV-infected patients from Rio de Janeiro, Brazil. It also shows that, in recent years, similar rates of death from AIDS-related and non-AIDS-related causes were observed. This finding evidences the complexity of HIV-infected patient management that is now clearly beyond the scope of care traditionally provided in most HIV specialized services and that calls for an integrated approach to treatment and prevention. Estimates of the burden of non-AIDS co-morbidities in populations affected by HIV and evidence from effective care delivery models would improve planning capabilities for better use of scarce resources. Furthermore, HIV testing targeting populations at increased risk coupled with linkage to care and early initiation of HAART are now, ever more, the cornerstone of the fight against HIV/AIDS. As for Brazil, this dramatic decrease of AIDS related causes of death happens in the midst of the country’s demographical and epidemiological transitions, where the burden of communicable and non-communicable diseases co-exist


Background. The homeostatic chemokine, CXCL13 , helps direct the recirculation of mature, resting B cells, which express its receptor, CXCR5. CXCL13/CXCR5 are expressed, and may play a role, in some non-AIDS-associated B cell tumors. Objective. To determine if CXCL13/CXCR5 are associated with AIDS-related non-Hodgkin's lymphoma (AIDS-NHL). Methods. Serum CXCL13 levels were measured by ELISA in 46 subjects who developed AIDS-NHL in the Multicenter AIDS Cohort Study and in controls. The expression or function of CXCL13 and CXCR5 was examined on primary AIDS-NHL specimens or AIDS-NHL cell lines. Results. Serum CXCL13 levels were significantly elevated in the AIDS-NHL group compared to controls. All primary AIDS-NHL specimens showed CXCR5 expression and most also showed CXCL13 expression. AIDS-NHL cell lines expressed CXCR5 and showed chemotaxis towards CXCL13. Conclusions. CXCL13/CXCR5 are expressed in AIDS-NHL and could potentially be involved in its biology. CXCL13 may have potential as a biomarker for AIDS-NHL. HIV infection is associated with a greatly increased risk of non-Hodgkin's B cell lymphoma (NHL) –3. The iAlthough it has been shown that cytokines probably play an important role in the biology of AIDS-NHL, little work has been done on chemokines, cytokines that are most known for their ability to direct chemotaxis of immune cells . In receα [α, indicating the potential for autocrine interactions [Although, in general, not much is known about the role that chemokines could be playing in AIDS-NHL, several studies are extant in the literature that cover aspects of this issue. Specifically, Rabkin et al. have reported that HIV(+) subjects who are at least heterozygous for a genetic deletion in the chemokine receptor, CCR5, are at significantly decreased risk for developing NHL. Conversely, HIV(+) individuals who carry particular polymorphisms in the gene for the chemokine, SDF-1, have a substantially increased risk of developing NHL . Sei et α –24. SomeRecently, we reported that serum levels of the chemokine, CXCL13, are substantially elevated during HIV infection . CXCL13 It should be noted that CXCR5 and/or CXCL13 have been shown to be associated with several non-AIDS-related B cell lymphomas, including extragastric lymphoma of mucosa-associated lymphoid tissue (MALT) and follicular lymphoma , 35. In 3, SD = 198) and Group II  were similar. Group III subjects (n = 43) were HIV(+), but had no AIDS-defining condition and were selected to have CD4 T cell counts greater than 500 . Group IV subjects (n = 40) were HIV seronegative. All subjects were naïve for highly active antiretroviral therapy (HAART).Archival stored serum specimens were obtained from the Los Angeles (UCLA) center of the Multicenter AIDS Cohort Study (MACS), an ongoing natural history study of HIV in adult homosexual men established in 1984 with 1637 original participants . In the CXCL13 levels in sera, and in culture supernatants of cell lines, were determined by ELISA . Levels of soluble CD44std (sCD44) in sera were determined by ELISA in earlier studies using the same sera as in the current study ; this daTissue arrays containing formalin-fixed, paraffin-embedded sections from AIDS-lymphomas were obtained from the AIDS and Cancer Specimen Resource (ACSR) of the National Cancer Institute. These AIDS-lymphomas were from subjects other than those who provided the serum samples for the CXCL13 serum studies described above, since tumor specimens were not available for most AIDS-NHL cases in the MACS that were used in the serum studies. Conversely, prediagnosis serum specimens were not available for the cases obtained from the ACSR. Of the AIDS-NHL tumors represented in the tissue arrays, about 1/3 were located in lymph nodes, while the remaining 2/3 were of extranodal origin.  Initially, one set of array slides was stained with standard hematoxylin and eosin (H&E) stain to allow general visualization of tissues and tumors. Tumors/tumor cells were generally easily identified in the arrays. 2O2 in 70% methanol for 10 minutes. The wash buffer in this study was PBS ; all antibodies were diluted in PBS + 1% bovine serum albumin and used at room temperature.  For immunohistochemical detection of specific markers, sections were initially deparaffinized in xylene and rehydrated through a graded alcohol series. Slides were pretreated for antigen retrieval in a steamer in citrate buffer  for 25 minutes at 90°C (CXCR5), or heated in a pressure cooker in TRIS (tris(hydroxymethyl)aminomethane) buffer (pH 9.0) for 2 minutes at 115°C (CXCL13). Endogenous peroxidase activity was then quenched with 0.3% H2b isotype control  was used . Next, rabbit antirat polyclonal antibody  and then horseradish peroxidase (HRP)-conjugated antirabbit EnVision reagent (DAKO) were applied, and color was developed using Fast Red . For CXCR5, a rat antihuman CXCR5 antibody  or IgGμg/mL, 30 minutes); the control was normal goat IgG . Next, a biotinylated secondary antibody  was applied, followed by Vectastain Elite ABC reagent. Color was developed using diaminobenzidine .For CXCL13, a specific polyclonal goat IgG (R&D Systems) was used  and R (diffuse large B cell lymphoma subtype), and the Epstein-Barr virus (EBV)-lymphoblastoid B cell line, 40102, were used in these studies –43. All 2b, BD Biosciences, San Diego, CA). The isotype control antibody was clone KLH/Gb-1-2 . The secondary antibody was phycoerythrin (PE)-conjugated goat anti-rat IgG . Flow cytometry was performed using a Becton Dickinson LSR machine. Data was analyzed using CellQuest Pro 5.1 software (Becton Dickinson).Surface CXCR5 expression on cell lines was examined by flow cytometry using a previously described indirect staining protocol . The priμg/mL of Calcein-AM . Cells were then placed in RPMI 1610 medium without phenol red  at a concentration of 3.6 × 106 cells/mL. For determination of chemotaxis, cells  were then loaded on top of the filter of ChemoTX chemotaxis plates . Recombinant human CXCL13 (R&D Systems) was then loaded into the bottom well, and plates were incubated for 2 hours at 37°C. Plate fluorescence was read using a Beckman Coulter  D7X880 Multimode Detector . A range of 0 (media only control) to 1000 ng/mL of CXCL13 was tested. Six to twelve replicate wells were used for each condition, and each experiment was performed at least three times. As an additional control, CXCL13 was loaded into both the lower and the upper wells at some locations on the plates, to test for chemokinesis. Cell migration assays were conducted on the 2F7 and R AIDS-NHL cell lines using the methods described by Kitchen et al. . Brieflyt test that accounted for left-censored values , as previously detailed by us in an earlier publication [z test that accounted for the censoring was used to test for significance. Statistical analysis was performed using the SAS system, version 9.1 . In the study of serum CXCL13 levels, a moderate number of subjects had values below the lower limit of detection of the ELISA used (16 pg/mL). Therefore, the significance of differences in serum CXCL13 levels between groups was determined using a variant of the two-sample lication . As we nlication . AlthougThe degree of association between serum CXCL13 and serum sCD44 was quantified using a bivariate linear regression analysis that again accounted for the left-censoring of CXCL13. Pearson correlation coefficients are used to report results of the regression analysis. For migration (chemotaxis) assays, differences between conditions were analyzed using the Wilcoxon rank sum test, as previously described [P = .02, P = .04), but not in the AIDS control group ; we previously showed that sCD44 levels are elevated prior to AIDS-NHL development [In these studies, we examined CXCL13 levels in AIDS-NHL subjects, using serum obtained at a mean time of 8.2 months prior to diagnosis. The mean CXCL13 level seen in the AIDS-NHL group  was ~50% higher than in the AIDS control group  was 1.7 (range = 1 to 3); the mean score for CXCL13 expression (n = 7) was 1.0 . AIDS-DLBCL showed higher expression of both CXCR5 and, particularly, CXCL13; the mean score for CXCR5 (n = 19) was 2.2 (range = 1 to 3); the mean score for CXCL13 (n = 17) was 1.9 . For most specimens, most expression of CXCR5 and/or CXCL13 appeared to be on tumor cells themselves, as most tumors did not appear to have many infiltrating cells (not shown). Eleven tumors had high numbers of cells expressing CXCR5 , and high numbers of cells expressing CXCL13, suggesting that some tumor cells coexpressed both markers. Indeed, this was very likely the case for several of the tumors, as virtually 100% of cells expressed CXCR5, and virtually 100% expressed CXCL13 (not shown). Sections of noncancerous lymph nodes were also included on the arrays as controls—these typically showed definite, but relatively low, expression of both molecules , which likely reflects the previously reported observation that CXCL13 and CXCR5 expression in normal lymph nodes is generally confined to cells located in or near germinal centers [For these studies, we examined CXCR5 and CXCL13 expression in tissue arrays containing sections of primary specimens of AIDS-NHL from different subjects, using immunohistochemistry. It was not technically feasible to examine both markers simultaneously using double staining. We therefore evaluated each marker using separate array slides containing sections from the same tumors. All AIDS-NHL tumors showed some degree of CXCR5 expression, and most (22/24) expressed CXCL13.  centers , 29, 34.In these studies, we examined expression of CXCR5 and CXCL13 on the AIDS-NHL cell lines, 2F7 (Burkitt subtype) and R (DLBCL subtype). Cell surface CXCR5 was detected using flow cytometry, and CXCL13 in cell culture supernatants was detected by ELISA. Both cell lines clearly expressed surface CXCR5; there was a large increase in mean fluorescence intensity (MFI) when cells were stained for CXCR5 compared to the isotype control . The twoP < .05) migration towards CXCL13 (The ability of the AIDS-NHL cell lines to respond to CXCL13 was examined using standard migration assays. Both cell lines demonstrated statistically significant (s CXCL13 . For theThese studies clearly demonstrate that there is an association between CXCL13 expression and AIDS-NHL. First, in the serum studies, serum CXCL13 levels were significantly elevated prior to lymphoma diagnosis in the AIDS-NHL group, compared to the AIDS control group . CXCL13 The receptor for CXCL13, CXCR5, appears to be commonly expressed in AIDS-NHL, as well. In the immunohistochemistry studies, all AIDS-NHL specimens showed expression of CXCR5 , as did Although our studies show that both CXCL13 and CXCR5 are commonly expressed in AIDS-NHL, future studies will be needed to determine more exactly what roles these molecules may be playing in these cancers. Several mechanisms, which are not necessarily mutually exclusive, appear possible: first, it seems plausible that CXCR5 and CXCL13 could be playing a role in the initial development of AIDS-NHL. As noted in A second possibility is that the CXCL13 and/or CXCR5 could be directly promoting AIDS-NHL tumor growth, or performing some other tumor-promoting functions, such as inhibiting apoptosis or enhancing angiogenesis. Other chemokines, such as SDF-1, have been shown to directly induce tumor cell growth in non-AIDS-related cancers , 12, andThird, it seems possible that CXCL13 could be directing movement and/or metastasis of AIDS-NHL cells in the body. As noted earlier , both AIIt should be noted that at least aspects of these potential mechanisms involving CXCR5 and CXCL13 could be operating in some non-AIDS-related B cell lymphomas, as well, given the similarities noted above between the expression/function of these molecules in AIDS-NHL in the current study, and their previously reported expression/function in several types of non-AIDS-related B cell lymphoma , 35, 36.In summary, we have demonstrated an association between expression of the chemokine, CXCL13, and its receptor, CXCR5, and AIDS-NHL. CXCL13 has potential as a biomarker for AIDS-NHL. Future studies will be needed to more fully determine the feasibility of using CXCL13 as a biomarker for AIDS-NHL, as well as to define the function of CXCL13 and CXCR5 in the pathogenesis of AIDS-NHL.


The number of nongovernmental organizations working on AIDS has grown. There is great diversity in the type of activities and population groups that have been targeted. The purposes of this study are: to describe and analyze the objectives and HIV-AIDS preventive activities that are carried out by the AIDS-NGOs that work with AIDS in Catalonia and that receive subsidies from the Department of Health; and to develop a comprehensive proposal for measurable and agreed upon core quality evaluation indicators to monitor and assess those objectives and activities that can have an impact on the fight against inequalities and stigmatization, and incorporate the perspectives of the service providers and users.A mixed method study has been carried out with professionals from the 36 NGOs that work with HIV/AIDS in Catalonia, as well as their users. This study achieved the completeness model using the following phases:1. A systematic review of AIDS-NGOs annual reports and preparation of a catalogue of activities grouped by objectives, level of prevention and AIDS-NGOs target population; 2. A transversal study through an ad-hoc questionnaire administered to the AIDS-NGOs representatives; 3. A qualitative study with a phenomenological approach through focus groups, individual interviews and observations; 4. Consensus meetings between AIDS-NGOs professionals and the research team using Haddon matrices in order to establish a proposal of evaluation indicators.The information was classified according to level of prevention and level of intervention. A total of 248 objectives and 258 prevention activities were identified. 1564 evaluation indicators, addressed to 7 target population groups, were produced. Thirty core activities were selected. The evaluation indicators proposed for these activities were: 76 indicators for 15 primary prevention activities, 43 for 5 secondary prevention activities and 68 for 10 tertiary prevention activities.The results could help to homogeneously assess the preventive-control activities carried out of AIDS-NGOs. The proposed indicators could help the professionals to improve the evaluation of the preventive-control AIDS-NGOs activities. Furthermore, the Haddon matrix enables us to identify deficiencies of activities at intervention levels and strategies to bear in mind in order to enhance the future AIDS prevention programs. The 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/AIDS adopted by the United Nations General Assembly are the guiding forces of the global response to AIDS. The process of preparing country progress reports should involve all partners in AIDS response and should provide an opportunity for reflection on the national response, its achievements as well as its shortcomings, in order to reach universal goals. Monitoring the response to the AIDS epidemic is essential to ensure that investments in AIDS achieve the expected results in health and society [HIV-related Non Governmental Organizations (AIDS-NGOs) work to promote prevention and to provide care and help to people affected by HIV in most countries of the world. The role of these AIDS-NGOs has been critical in the fight against HIV infection since the onset of the epidemic . The actSince the inception of the AIDS National Program in Catalonia, the promotion and coordination of activities carried out by AIDS-NGOs has been emphasized. To support the AIDS-NGOs, since 1992 the Department of Health has provided annual subsidies that have progressively increased to reach 1.4 million Euros in 2007 -10. TherThe number of AIDS-NGOs and their activities has grown to meet the demand and the needs of individuals in preventive materials, determination of serostatus and HIV care. For this reason there is great diversity in the type of activities, as well as in the social levels and population groups that have been targeted.In Spain, Peiró et al. systematically classified and evaluated the activities of national AIDS programs, including AIDS-NGOs activities using the Haddon matrix. This study concluded that there is much heterogeneity in the structure and indicators of the various programs. Concepts such as goals, objectives and priorities are poorly defined. Moreover, in all countries the implementation of preventive programs shows a predominance of individual interventions over social ones .A more recent report, the Health Plan of the Community of Valencia 2005-2009  includesMoreover, the methodology that has been proposed to compare the different ways to prioritize issues and to forecast a policy's application in terms of results and outcomes is the Haddon Matrix. This matrix is a way to synthesizes the enormous amount of information available in strategy documents, shorten the time needed to produce an assessment, and improve a policy's value by comparing it with external models. In this paper we use this theoretical framework developed with the explicit intention of covering the need of the AIDS National Program of Catalonia to know what preventive and control interventions are done by AIDS-NGOs with the objective of improving the praxis of these activities and establishing new strategies for the AIDS National program . FurtherIt is important to provide key constituents who are actively involved in a country's response to AIDS with essential information on core indicators that measure the effectiveness of the national response. The indicators will help to ensure the consistency and transparency of the process used by national governments. Increasingly, countries are strongly encouraged to integrate the core indicators into their ongoing monitoring and evaluation activities .The key motivation for undertaking this work is to propose quality indicators which include users' satisfaction, psychosocial aspects that can have an impact on the fight against inequalities and stigmatization, and the perspectives of professional service providers. Until now, in many evaluation proposals, these aspects were not really addressed in the HIV literature, while their consideration would permit an important step toward the incorporation of strategies for evaluation of NGO prevention and more comprehensive control activities.The purposes of this study are: to describe and analyze the objectives of and the HIV-AIDS preventive activities carried out by the AIDS-NGOs that work with AIDS in Catalonia and that receive subsidies from the Department of Health; and to develop a more comprehensive set of measurable and agreed upon core quality evaluation indicators to monitor and assess those objectives and activities that can have an impact on health and the fight against inequalities and stigmatization, and incorporate the perspectives of service providers and users.A mixed method strategy was used in order to achieve the objectives of the study. The way to combine quantitative and qualitative research was by completeness, in order to achieve more complete and comprehensive answers to research questions. The strategy was divided into four phases and there was full data integration of each phase (each new phase includes the findings of previous phases) -23 Figu.A systematic reading and review of the 36 annual reports from the all AIDS-NGOs working in Catalonia and which received subsidies from the Catalan Government in 2006. The annual reports of AIDS-NGO were provided by the AIDS National Program exclusively for this study.From this systematic reading, we found objectives and activities of prevention were classified according to the following criteria ,15,16: AFrom this synthesis, a database relating the objectives and activities described in the AIDS-NGOs annual reports was created.What new information does this methodological phase of the study provide?This phase provides new basic information on the objectives of and the activities carried out by the AIDS-NGOs as described in the annual reports these organisations prepare for the Health Department. A Haddon matrix has also been constructed with the activities classified by strategy, level of prevention, and level of intervention.An ad-hoc questionnaire was constructed in order to identify activities and objectives classified according to AIDS-NGOs target populations that were not explicit in the AIDS-NGOs annual reports.A pilot study was carried out in 2008, using a cognitive interview which allowed assessment of the understanding and applicability of the questionnaire ,25.The questionnaire was self-administered and it was sent by mail to all the 36 AIDS-NGOs. It consisted of 15 questions,  and included the followed sections: (1) Profile of the individual responding to the questionnaire, (2) Information regarding the AIDS-NGOs target population, (3) Objectives of the AIDS-NGOs and preventive activities of the program, (4) Preventive activities carried out by the AIDS-NGOs, (5) Agreement to participate in the future consensus meetings between AIDS-NGOs professionals and the research team to establish an evaluation indicators proposal. In each section, there was one open question to express opinions and experiences that were not covered by the questionnaire.To facilitate the highest percentage of responses, two rounds of confirmatory phone calls were conducted and a descriptive analysis (absolute frequencies and percentages) was performed.What new information does this methodological phase of the study provide?The results of the transverse study complement those of the first phase of the elaboration of the Haddon matrix based on the systematic study of the reports. In this methodological phase we have also been able to establish a relationship between objectives and activities.A qualitative study was conducted in order to identify the experiences that professionals in the Catalan AIDS-NGOs had in preventive activities, the potential areas of improvement of the activities, the professionals' evaluation of their activities, the experiences and practices of AIDS-NGOs with regard to HIV infection and prevention, and elements that enhanced their relationship with the AIDS-NGOs.A theoretical sampling  and opportunistic sample (participants) was proposed. Professionals and users from 36 AIDS-NGO funded by the Health Department to take part in the study. For the professionals, a theoretical sampling based on the previous definition of the characteristics of the participants has been carried out to obtain the greatest variety and discursive wealth to reach data saturation. Variables used to define the informant profile for the professionals of AIDS-NGO are: AIDS-NGO target population , age, sex, professional profile, setting  and years of experience.Due to the difficulties of the theoretical sampling, an opportunistic sampling was finally chosen for the AIDS-NGO users. However, heterogeneity criteria were taken into account. Variables used to define the users are: AIDS-NGO target population, age, sex, nationality, serostatus, and time in contact with the NGO .Different techniques have been used . For theData collection was between February and June 2008. Focus groups took place in a neutral place (IDIAP Jordi Gol) and they included a moderator and an observer. The semi-structured interviews took place in the working place of the users or at the AIDS-NGO places. The observations were made in two secondary schools.A thematic interpretive content analysis was conducted by three analysts. More details about the methodology of this phase have been published elsewhere .What new information does this methodological phase of the study provide?This methodological phase of the study has permitted a deeper knowledge of how AIDS-NGO professionals carry out their activities. It has also allowed exploration of the barriers professionals encounter in carrying out evaluation. Users also took part in this methodological phase of the study, in which their knowledge and perception of HIV-AIDS risks was explored.From the synthesis of the information obtained in phases 1, 2 and 3, the Haddon matrices described in phase 1 were completed. Later, consensus meetings were held between five AIDS-NGOs professionals and four members of the research team, in order to review and redevelop the Haddon matrices and to identify new preventive activities when possible.The AIDS-NGOs professional selection was carried out considering the inclusion of different professional profiles, work with different AIDS-NGOs target groups, years of antiquity and the geographical setting.From the Haddon matrices, a proposal of qualitative and quantitative evaluation indicators was developed, both for process and outcomes of activities carried out by AIDS-NGOs. The structure and methodology that was followed in order to develop the indicators proposal is shown in tables Finally, core indicators were selected according to the following criteria: (i) relevance of the indicator (ii) adequacy of the indicator in the AIDS-NGOs context (iii) ability of AIDS-NGOs to change the indicator outcome (iv) feasibility of obtaining the information needed to construct the indicator and (v) activity common to all AIDS-NGOs target group ,35.What new information does this new methodological phase of the study provide?This new methodological phase, through consensus meetings between AIDS-NGO professionals and the IDIAP Jordi Gol research team, has allowed the elaboration of a Haddon matrix for each target group as well as evaluation indicators for each activity carried out by the AIDS-NGOs with regard to the objective of this activity.The study has been conducted according to Guidelines of the Helsinki Declaration of Good Clinical Research Practice. The project has been approved by the Ethical and Clinical Research Committee of the Institute of Research in Primary Health Care (IDIAP) Jordi Gol.Informed Consent: The information for the study has been provided orally as well as in writing. Study subjects had sufficient opportunity to ask questions regarding details of the study. Written informed consent following the guidelines of the Helsinki Declaration was obtained.Data confidentiality: Confidentiality and anonymity of the data have been ensured according to the Spanish law 15/1999 of data confidentiality, both in the implementation phase of the project and in presentations or publications resulting there from. Individual data was encoded to ensure anonymity. Only researchers and monitors have access to the data.The objectives and activities identified using the review of the reports were aimed at 5 target populations established by the AIDS Program of Catalonia , and 2 more identified target population established for this study . Consequently, objectives and activities were collected into seven Haddon matrices.248 objectives were detected, 118 for Primary Prevention, 44 for Secondary Prevention and 86 for Tertiary Prevention . Women accounted for 57.7% of the respondents.The AIDS-NGO carried out activities for different target population. It was seen that 2/26 of the AIDS-NGOs target their activities to 7 different target groups, 12/26 to 4, 5 or 6 and 11/26 to 2 or 3 target groups.Regarding the position of the person answering the questionnaire, "coordinator of HIV prevention activities" was the most frequent answer (15/26), followed by "person with most administrative knowledge of the AIDS-NGOs" (11/26). The category "others" was also frequently chosen (9/26). This last category included administrative personnel, managers and individuals responsible for specific programs within the AIDS-NGOs.Regarding the question about what professionals work in AIDS-NGOs, the answer was that they have interdisciplinary teams, psychologists (64%), social workers (31%), doctors (27%), educators (23%), nurses (17%), and affected volunteers (20%) being the most frequent professional profiles.The number of identified activities increased to 258 in total, while seventeen activities (6.6%) that were not covered in the annual reports were detected. Three were especially addressed at the primary prevention level , 3 at secondary prevention , 5 for tertiary prevention  and 6 activities present at the different levels of prevention .The main results achieved through the qualitative study were: AIDS-NGOs offered different activities adapted to the needs of the users (people who use AIDS-NGOs' services); The NGO professionals perceived that users were satisfied. The users were satisfied and felt comfortable with the education and health promotion model; the preventive activities of the AIDS-NGOs were based on a participatory health education model adjusted to the people's needs, based on empowerment and focusing on the ideas of knowledge and skills; AIDS-NGOs professionals worked in interdisciplinary groups using a holistic approach with cultural and professional competence; they were flexible, innovative and motivated; and they traveled to where the users are.Regarding the evaluation of the AIDS-NGOs objectives and activities, the main conclusions were: evaluating the work of AIDS-NGOs is difficult (a concern voiced in most group meetings); some activities require great effort and dedication and quantitative indicators such as the number of cases are not enough to evaluate them; to improve the assessment of the activities and objectives of the AIDS-NGOs, the professionals suggest looking for quantitative and qualitative indicators that provide a reliable measure of the process and the results. More details about results in this phase have been published elsewhere .AIDS-NGO professionals carry out their activities on a holistic basis, maintaining confidentiality, with professional competence and cultural awareness and respecting the principle of equality. The relationship between AIDS-NGO professionals and users is based on attention, a holistic focus , and user needs.Users often apply to NGOs for help not only with their basic needs  but also for legal aid and assistance with employment and health. Activities aimed at the prevention of HIV-AIDS infection are more effective if they take these basic needs into account. NGOs carry out specific activities aimed at promoting the accessibility of and user links with these associations. NGO professionals form flexible, motivated and innovative interdisciplinary teams ready to go wherever their users are. They require continued training and coordination between the different fields.NGO professionals recognise the need for an adequate system for the collection of information in order to facilitate information management. They also emphasise the need to support and improve the planning and execution of the current process of the evaluation of objectives and activities. NGO professionals cite perception of a high level of satisfaction among users with regard to the attention received, as well as a lack of recognition of their activities by other professional and institutional groups.Seven Haddon matrices were developed with the results achieved in the three previous phases. In total, 1564 evaluation indicators, 720/1564 of primary prevention, 255/1564 of secondary prevention and 589/1564 of tertiary prevention were proposed  and also with other services .Evaluation is a continuous process that facilitates the identification of areas for improvement. It should also contribute to the recognition of tasks that have been satisfactorily carried out by professionals. The professionals belonging to the participating AIDS-NGOs of this study consider evaluation to be an activity which is relevant to them and share the evaluation needs. Therefore, there is concordance between the necessities detected by the HIV-AIDS program  and those identified through a revision of international publications ,43-45.In order to evaluate the objectives and activities of AIDS-NGOs, it is essential to use good indicators bringing together characteristics such as: acceptability, feasibility, reliability, sensitivity to change, validity and meaningful and possible communicability ,46.The latest update of the "Compendium of Evidence-Based HIV Prevention Interventions", elaborated by the CDC, as well as the "Community guide" website, both show a broad range of evidence-based preventive activities. However, these activities are included in programs aimed at very specific groups , while our study presents a broader evaluation and suggests multiple indicators to evaluate concrete activities, which can be applicable to diverse intervention programs and to different groups. Thus, this proposal of indicators can help provide new evidence about the effectiveness of specific activities according to the level of prevention and intervention .http://www.gencat.cat/salut/depsalut/html/ca/dir2068/informefinal_actongsida2009.pdf) [Through the development of the first phase of this study, two more target groups of population were identified: inmates and immigrants. These two target populations had specific characteristics deserving of special consideration and their own preventive programs on the part of the AIDS-NGOs, and they were added as target populations for purposes of this study. Specific objectives and activities addressed to these groups were identified, and specific evaluation indicators proposed through the seven final Haddon matrices, available via the following link (009.pdf) .Our proposal agrees with some of the quality measures of HIV care proposed by the CDC and UNAIDS ,45,47. WAnother important aspect to note is that, by using the Haddon matrix, many preventive interventions and evaluation indicators have been identified and defined on the individual, external and social levels, while less have been directed towards the individual's immediate environment. These findings are consistent with those observed by Peiró et al . A possiThe consensus phase among AIDS-NGOs professionals and the research team to develop the indicators has meant the cooperation and participation of the professionals in this study and constitutes a key element in facilitating the acceptance and implementation of the improvements proposed in the evaluation. It is also worth mentioning that professionals belonging to the AIDS-NGOs that participated in the consensus phase make up a multidisciplinary team much like the AIDS-NGOs. This gives the proposed indicators wide variability and richness, encompassing all of the activities undertaken by the AIDS-NGOs ,35,45.The main limitation of this proposal of indicators is that it has not been applied. It would be important to share and disseminate it among professionals of the various programs and organizations that work with HIV in order to test its applicability, usefulness, validity and practical relevance.A possible selection bias could also be argued, given that these indicators have been designed with the participation of professionals from AIDS-NGOs that work in Catalonia and are financed by this autonomous community's Department of Health. Nonetheless, as mentioned above, the enormous variability in the number of activities and proposed evaluation indicators minimizes this bias and raises their potential usefulness for AIDS-NGOs located in other geographical areas. Furthermore, one limitation of the study was not to have studied the views of other health providers that work with HIV-AIDS prevention or control-programmes . Although their contributions would have been of great interest, for reasons of practicality and insufficient resources this aspect could not be included.We also want to mention that indicators for global results such as HIV mortality, rate of hospitalizations and approach to other health problems  have not been proposed. However, the improvements in these epidemiological indicators can be attributed to multiple factors  and not only to the AIDS-NGOs' activities. Nonetheless, studies that directly involve classic systems of epidemiological surveillance for HIV-AIDS would be of interest.For the selection of indicators in future evaluations of preventive activities in AIDS-NGOs, the elements that make up the third dimension of the Haddon matrix should be taken into consideration: effectiveness, cost, freedom, equity, stigmatization, preferences of the affected community or individual and viability. These factors can be considered from different points of view and can have greater or lesser weight when selecting indicators, based on the general objectives of future health policies and on HIV-AIDS ,15,16.It is also important that the strategic plan of future HIV-AIDS policies emphasize activities that address the population that makes up the affected or at-risk person's immediate environment . AlthougThis study showed the importance of methodological combination for a better understanding of results and the mechanisms of changes in the evaluation of AIDS-NGO activities. Although the study had some limitations, the combination of quantitative and qualitative data gave the opportunity to construct core evaluation activities and the corresponding indicators. The results could help to homogeneously assess the preventive-control activities carried out by several AIDS-NGOs. Moreover, the indicators could help the professionals to understand and therefore to improve the evaluation of the preventive-control AIDS-NGO activities. The Haddon matrix enables us to detect the gaps in intervention levels and, as a consequence, to keep in mind strategies that could enhance AIDS programs in the future. A further important message of the research was that qualitative approaches are essential in order to identify underlying processes and to detect activity procedures in order to better define the indicators.The authors declare that they have no competing interests.AB, EPR, CV, AR, RM, AG and JA have been involved in writing the manuscript, and all authors critically revised and approved the final manuscript. AB, EPR, CV, AR and JA designed the methodology and contributed to the description of the background. AB, EPR, CV, AR, CA and JA have done the fieldwork and the analysis and interpretation of data. All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/176/prepubComplete information about core objectives, activities and indicators. NGO: Nongovernmental organizations. STI: Sexual Transmitted Diseases. QOL: Quality of life questionnaire. HAART: Highly Active Antiretroviral treatment. DO: Direct Observation. FG: Focus Groups.Click here for file


HIV/AIDS has orphaned 11.6 million children in sub-Saharan Africa. Expanded antiretroviral therapy (ART) use may reduce AIDS orphanhood by decreasing adult mortality and population-level HIV transmission.We modeled two scenarios to measure the impact of adult ART use on the incidence of orphanhood in 10 sub-Saharan African countries, from 2009 to 2020. Demographic model data inputs were obtained from cohort studies, UNAIDS, UN Population Division, WHO and the US Census Bureau.Compared to current rates of ART uptake, universal ART access averted 4.37 million more AIDS orphans by year 2020, including 3.15 million maternal, 1.89 million paternal and 0.75 million double orphans. The number of AIDS orphans averted was highest in South Africa (901.71 thousand) and Nigeria (839.01 thousand), and lowest in Zimbabwe (86.96 thousand) and Côte d'Ivoire (109.12 thousand).Universal ART use may significantly reduce orphanhood in sub-Saharan Africa. An estimated 11.6 million children (aged 0 to 17 years) in sub-Saharan Africa have lost one or both parents due to human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) since the beginning of the epidemic , and eleAntiretroviral therapy (ART) has substantially reduced HIV-related morbidity and mortality worldwide . A growiWe projected the impact of ART expansion to adults (15-49 years) on the incidence of paternal, maternal and dual orphans in 10 sub-Saharan African countries, from 2009 to 2020. We included 10 sub-Saharan African countries with the highest number of AIDS orphans living in 2007: Cote D'Ivoire, Ethiopia, Kenya, Malawi, Nigeria, South Africa, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe [In order to explore the impact of expanded ART use on orphanhood, we modeled two scenarios. Scenario 1 theoretically assumed that all (100%) HIV infected adults in the countries under study would receive ART immediately after year 2008, irrespective of CD4+ cell count or clinical stage. Scenario 2 assumed that the number of adults receiving ART remained constant following year 2008, reflecting country-specific rates of ART uptake and clinical eligibility of people living with HIV/AIDS in that year .These scenarios were developed using DemProj and AIM programs within the Spectrum Policy Modeling System  software package, Version 3.34. These programs are designed to produce information that is useful for policy formulation and program planning, and have been used by UNAIDS, UNICEF, USAID and the US Census Bureau to estimate orphanhood. Detailed descriptions of how Spectrum models the impact of HIV/AIDS on demographic parameters, including background mathematical methodology and parameter estimates, are described elsewhere -26. We fCountry-specific demographic and epidemiological model inputs are described in Table As a first step to developing our AIDS orphanhood projection model, we conducted a demographic projection. This involved inputting non-HIV country-specific demographic estimates, such as population size, fertility and life expectancy, into the Spectrum Policy Modeling System's DemProj Program.Country and age-specific population estimates for each year were obtained from the United Nations Population Division. In order to ensure consistency between population sizes from our demographic projections and country-specific census estimates, some of our demographic inputs were obtained from the US Census Bureau instead of the United Nations Population Division . This prWe obtained country- and age-specific total fertility rates (TFR) from the US Census Bureau's World Population Profile . The ageFor non-HIV infected individuals, we inputted age-specific distributions of life expectancy at birth for non-AIDS-related mortality using the DemProj feature of Spectrum.A review and meta-analysis of 19 studies examining the population-level impact of HIV on fertility in sub-Saharan Africa reported that HIV-positive women not receiving ART have substantially lower TFR compared to HIV-negative women. This fertility differential resulted in a 0.37% decrease in population-attributable fertility for each percentage point of HIV prevalence within a country . In ordeCountry-specific HIV incidence inputs for adults 15-49 years) for years 1985 to 2008 were obtained using the UNAIDS-developed Estimation and Projection Package (EPP) software, and were converted into percentages before being inputted into the AIM program . We assu-49 yearsWe inputted varying disease progression data for Scenarios 1 and 2. In Scenario 1, we assumed that all HIV infected individuals were clinically eligible to receive ART from end 2008 onward . In ScenFor individuals not receiving ART, we assumed that the median time from HIV infection to AIDS death, without treatment, was 10.5 years for men and 11.5 years for women . These aIn Scenario 1, we assumed that all HIV-positive individuals were receiving ART as of year 2009. In Scenario 2, we inputted country-specific estimates for annual ART uptake, based on UNAIDS 2008 figures . We assuOur primary outcomes were the number of maternal, paternal and dual AIDS orphans in each country at year 2020 following varying scenarios of ART uptake. Maternal and paternal AIDS orphans were defined as children under the age of 17 who have lost either their mother or father to AIDS. Dual orphans are children who have lost both parents to AIDS .We ran each country's DemProj and AIM input data together from Spectrum to project the number of AIDS orphans incurred in each year. In order to calibrate our model, we ran DemProj and AIM programs for each country, using the above inputted data and parameters, from 1985 to end 2007. We verified the accuracy of our AIDS orphans projections by comparing our results for 2007 to the 2007 AIDS orphan estimate published in UNAIDS country-specific epidemiological fact sheets . In ordeTable versus 361,599), Uganda , Nigeria , Kenya , Zimbabwe , Tanzania , Ethiopia , Zambia , Malawi , and Cote d'Ivoire Countries with the largest number of AIDS orphans averted over the study period included South Africa , Nigeria , and Kenya . Countries with the least number of AIDS orphans averted were Zimbabwe , Malawi  and Côte d'Ivoire . The number of maternal orphans averted was higher than the number of paternal orphans averted in all countries: South Africa  in conjunction with Spectrum may have rectified this issue. Developers of Spectrum previously tested and validated the age and sex-specific HIV prevalence values for several countries included in our analysis  . The verProgram limitations relate to the detailed methodology for calculating AIDS orphans in the presence and absence of ART. For instance, there is little quantitative information regarding the effect of ART on female fertility and its effect on orphanhood. While there is an input for adult and child survival on ART, these values are fixed, and are based on a single study . AnotherDiscrepancies between Spectrum-based and empirical household survey estimates of orphanhood have been previously identified. Projected estimates of orphanhood have tended to be higher than empirical approximates ,29. ThisThis study only indirectly considered the impact of non-adherence on HIV outcomes by means of inputting empirically obtained mortality rates. A closer examination of adherence would have been valuable given the association between adherence and mortality . A systeAnother potential limitation of our analysis relates to our assumption that the TFR of women on ART would be comparable with that of the general population, while the TFR of women not on ART is depressed ,42. A reOur projection model strongly argues that expanded access to HIV treatment will have immediate preventive impact on the health and welfare of children in sub-Saharan Africa. If we are to make important gains in livelihood for future generations in Africa, expanding access to ART should be of paramount importance.(AIDS): Acquired immune deficiency syndrome; (ART): antiretroviral therapy; (HIV): human immunodeficiency virus; (MTCT): mother-to-child transmission; (PMTCT): prevention of mother-to-child transmission; (TFR): total fertility rate; HIV/AIDS (UNAIDS): Joint United Nations Programme on HIV/AIDS; (UNICEF): United Nations Children's Fund; (USAID): United States Agency for International Development; (WHO): World Health Organization.The authors declare that they have no competing interests.AA conceived the study design, contributed to the demographic modeling methods, and wrote the first draft of the manuscript. CA and MJ ran the demographic projection software and contributed to the first draft of the paper. AK contributed to specialized knowledge on reproductive health issues specific countries under investigation. SK, KV, JSGM and BRSH provided critical feedback on study design and manuscript draft. All authors read and approved the final manuscript.