Challenges in HIV Treatment
and Care in a Resource
Constrained Environnement
Serge Paul Eholié
Xavier Anglaret
Affiliation:
•ANRS research site in Côte d’Ivoire
•Infectious Disease Department, Treichville University Hospital, Abidjan
•Inserm U897, ISPED, Bordeaux University
1
INTRODUCTION
• In 1998-2001, pilot programs gave evidence that ART could
be feasible and effective in resource limited settings:
– UNAIDS Initiative (Uganda, Côte d’Ivoire, Chile, Vietnam)
– Countries (Senegal) or NGOS (MSF) initiatives
• From 2000 to 2010, large programs confirmed that ART was
feasible and effective in resource limited settings:
– As of june 2010, approx 6.6 million people on ART in lowand middle-income countries (4.5 millions in sub-Saharan
Africa);
– With success in Scaling program and decentralization, almost
19 000 health facilities implemented;
– With extensive evidence that ART reduces morbidity and
mortality in routine conditions.
2
Successes of ART
in low and middle income settings
3
SUCCESSES
However, challenges remain!!!!
4
Challenges to ensure the success
of ART programs in low- and middle-income
countries
* Increase coverage
* Ensure financing sustainability
* Reduce AIDS and HIV non-AIDS morbidity, and
mortality
* Implement 2010 WHO guidelines
* Improve assessment of programs efficacy
* Improve prevention, diagnosis, and management of
adverse events
* Improve retention
* Ensure comprehensive HIV care
5
CHALLENGE 1
Coverage
6
COVERAGE, December 2009: 36% in LMIC
Intraregional differences
Number of people
receiving ART in
december 2009
ART coverage in
2009, based on
2006 guidelines
ART coverage in
2009, based on
2010 guidelines
South Africa
971 556
56%
37%
Kenya
336 980
65%
48%
Nigeria
320 024
31%
21%
Zambia
283 863
85%
64%
Thailand
216 118
76%
67%
Uganda
200 413
57%
39%
Botswana
145 190
>95%
83%
Cameroon
76 228
41%
29%
Côte d’Ivoire
72 011
39%
28%
Towards universal access: Scaling up priority HIV/AIDS interventions in the
health sector. Progress report 2010
7
Challenge 2:
Financing sustainability
80-95% of funds are from international donors
Achilles’ heel of ART programs
Courtesy of PM Girard
8
Source Hecht R, Lancet 2010
CHALLENGE 3
REDUCE MORBIDITY AND MORTALITY
9
ART Mortality
Countries
* Zambia, Stringer JSA, JAMA 2006
Mortality rate
7%
* Senegal, Etard JF, AIDS 2006
23.1%
* Zimbabwe, Erisktrup C, JAIDS 2007
29.5%
* Haiti, Tuboi H, JAIDS 2009
12.4%
* Honduras, Tuboi H, JAIDS 2009
10.1%
Risk factors for mortality
•
•
•
•
•
•
Male sex
Clinical stage, WHO 3-4, CDC C
Body Mass Index <18-19 Kg/m2
Haemoglobin<10g/dl
CD4 <200 cells/mm3
Viral load >5 log10 copies/ml
Stringer JF JAMA 2006, Etard JF AIDS 2006, Erisktrup C JAIDS 2007,
Moh R AIDS 2007, Tuboi SH JAIDS 2009, Mills EJ AIDS 2011,
Toure AIDS 2008, Lawn AIDS 2009
11
200-350 CD4/mL
< 200 CD4/mL
Mortality reduction 75%
Severe P, N Engl J Med 2010
12
Challenge 3: REDUCE MORBIDITY AND
MORTALITY
1) Certainly start ART earlier… but how much earlier ?
< 350 CD4 : minimal threshold worldwide1
< 500 CD4 : minimal threshold in increasing number of rich countries2,3
> 500 CD4 : ongoing randomized trials (START, Temprano4…)
2) Improve access to care, diagnosis and treatment of
comon morbity (TB, bacterial diseases…)
1-WHO, Antiretroviral Therapy for HIV infections in adults and adolescents, Recommandations,
2010, h http://www.who.int ttp://www.who.int
2- Prise en Charge Me´dicale des Personnes Infecte´es par le VIH Ministry of Health France,
2008. http://www.sante-sports.gouv.fr/
3- Panel on Antiretroviral Guidelines for Adults, and Adolescents. Guidelines for the use of
antiretroviral agents in HIV-1-infected adults and adolescents. DHHS, USA,2009
4- Temprano study ANRS 12 136, clinicaltrials.govNCT00495651
13
Challenges 4
IMPLEMENT 2010 WHO GUIDELINES
14
Main changes in WHO 2010 Guidelines
* Start earlier: CD4 < 350/mm3 or WHO stage 3,4
(vs. 200 CD4 or WHO stage 4 or WHO stage 3 & 200-350)
* First line regimen:
* Include viral load in routine monitoring
* Second line regimen:
WHO, Antiretroviral Therapy for HIV infections in adults and adolescents,
Recommandations, 2010, h http://www.who.int ttp://www.who.int
15
Main changes in WHO 2010 Guidelines
1) Start earlier: CD4 < 350/mm3 or WHO stage 3,4
(vs. 200 CD4 or WHO stage 4 or WHO stage 3 & 200-350)
* First line regimen:
* Include viral load in routine monitoring
* Second line regimen:
WHO, Antiretroviral Therapy for HIV infections in adults and adolescents,
Recommandations, 2010, h http://www.who.int ttp://www.who.int
16
ART at 350 CD4 vs. 200 CD4
Where to find patients at earlier
stage of HIV disease ?
17
ART at 350 CD4 vs. 200 CD4
• Find patients with higher CD4 counts??
• Increase Voluntary Counseling and Testing (VCT)
• Facilitate or strenghten the link between
VCT centers and ART clinics
• Anticipate and face an increase in the number of
patients on ART
• Demonstrate cost effectiveness/acceptability to
governments and donors
18
8 countries:3 Eastern Africa, 3
Southern Africa, 1 Western Africa,
1 Central Africa
267 sites (ICAP centers)
121 404 patients
Median CD4
136 cells/l
Nash D, AIDS 2011 19
ART at 350 CD4 vs. 200 CD4
• Find patients wiht higher CD4 counts
– Change the paradigm
– Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)
• Facilitate or strenghten the link between
VCT centers and ART clinics
• Anticipate and face an increase in the number of patients on
ART
• Demonstrate cost effectiveness/acceptability to governments
and donors
20
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients
– Change the paradigm
– Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)
• Facilitate or strenghten the link between
VCT centers and ART clinics
• Anticipate and face an increase in the number of patients on
ART
• Demonstrate cost effectiveness/acceptability to governments
and donors
21
Why don’t physicians test for HIV? A review of the US littérature.
Burke RC, AIDS 2007
Insufficient time
Prenatal
Consent process
24 barriers
Lack of knowledge/training
Other medical
Language
Lack of patient acceptance
settings
23 barriers
Pre-test counselling requirements
Competing priorities
Inadequate reimbursement
Much of the failure to expand HIV Testing guidelines are
related to physicians
22
Standard of Care and Intervention periods in a routine HIV
Testing Cohort in an out patient department, Durban, SA
Bassett IV, JAIDS 2007
Standard of Care
(14 weeks)
Intervention
(12 weeks)
Patients tested/offered, N (%)
137/435 (31.5%)
1414/2912 (48.6%)
HIV-infected patients, N (%)
102/137 (74.5%)
463/1414 (32.8%)
HIV infection identified,
8
39
average N per week
We need a pro-active approach!!!!
23
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients
– Change the paradigm
– Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)
– HIV testing is general medicine (« it’s all HCW business »)
– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics
• Anticipate and face an increase in the number of patients on
ART
• Demonstrate cost effectiveness/acceptability to governments
and donors
24
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients
– Change the paradigm
– Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)
– HIV testing is general medicine (« it’s all care workers business »)
– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers, Ante Natal Clinic and ART clinics
• Anticipate and face an increase in the number of patients on
ART
• Demonstrate cost effectiveness/acceptability to governments
and donors
25
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients
– Change the paradigm
– Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)
– HIV testing is general medicine (« it’s all care workers business »)
– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics
• Anticipate and face an increase in the number of patients on
ART
• Demonstrate cost effectiveness/acceptability to governments
and donors
26
Source: Konde-Lule J, AIDS Care 2010
<200
% ELIGIBLE
<250 (2008 criteria)
%ELIGIBLE
<350
%ELIGIBLE
Age
15-24
25+
22.4%
41.5%
25.9% (1,15 increase) 41.4% (1,85 increase)
51.1% (1,24 increase) 63.1% (1,53 increase)
Sex
Female
Male
35.2%
37.5%
43.4% (1,23 increase) 57.2%(1,63 increase)
40.5% (1,20 increase) 55.0%(1,47 increase)
Overall
35.7%
43.7% (1,23 increase) 56.8% (1.59 increase)
< 350 vs <200 = 59% increase in demand of services
27
Patients Volume, Human Resources Levels and Attrition
from HIV Treatment Programs in Central Mozambique
Lambdin BH, JAIDS 2011
Patient volume
Low (reference)
Medium
High
Clinical Staff Burden
Low (reference)
Medium
High
Pharmacy Staff Burden
Low (reference)
Medium
High
Adjusted HR
p
(95% CI)
1.40 (1.03-1.92)
1.34 (0.95-1.89)
0.47
1.01 (0.78-1.32)
1.02 (0.69-1.52)
0.91
1.68 (1.29-2.19)
2.63 (1.70-4.06)
< 0.001
Staff burden : do not forget those who deliver the pills !
(200-300 patients/day or more !!!!)
28
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients
– Change the paradigm
– Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)
– HIV testing is general medicine (« it’s all care workers business »)
– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics
• Anticipate and face an increase in the number of patients on
ART
– Set up or strenghten task shifting
• Demonstrate cost effectiveness/acceptability to governments
29
and donors
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients
– Change the paradigm
– Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)
– HIV testing is general medicine (« it’s all care workers business »)
– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics
• Anticipate and face an increase in the number of patients on
ART
– Set up or strenghten task shifting
* Demonstrate benefits and cost effectiveness for acceptability
by governments and donors
30
Benefits on morbidity, mortality and transmission
Source: Stover J, AIDS Research and Treatment 2011
CD4<200
CD4<350
Difference
P-Y of ART
40 752 534
61 292 374
+ 20 539 839
(+ 50%)
* AIDS/
deaths
8 180 609
6 501 483
- 1 679 126
(- 21%)
* Life years
162 032 903
163 012 351
+ 979 448
(+ 1%)
* New HIV
infections
11 198 013
9 946 912
- 1 251 101
(- 11%)
Cost effectiveness: Walensky R, Ann Intern Med 2009
31
Main changes in WHO 2010 Guidelines
1) Start earlier : CD4 < 350/mm3 or WHO stage 3,4
(vs. 200 CD4 or WHO stage 4 or WHO stage 3 & 200-350)
2) First line regimen:
* Include viral load in routine monitoring
* Switch when VL>5,000 copies/ml (vs. >10,000 copies/ml in
2006 guidelines)
* Second line
* Stop ABC+ DDI.
* AZT/TDF+XTC+ATVr/LPVr
* Start as soon as possible in case of tuberculosis and HVB
32
Challenges for first line regimen
* Costs
* Phase out d4T
* Choice between AZT and TDF
- Haematological toxicity, LD (AZT)
- Renal safety, bone mineral toxicity (TDF)
* Choice between efavirenz and nevirapine
Cost,
efficacy,
costeffectiveness
and tolerance
issues
- Percentage of young women, pregnancy (NVP)
- One pill, once a day, TB co-morbidity (EFV)
* Availabililty of fixed drug combination
* Paediatric formulation
33
Phase out stavudine : issues
* Lingering stocks of d4T
- 30 countries have implemented d4T phase out plan (12/2009)
- 60% first line started with d4T (12/2009)
* Finance constraints
– TDF or ZDV first line 2-3 times as high as d4T regimen
– … at a time when we still need to scale up the number of
people initiating ART
Need for :
- Further drug price reductions (AZT and TDF)
- Increase funds for ART programme
Renaud-Thery F, AIDS Res and treatment 2011
34
Bendavid E, AIDS 2011
WHO MEETING REPORT. Short-Term Priorities for Antiretroviral
Drug Optimization, London UK, 18-19 avril 2011.
35
Prevalence of Renal dysfunction in HIV-seropositive
untreated patients in Sub saharan Africa
* Nigeria (n=400)
Emen CP, Nephrol Dial Transplant 2008
38%
* South Africa (n= 1322)
Brennan A, AIDS 2011
35.7%
* Zambia (n=24 596)
Mulenga BL, AIDS 2008
33.7%
* Msango L (n=335)
AIDS 2011
63.6%
HIV is THE kidney killer (not tenofovir)
36
Incidence of severe renal dysfunction
DART (n=3316)  eGFR < 30ml/mn
* Median time to severe renal dysfunction14 weeks IQR [4-52]
* TDF
* NVP (Open-label)
* ABC (Nora Study)
* NVP (Nora Study)
* Zambia,
41/2469 (1.7%)
4/247 (1.6%)
P=0.94
3/300 (1.0%)
4/300 (1.3%)
Reid A, Clin Infect Dis. 2008
30/960 (3.2%), M12 (Chi BH, JAIDS 2010)
* Lesotho, 31/566 (5.5%), M12 (Bygrave H, Plos One 2011)
Follow WHO guidelines for tenofovir prescription
* Creatinine dosage (creatinine clearance calculation)
* Proteinuria with urines sticks
38
Main changes in WHO 2010 Guidelines
1) Start earlier : CD4 < 350/mm3 or WHO stage 3,4
2)°First line:
3) Include viral load in routine monitoring
* Second line
WHO, Antiretroviral Therapy for HIV infections in adults and adolescents,
Recommandations, 2010, h http://www.who.int ttp://www.who.int
39
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line  limit NRTI and
NNRTI cumulative resistance;
* Cost effectiveness
40
Status at 12
months of ART :
Messou E, JAIDS 2010
41
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line  limit NRTI and
NNRTI cumulative resistance;
* Cost effectiveness
42
M6
N=996
M12
N=925
Undectable VL
799 (80.2%)
693 (75%)
Detectable VL
197 (19.8%)
232 (25%)
7%
11%
Messou E, JAIDS 2010
Resistance ≥ 1 mutation
Half of patients with detectable viral load at 12 months have no
resistance mutations
Interest of early viral load (M4-M6)
Interventions to reinforce adherence, maintain first line
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line  limit NRTI and
NNRTI cumulative resistance; Keiser et al, AIDS 2011
* Cost effectiveness
44
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line  limit NRTI and
NNRTI cumulative resistance;
* Cost effectiveness
45
Relative increase in Incremental
Life Expectancy
Cost
(vs. only one line
Effectiveness
of ART)
Ratio1
($ US/LYS)
Incremental
Cost
Effectiveness
Ratio2
($ US/LYS)
Switch to 2nd line on :
- WHO stage 3-4 event
24.3
1670
1670
-  50% in peak CD4
46.4
2120
Dominated
61.3
2280
1990
- HIV RNA*,  1 log or
return to pretreatment
HIV-RNA
1 HIV RNA Tests Cost 87 USD
2 HIV RNA Tests Cost 25 USD
Source: Kimmel AD,JAIDS 201046
Challenges for use of viral load in RLS
* Affordability (once again… costs…) :
- Advocacy (same as before with ARV drugs)
- Generics tests
* Availability in rural settings:
- Point of care
- Dried Blood Spot
- Power (electricity)
- Maintenance
Rouet F and Rouzioux C, Expert Rev Mol Diagn 2007
Calmy A, AIDS 2008
47
Main changes in WHO 2010 Guidelines
1)Start earlier : CD4 < 350/mm3 or WHO stage 3,4
2) First line:
«3) Include viral load in routine monitoring
4) Second line
48
Challenges for second line
* Costs
* Time to switch to second line in patients failing 1st
line
* Effective NRTI backbone
* Place of drugs already ordered or used (ABC/ddI)
* Fixed Drug Combination or co-blister
* Availability of ritonavir heat stable capsule
* Use in TB co-infected patients
* Forecasting (Renaud-Thery F, AIDS Res and Treatment 2011)
49
ARV cost per patient per year
Regimen
Low income
countries
Middle Income
Countries
d4T + 3TC + NVP
$ 89
$ 88
AZT + 3TC + NVP
$ 149
$ 226
AZT + 3TC + EFV
$ 220
$ 281
TDF + 3TC + EFV
$ 210
$ 268
TDF + FTC + EFV
$ 255
$ 325
TDF + 3TC + NVP
$ 190
$ 243
AZT + 3TC + LPV/r
$ 585
$ 1150
TDF + 3TC + LPV/r
$ 590
$ 1070
TDF/AZT + 3TC + ATV/r
$ 395/465
Sources: WHO/UNAIDS/UNICEF, Clinton Foundation Health
Access Iinitiative, MSF
50
1.4% of adults receiving ART
76.5% LPV/r
45% suboptimal NRTI regimen??
Towards universal access: Scaling up priority HIV/AIDS interventions in the health
51
sector Progress report 2010
Challenges for second line
* Costs
* Time to switch to second line in patients failing 1st
line Keiser et al, AIDS 2011
* Effective NRTI backbone
* Place of drugs already ordered or used (ABC/ddI)
* Fixed Drug Combination or co-blister
* Availability of ritonavir heat stable capsule
* Use in TB co-infected patients
* Forecasting (Renaud-Thery F, AIDS Res and Treatment 2011)
52
Second line efficacy in LMIC
* South Africa (n= 1648)*
46% failure > 6 months FU
Pujades-rodriguez M,
Jama 2010
Low CD4 cells counts
Factors associated
Suboptimal regimen (NRTI +++)
* Cambodgia** (n=70, all LPV/r) Ferradini L, J Int Aids Soc 2011
15% VL failure, FU 24 months
* Thailand (n=95)
2nd line based on genotype
test: VL failure
15% (M24), 10% (M36);
May Myat W, J int Assoc Phys
Aids Care 2011
* MSF programs, ** ESTHER
53
Challenges for second line
* Time to switch to second line in patients failing 1st line
* Costs
* Effective NRTI backbone
* Place of ABC and ddI
* Fixed Drug Combination or co-blister
* Availability of ritonavir heat stable capsule
* Paediatric formulation
* Use in TB co-infected patients
* Forecasting
Renaud-Thery F, AIDS Res and Treatment 2011
54
Challenge 5
Third line: Salvage Therapy in LMIC
1-5% or more??
55
Challenges for Third Line
* Cost of darunavir, raltegravir, and etravirine
* Use of genotype test: necessary or essential?
* Assessment of real needs
* Pilot studies assessing : resistance patterns in patients
failing 2nd line, place of adherence reinforcement,
adherence efficacy and tolerance of third line drugs…
(ANRS third line trial in 5 west african countries)
56
Comparaison of prices for ART regimen according
to line of treatment
X7
MSF, Antiretroviral Therapy price reductions, 13th edition, July 2010
57
Challenges for Third Line
* Cost of darunavir, raltegravir, and etravirine
* Place of genotype test: necessary or essential?
* Set up pilot studies assessing resistance patterns
in patients failing 2nd line, place of adherence
reinforcement, efficacy and tolerance of third line
drugs… (ANRS third line trial in 5 West African
countries, 1 South East Asian country)
58
Challenge 6
Long term issues :
• Improve monitoring
• Ensure long term adherence
• Prevent and take care of long-term toxicity
• Diagnose and treat HIV non-AIDS morbidity
59
ART laboratory monitoring (WHO 2010)
Phase of HIV
Management
Recommended
Test
At HIV diagnosis
CD4
Pre ART
CD4
Desirable Test
HBs Ag, anti-HCV?
CD4
Hb for AZT1
Creatinine clearance for TDF2
ALT for NVP3
On ART
CD4
Hb for AZT1
Creatinine clearance for TDF2
ALT for NVP3
At clinical failure
CD4
Viral load
At immunological failure
Viral load
At start of ART
1 Recommended test in patients with high risk of adverse events associated with AZT (low CD4 or low BMI).
2 Recommended test in patients with high risk of adverse events associated with TDF (underlying renal disease, older age group, low BMI, diabetes, hypertension
and concomitant use of a boosted PI or nephrotoxic drugs).
3 Recommended test in patients with high risk of adverse events associated with NVP ( ART naive HIV+ women with CD4 > 250 cells/mm3, HCV co-infection)
60
61
Long term monitoring issues
We need tests for :
• Metabolic syndrom…
• Renal function …
• Bone Mineral density …
• Cardio-vascular assessment …
• Malignancies diagnosis …
62
Challenges for long term follow-up
• HIV and ageing: 3 millions HIV
individuals >50 years in subSaharan Africa (14% of overall
HIV adults)
• Access to treatment for:
malignancies, cardiovascular
diseases/neurological diseases,
diabetis, dyslipidemia, renal
insufficiency …
Mills EJ, Lancet Infect Dis 2010
Negin J, JAIDS 2010
Nakimuli-Mpungu E, Neurobehavioral HIV Medicine 2011
63
Challenges 7
ENSURE
COMPREHENSIVE HIV CARE
64
Percentage of household expenditures
Non ARVs and non CD4 costs among patients receiving ART
Cameroun1
Côte d’Ivoire2
Health expenditures
20 USD/month
24.3 USD/month
Medical visits and others
44%
50%
Transportation
12%
25%
1- Boyer S, Bull WHO 2010
2- Beaulière A, PLoS ONE 2010
65
Challenges 8
IMPROVE RETENTION
66
Towards universal access: Scaling up priority HIV/AIDS
interventions in the health sector. Progress report 2010
67
* Serious barriers
- Transport costs
- Time needed for treatment
- Logistical challenges
Patients’ perception
* Less influencal factors
- Stigma around HIV/AIDS
- Side effects
68
1)
Set up and maintain simple standardized monitoring
systems
2) Reliably ascertain true treatments outcomes
3) Reduce death rates
4) Ensure uninterrupted drugs supplies
5) Use simple, non toxic and free ART-regimens
6) Decentralized ART clinics and reduce frequency of visits
7) Reduce indirect patients costs
8) Strenghten ART-links within and between health services
and the community
9) Use ART-services to deliver other useful interventions
10) Innovative (tining out of the box intervention)
69
Harries AD, Trop Med Intern Health 2010
Challenge 9: Human resources
* Motivation: Increase salary
* Struggle the brain draining of health care workers to national
or international NGOs (disparities)
* Cure an emerging disease, « the perdiemitis »
(Ridde V, Trop Med Int Health 2010)
* Set up the task shifting
(monitoring ART: nurses vs doctor, 1.09 (95% CI 0.89–1.33)
(Sanne I, CIPRA Study-South Africa, Lancet 2010)
70
Challenges 10
Out-of-control
Humanitarian crisis
Earthquake (Haiti)
Floads
Dryness and Food crisis (eg; East Africa)
Socio-political crisis (Eg:Côte d’Ivoire)
Jeopardize 10-15 years of successes! !
71
“Justice must prevail against those who exploit patients
as political weapons and thereby undermine years of
human rights progress. Much has been said and written
about the need to treat as war crimes all failures to
protect civilians during conflict. Obstructing access to
needed medical care should rank high among these.”
http://www.lemonde.fr/idees/article/2011/04/05/l-attention-aux-malades-du-sidabarometrede-l-humanite_1502634_3232.html
72
Conclusion
73
« A perpetual challenge will be living up with the
commitment and courage of those who went
before- health care workers, scientists, and
affected persons- who faced the unknown and took
risks. In general 30 years of AIDS confirm that
there is indeed « more to admire in men than to
despise »
74
Courtesy of S Matheron
75
Acknowledgements
* E Bissagnéné
* A Calmy
* JF Delfraissy
* DK Ekouevi
* PM Girard
* C Kouanfack
* PS Sow
* M Vitoria
76
Choukran
Thank you
Dieureudieuf
Djaraman
Grazie
Mo
M"pussda
barka
Merci
Bondodi
Akpé
Ngiyabonga
Amesegnalehu
I ni tché
Mo Pi Wo
Asanti
Obrigado
Gracias
77