Objective: To compare and contrast doravirine (DOR) with other agents in the nonnucleoside reverse transcriptase inhibitor (NNRTI) class, review safety and efficacy data from both completed and ongoing clinical trials, and outline the potential place in therapy of DOR. Data Sources: A literature search using the PubMed database (inception to June 2019) was conducted using the search terms HIV, doravirine, non-nucleoside reverse transcriptase inhibitor, NNRTI, and MK-1439. Study Selection and Data Extraction: Clinical data were limited to those published in the English language from phase 2 or 3 clinical trials. Ongoing trials were identified through ClinicalTrials.gov. Data Synthesis: DOR was approved by the US Food and Drug Administration on the strength of 2 phase 3 randomized, double-blind, noninferiority clinical trials with additional studies currently underway examining its utility in other clinical scenarios. Relevance to Patient Care and Clinical Practice: The role of NNRTIs as part of antiretroviral (ARV) therapy has diminished in recent years given the introduction of more tolerable individual ARV agents and regimens. Despite this, new agents are still needed in the therapeutic arena because treatment failure as well as intolerance can still occur with many first-line therapies. The optimal place in therapy of DOR remains to be defined. Conclusions: DOR is a new NNRTI that represents a potential treatment option for treatment-naïve patients, without many of the previously described untoward effects of the NNRTI class.

A biodisponibilidade de um fármaco é o fator determinante da eficácia clínica e depende principalmente das seguintes etapas: liberação da substância ativa a partir da forma farmacêutica e absorção. Assim, o controle da extensão e da velocidade de absorção de um fármaco administrado por via oral depende basicamente de dois aspectos: solubilidade nos líquidos fisiológicos e permeabilidade através das membranas biológicas. Fundamentado nestas características, o Sistema de Classificação Biofarmacêutica (SCB) foi proposto como ferramenta que permite a classificação dos fármacos e tem como finalidade auxiliar nas bioisenções e na predição da biodisponibilidade in vivo. Neste sentido, o presente trabalho teve como objetivo avaliar a solubilidade da estavudina e a permeabilidade intestinal de fármacos antirretrovirais por meio do modelo de perfusão in situ. Os meios empregados nos estudos de solubilidade e dissolução intrínseca foram: água purificada, tampão pH 1,2, tampão pH 4,5, tampão pH 6,8 e tampão pH 7,5. Para a determinação da solubilidade pelo método do equilíbrio (técnica shake-flask), quantidades conhecidas do fármaco foram adicionadas em cada meio até atingir a saturação e esta mistura foi submetida à agitação de 150 rpm por 72 horas a 37°C. Para os ensaios de dissolução intrínseca, quantidade conhecida de estavudina foi compactada na matriz do aparato de Wood e submetida à dissolução em cada meio, sob agitação de 50 rpm a 37°C. A determinação da permeabilidade dos antirretrovirais foi realizada empregando o modelo de perfusão in situ em ratos machos Wistar. Uma porção do jejuno foi isolada e a solução de perfusão (pH 6,5) contendo o fármaco foi perfundida a um fluxo de 0,2 mL.min-1 a 37°C por 120 minutos. Os resultados obtidos referentes à solubilidade da estavudina pelo método do equilíbrio foram (em mg.mL-1): 146,49 (água), 149,22 (pH 4,5), 139,43 (pH 6,8) e 130,15 (pH 7,5). A determinação da razão dose:solubilidade (D:S) em cada meio permitiu a obtenção dos seguintes resultados (em mL): 0,27 (água), 0,27 (pH 4,5), 0,29 (pH 6,8) e 0,31 (pH 7,5). Tais dados indicaram que este fármaco apresenta alta solubilidade nos meios utilizados no estudo, exceto em meio pH 1,2, onde a estavudina apresentou instabilidade demonstrada pela presença de coloração e odor alterados, inviabilizando a determinação da solubilidade nestas condições. Os ensaios de dissolução intrínseca da estavudina permitiram a determinação das taxas de dissolução intrínseca (TDI), as quais foram (em mg/min/cm²): 2,3570 (água), 2,7389 (pH 1,2), 2,7590 (pH 4,5) e 2,5947 (pH 6,8), demonstrando que este fármaco apresenta alta velocidade de dissolução nos meios utilizados. Com relação ao estudo de permeabilidade por meio do modelo de perfusão in situ, nas condições experimentais empregadas, os resultados obtidos foram (em cm.s-1): 3,96 x 10-5 (estavudina), 3,08 x 10-5 (lamivudina) e 4,17 x 10-5 (zidovudina) sugerindo que os fármacos estavudina e zidovudina apresentam alta permeabilidade. Para a lamivudina não é descartada a possibilidade de ser considerada como fármaco de alta permeabilidade, mesmo apresentando resultado ligeiramente abaixo em relação aos outros dois antirretrovirais utilizados no estudo. / Drug\'s bioavaliability is a determinant factor of clinical efficacy and it depends on the following steps: release of active ingredient from the dosage form and absorption. Thus, control of extend and rate of absorption of a drug orally administered depends on two aspects: the drug solubility in physiological fluids and permeability across biological membranes. Based on these characteristics, the Biopharmaceutical Classification System (BCS) was proposed as a tool that allows the drug\'s classification and it assists in biowaiver and in vivo bioavailability prediction. The aim of this study was to evaluate stavudine solubility and intestinal permeability of antiretroviral drugs through the in situ perfusion model. The means employed in the solubility studies and intrinsic dissolution were: purified water, buffer pH 1.2, buffer pH 4.5, buffer pH 6.8 and buffer pH 7.5. For solubility study by equilibrium method (shake-flask technique), known amounts of the drug were added in each media to reach saturation and the mixture was subjected to agitation of 150 rpm for 72 hours at 37°C. For intrinsic dissolution test, known amount of stavudine has been compressed in the matrix of Wood\'s apparatus and subjected to dissolution in each media with agitation of 50 rpm at 37°C. Permeability evaluation of antiretroviral drugs was performed using the in situ perfusion model in male Wistar rats. A portion of jejunum was isolated and perfusion solution (pH 6.5) with the drug was perfused at 0.2 mL/min at 37°C for 120 minutes. Results of stavudine solubility by equilibrium method were (in mg/mL): 146.49 (water), 149.22 (pH 4.5), 139.43 (pH 6.8) and 130.15 (pH 7.5). Dose:solubility (D:S) ratio determinations allowed to obtain the following results (in mL): 0.27 (water), 0.27 (pH 4.5), 0.29 (pH 6.8) and 0.31 (pH 7.5). These results indicate that stavudine has high solubility in the means employed in this study, except in buffer pH 1.2, where stavudine showed instability demonstrated by presence of stain and odor changed, which prevented the determination of solubility in these conditions. The intrinsic dissolution study allowed the determination of intrinsic dissolution rates (IDR), which were (in mg/min/cm²): 2.3570 (water), 2.7389 (pH 1.2), 2.7590 (pH 4.5) and 2.5947 (pH 6.8), demonstrating that this drug has a high dissolution rate in each media used. In permeability study through the in situ perfusion model, under experimental conditions adopted, the results obtained were (in cm/s): 3.96 x 10-5 (stavudine), 3.08 x 10-5 (lamivudine) and 4.17 x 10-5 (zidovudine), suggesting that stavudine and zidovudine have high permeability. It\'s possible that lamivudine might be considered high permeability drug, although its effective permeability result was slightly lower compared to effective permeability of stavudine and zidovudine.

A biodisponibilidade de um fármaco é o fator determinante da eficácia clínica e depende principalmente das seguintes etapas: liberação da substância ativa a partir da forma farmacêutica e absorção. Assim, o controle da extensão e da velocidade de absorção de um fármaco administrado por via oral depende basicamente de dois aspectos: solubilidade nos líquidos fisiológicos e permeabilidade através das membranas biológicas. Fundamentado nestas características, o Sistema de Classificação Biofarmacêutica (SCB) foi proposto como ferramenta que permite a classificação dos fármacos e tem como finalidade auxiliar nas bioisenções e na predição da biodisponibilidade in vivo. Neste sentido, o presente trabalho teve como objetivo avaliar a solubilidade da estavudina e a permeabilidade intestinal de fármacos antirretrovirais por meio do modelo de perfusão in situ. Os meios empregados nos estudos de solubilidade e dissolução intrínseca foram: água purificada, tampão pH 1,2, tampão pH 4,5, tampão pH 6,8 e tampão pH 7,5. Para a determinação da solubilidade pelo método do equilíbrio (técnica shake-flask), quantidades conhecidas do fármaco foram adicionadas em cada meio até atingir a saturação e esta mistura foi submetida à agitação de 150 rpm por 72 horas a 37°C. Para os ensaios de dissolução intrínseca, quantidade conhecida de estavudina foi compactada na matriz do aparato de Wood e submetida à dissolução em cada meio, sob agitação de 50 rpm a 37°C. A determinação da permeabilidade dos antirretrovirais foi realizada empregando o modelo de perfusão in situ em ratos machos Wistar. Uma porção do jejuno foi isolada e a solução de perfusão (pH 6,5) contendo o fármaco foi perfundida a um fluxo de 0,2 mL.min-1 a 37°C por 120 minutos. Os resultados obtidos referentes à solubilidade da estavudina pelo método do equilíbrio foram (em mg.mL-1): 146,49 (água), 149,22 (pH 4,5), 139,43 (pH 6,8) e 130,15 (pH 7,5). A determinação da razão dose:solubilidade (D:S) em cada meio permitiu a obtenção dos seguintes resultados (em mL): 0,27 (água), 0,27 (pH 4,5), 0,29 (pH 6,8) e 0,31 (pH 7,5). Tais dados indicaram que este fármaco apresenta alta solubilidade nos meios utilizados no estudo, exceto em meio pH 1,2, onde a estavudina apresentou instabilidade demonstrada pela presença de coloração e odor alterados, inviabilizando a determinação da solubilidade nestas condições. Os ensaios de dissolução intrínseca da estavudina permitiram a determinação das taxas de dissolução intrínseca (TDI), as quais foram (em mg/min/cm²): 2,3570 (água), 2,7389 (pH 1,2), 2,7590 (pH 4,5) e 2,5947 (pH 6,8), demonstrando que este fármaco apresenta alta velocidade de dissolução nos meios utilizados. Com relação ao estudo de permeabilidade por meio do modelo de perfusão in situ, nas condições experimentais empregadas, os resultados obtidos foram (em cm.s-1): 3,96 x 10-5 (estavudina), 3,08 x 10-5 (lamivudina) e 4,17 x 10-5 (zidovudina) sugerindo que os fármacos estavudina e zidovudina apresentam alta permeabilidade. Para a lamivudina não é descartada a possibilidade de ser considerada como fármaco de alta permeabilidade, mesmo apresentando resultado ligeiramente abaixo em relação aos outros dois antirretrovirais utilizados no estudo. / Drug\'s bioavaliability is a determinant factor of clinical efficacy and it depends on the following steps: release of active ingredient from the dosage form and absorption. Thus, control of extend and rate of absorption of a drug orally administered depends on two aspects: the drug solubility in physiological fluids and permeability across biological membranes. Based on these characteristics, the Biopharmaceutical Classification System (BCS) was proposed as a tool that allows the drug\'s classification and it assists in biowaiver and in vivo bioavailability prediction. The aim of this study was to evaluate stavudine solubility and intestinal permeability of antiretroviral drugs through the in situ perfusion model. The means employed in the solubility studies and intrinsic dissolution were: purified water, buffer pH 1.2, buffer pH 4.5, buffer pH 6.8 and buffer pH 7.5. For solubility study by equilibrium method (shake-flask technique), known amounts of the drug were added in each media to reach saturation and the mixture was subjected to agitation of 150 rpm for 72 hours at 37°C. For intrinsic dissolution test, known amount of stavudine has been compressed in the matrix of Wood\'s apparatus and subjected to dissolution in each media with agitation of 50 rpm at 37°C. Permeability evaluation of antiretroviral drugs was performed using the in situ perfusion model in male Wistar rats. A portion of jejunum was isolated and perfusion solution (pH 6.5) with the drug was perfused at 0.2 mL/min at 37°C for 120 minutes. Results of stavudine solubility by equilibrium method were (in mg/mL): 146.49 (water), 149.22 (pH 4.5), 139.43 (pH 6.8) and 130.15 (pH 7.5). Dose:solubility (D:S) ratio determinations allowed to obtain the following results (in mL): 0.27 (water), 0.27 (pH 4.5), 0.29 (pH 6.8) and 0.31 (pH 7.5). These results indicate that stavudine has high solubility in the means employed in this study, except in buffer pH 1.2, where stavudine showed instability demonstrated by presence of stain and odor changed, which prevented the determination of solubility in these conditions. The intrinsic dissolution study allowed the determination of intrinsic dissolution rates (IDR), which were (in mg/min/cm²): 2.3570 (water), 2.7389 (pH 1.2), 2.7590 (pH 4.5) and 2.5947 (pH 6.8), demonstrating that this drug has a high dissolution rate in each media used. In permeability study through the in situ perfusion model, under experimental conditions adopted, the results obtained were (in cm/s): 3.96 x 10-5 (stavudine), 3.08 x 10-5 (lamivudine) and 4.17 x 10-5 (zidovudine), suggesting that stavudine and zidovudine have high permeability. It\'s possible that lamivudine might be considered high permeability drug, although its effective permeability result was slightly lower compared to effective permeability of stavudine and zidovudine.

Thesis (MFamMed)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Introduction This cross-sectional study assessed factors affecting access to antiretroviral therapy (ART) among HIV patients. The aim of this study was to explore factors that delay patients from accessing antiretroviral treatment at an East London Hospital Complex clinic and to determine the pathway that people from communities in the surrounding area take in order to access antiretroviral treatment at the referral hospital ART clinic Methods The study design was a descriptive cross-sectional survey using both open and closed questions to generate qualitative and quantitative data. The survey used a questionnaire administered via a face to face interview. 200 Adult patients (>18years old) from the local population with a CD4 count of ≤100/mm3 referred to the ART clinic at East London Hospital Complex for the first time during May to October 2011 were interviewed. Results With the health system, some issues were structural (staffing, availability of CD4 counts) and most were process related and reflected a poor patient experience and lack of trust in the quality of care. Contextual related issues were mainly geographic accessibility (cost and lack of transport, distance to health care facility), stigma and discrimination about HIV. Patients related factors included misperceptions and false beliefs about HIV, low level of education, socioeconomic factors, lack of family and social support such as unavailability of treatment supporter and status of patient’s general health discouraged people from seeking ART. Coping strategies such as denial of results and reluctant to disclose results to other people came out as a distrust of patients in community. Conclusions This study gives evidence that people living with HIV experience health system, patient and contextual related barriers to access HIV treatment. The majority accessed care via their local primary care clinic and traditional or alternative practitioners did not appear to play a major role. The distance from and cost of transport to the referral hospital ART service was a major issue compounded by the difficulty of travelling when acutely sick. The expectation of long waiting times and sometimes negative staff attitudes reduced motivation. A number of other factors related to the patient, the health service and the community context were also identified. Many of these factors that reduce access to ART are amenable to change.

Magister Scientiae - MSc (Pharmaceutical Chemistry) / The rapid increase in access to new antiretrovirals (ARVs) worldwide and, especially in sub-Saharan Africa, coupled with the well-documented problem of poor quality ARVs in developing countries has underscored the need for quality assessment of these medicines. South Africa has the worst human immunodeficiency virus (HIV) epidemic profile in the world; consequently, it has rolled out the world's largest antiretroviral ARV programme. With increasing market penetration of generic medicine in South Africa and especially ARVs, there is a call for stringent quality control mechanisms following the marketing approval (post-market quality control) of these medications. Unfortunately, evidence suggests that the World Health Organisation (WHO) recommendations for this aspect of quality assurance is not met by most Medicine Regulatory Authorities. In South Africa and many other countries this is attributed to a lack of physical and financial resources to enforce effective post-marketing surveillance (PMS) of all pharmaceuticals available in the country.

Magister Pharmaceuticae - MPharm / South Africa is faced with a high number of people living with HIV/AIDS, and subsequently a great need to access quality medicines for improving patient therapeutic outcomes. Antiretroviral drugs (ARVs) require rigid, efficient and effective management, due to their valuable efficacy in prolonging the survival of HIV/AIDS patients, and the limited possibility of substitution. Managing their flow is vital to ensure an uninterrupted supply. Problematic inventory management was experienced by some healthcare facilities in South Africa where in recent years it resulted in stock outs and stock losses through thefts. These factors present obstacles to the availability of quality medicines, which ultimately leads to treatment failure and deterioration of the health status of patients. The aim of this study was to characterise the inventory management practices and medicine store maintenance of ARVs in community health centres (CHCs) in the Cape Metropole, Western Cape, in order to identify specific problems associated with ARV stock management. The study used a descriptive, cross-sectional study design to examine ARV records and to highlight associated discrepancies between recorded iii quantities on logistics tools used and physical counts, to assess the store maintenance, to measure the supply rate and identify factors contributing to poor stock management. The sample comprised 15 CHCs under the Western Cape Provincial Government (WCPG) accredited to provide ARV treatment. A checklist developed by Management Sciences for Health was adapted and was used to gather quantitative information (e.g. physical stock count). Some qualitative data was collected from responsible personnel for ARV drug management at each site. 86.7% of CHCs utilised a logistics tool (either manual or electronic) to manage ARVs. The average number of adult ARV drugs with a logistics tool available in all CHCs was 82.7% of which 21.9% met the criteria for accuracy. Only 32.9% of all logistics tools had records that were up to date. The average percentage of total variation between stock records and physical counts for the ARV drugs assessed was 51.6%. No historical data on stock outs and monthly usage (monthly consumption) could be retrieved in any of the CHCs, although there were no actual stock outs on the day of the fieldwork. The order fill rate was 91.9%. Since ordering is done more often that it should, stock availability did not appear to be problematic. Standard appropriate physical dimensions were not met by 20% of the CHCs and only 66.7% of the CHCs had appropriate labeling of the shelves in the dispensary and in the storeroom. This study demonstrated poor inventory management with respect to the general quality of record keeping, space allocation and general organisation of the medicine storeroom. Making timely entries and recording issues on logistics tools are recommended to keep up to date inventory records and management information system. Frequent monitoring of stock status is suggested, to avoid discrepancies and to keep it to adequate levels iv which will minimise multiple ordering. Regular supervision by the district pharmacist is needed to identify training and other needs. A study on general cost and delivery costs associated with poor record keeping should be carried out.

Atualmente cerca de 38,6 milhões de pessoas estão infectadas pelo vírus da síndrome da imunodeficiência adquirida (AIDS) em todo mundo. O único modo de tratamento para esta doença é através da utilização de medicamentos responsáveis por atuarem em diferentes pontos do ciclo replicativo do vírus. No Brasil esta doença é tratada como de calamidade pública, sendo seu tratamento feito através do programa nacional DST/AIDS, o qual distribui gratuitamente os medicamentos necessários para o tratamento. Tendo em vista que vários desses medicamentos são formulados pela indústria local, esta dissertação tem como objetivo o desenvolvimento de métodos analíticos passiveis de aplicação na rotina farmacêutica para a qualificação de matérias primas, bem como o controle de qualidade dos produtos acabados. As determinações nas formulações de nevirapina e lamivudina foram realizadas por CZE, em eletrólitos ácidos com pH < 2,5. Para a lamivudina a determinação foi realizada em um eletrólito de 0,5 % de TEA, 20 mmol.L-1 de TRIS, pH = 2,5, ajustado com ácido fosfórico, com um tempo de análise inferior a 4 minutos. O método desenvolvido para a nevirapina foi conduzido em um eletrólito de 10 mmol.L-1 de fosfato de sódio (pH =2,5), com um tempo de análise de 3 minutos. Um outro método foi desenvolvido permitindo a determinação de efavirenz, estavudina e ritonavir por MEKC, utilizando-se um planejamento fatorial 23 com ponto central, um tempo inferior a 9 minutos em um eletrólito consituído de 20 mmol.L-1 de tetraborato de sódio, 20 mmol.L-1 de SDS e 30 % de acetonitrila. Os métodos desenvolvidos foram validados de acordo com os protocolos oficiais, mostrando que estes métodos apresentam características adequadas para a análise de formulações farmacêuticas. Outra abordagem foi feita utilizando o acoplamento da eletroforese capilar à espectrometria de massas, onde amostras de urina fortificadas foram analisadas. As análise foram conduzidas utilizando 400 mmol.L-1 de ácido fórmico e líquido auxiliar constituído de 0,5 % de ácido fórmico diluído com uma solução metanol:água (1:1), permitindo a identificação inequívoca dos fármacos. / There are approximately 38.6 million people infected by the immunodeficiency acquired virus (AIDS) over the world. The only way of treatment for this illness is administrating drugs that act in different points of the replicative cycle of the virus. In Brazil this illness is dealt as public calamity, being its treatment made through the national program DST/AIDS, which distributes free of charge necessary medicines for the treatment. Considering that many of these drugs are formulated by the local industries, this thesis has as objective the development of analytical methods to be applied in the pharmaceutical routine for the qualification of raw materials, as well as the quality control of the finished products. The analysis of drug formulations of nevirapine and lamivudine were carried by CZE, in acid electrolytes with pH < 2.5. For lamivudine the analysis was carried using an electrolyte composed of 0.5 % of TEA, 20 mmol.L-1 of TRIS, pH = 2.5, adjusted with phosphoric acid, with an analysis time less than 4 minutes. The method developed for the nevirapine, was lead in an electrolyte composed of 10 mmol.L-1 of phosphate buffer (pH = 2.5), with a time of analysis of 3 minutes. Another method was developed for efavirenz, estavudine and ritonavir by MEKC, using 23 a factorial design with central point, with an analysis time less then 9 minutes in an electrolyte of 20 mmol.L-1 of sodium tetraborate, 20 mmol.L-1 sodium dodecyl sulfate and 30 % acetonitrile. The developed methods were validated in accordance with official protocols, showing that these methods can be advantageously used in the analysis of pharmaceutical formulations. Another approach was to use the coupling of capillary electrophoresis with mass spectrometry, where fortified samples of urine had been analyzed. The analysis were performed using 400 mmol.L-1 formic acid and liquid sheath consisting of 0.5 % of formic acid diluted with a solution of (1:1) methanol:water, allowing the unequivocal identification detection of the drugs in the samples.

<p>HIV and AIDS are disease conditions that have led to high mortality rates in Southern Africa since the late 1970s. The socio-economic system has led to the unequal spread of resources&rsquo / and vulnerability and exposure to HIV is more prevalent in poorer communities. The added burden of life stresses cause for many to be isolated and stigmatised and are often not equipped with the necessary support and coping skills to deal with the magnitude of these circumstances. There is a high prevalence of mental disorders and especially depression amongst individuals infected with either HIV or AIDS. Research shows that stressful life events can impact HIV course progression and impacts the QoL of those infected with HIV or AIDS. Given the social and psychological context of HIV and AIDS, the aim of the study was to examine the relationship between depression and QoL in a sample of adults diagnosed with HIV or AIDS. This quantitative, cross-sectional study used the Becks Depression Inventory II (BDI II) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), to measure the variables concerned. This battery of&nbsp / questionnaires was administered to a purposive sample of adult individuals diagnosed with HIV or AIDS residing in a previously disadvantaged area in the Cape Metropole region. Using SPSS,&nbsp / data was analysed and descriptive and inferential statistics were conducted. The study found that there were more women than men with HIV or AIDS that were found to be depressed (mild, moderate and severe depression). Furthermore, the depressive state increased when the progression of the disease increased. There were generally no significant differences in the QoL&nbsp / experienced within various areas of life and overall life satisfaction experienced. However, the QoL experienced in work was lower. There was a significant relationship between the depressed state and QoL and life satisfaction experienced in household duties and tasks. The contribution of this study includes informing the larger research project, with regards to future treatment&nbsp / regimes. It will update statistics on the prevalence of depression and QoL of adults diagnosed with HIV or AIDS in the area. This study is framed within a biopsychosocial model and is&nbsp / theoretically underpinned by Beck&rsquo / s theory of depression. Key words: HIV, AIDS, adults, depression, quality of life (QoL), Beck Depression Inventory II (BDI II), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), Antiretrovirals (ARV&rsquo / s), prevalence data, correlations.</p>

It is widely known that HIV and ARV drugs trigger mitochondrial impairment in adults. However, their effects in perinatally-infected children have been poorly explored. For this reason, the main hypothesis of the present Thesis was to demonstrate that mitochondrial abnormalities are present in HIV-infected pediatric patients treated with ARV. It is expected to find mitochondrial alterations in asymptomatic perinatally HIV-infected children. This mitochondrial lesion, manifested in a depletion of the mitochondrial genome, would lead to a reduction of the mitochondrial protein synthesis or to a mitochondrial dysfunction and, as a last resort, compromising the cellular viability. However, it is also possible that the presence of homeostatic mechanisms in mitochondria entails a proper function of some complexes, even in the presence of mitochondrial genome depletion. Rather than a localized mitochondrial alteration in a specific enzymatic activity, it is possible that HIV and ARV cause a diffuse damage in the organelle which may be observed in a general assessment of the respiratory chain. In case of a mitochondrial alteration, either in asymptomatic or symptomatic patients, it would be expected a more evident presentation of mitochondrial toxicity in case of the latter. If our hypothesis of an evidence of mitochondrial toxicity derived from HIV and ARV in children is confirmed, we believe that, once the detrimental agent is withdrawn, a recover of the mitochondrial affectation is possible. Mitochondrial impairment may change depending on the type of HAART regimen, leading us to use mitochondrial parameters as a biomarker or a trail to find the best therapeutic options in the choice of different HAART schedules. In this context, the intensity of mitochondrial impairment over time would be higher in children receiving first generation NRTI which, in turn, have been demonstrated to present a higher mitochondrial toxicity in vitro, than those under second generation NRTI. In order to study and test our hypothesis, the main objectives of the present Thesis are: A) General Objective To test if HIV and ARV mechanisms of mitochondrial toxicity found in adults are present in perinatally HIV-infected children. B) Specific Objectives - Objective 1: To elucidate whether ARV treatment or HIV infection were exerting a mitochondrial toxic effect in asymptomatic perinatally HIV-infected pediatric patients receiving HAART. - Objective 2: To investigate if hypothetic alterations in the mitochondrial genome of asymptomatic HIV-infected children receiving ARV are downstream reflected at transcriptional, translational and functional levels. In case of mitochondrial dysfunction was present, to test whether MRC alterations are focalized or diffuse. - Objective 3: To determine mitochondrial status in lipodystrophic HIV-children and compare them to a group of asymptomatic children and to a group of uninfected controls. - Objective 4: To evaluate whether a 12-month interruption of ARV is able to improve or revert these hypothetic mitochondrial alterations at molecular and/or clinical level. - Objective 5: To compare mitochondrial toxicity derived from different HAART schedules in a longitudinal 2-year follow-up assessment of immunovirological and mitochondrial status under first or second generation NRTI. To elucidate whether those NRTI demonstrated to present high mitochondrial toxicity in vitro present a major toxicity in vivo as well.

Statement of the issue: Facing large HIV-infected populations, Sub-Saharan African countries are producing antiretroviral (ARV) drugs under provisions of the World Trade Organization’s Agreement on the Trade-Related Aspects of Intellectual Property (TRIPS). Article 7 states that the protection of intellectual property should increase technology transfer to developing countries. This clause and the debate over domestic manufacturers’ ability to provide low-cost ARVs need examination. Methods: Case studies from ARV manufacturing initiatives in Tanzania and South Africa analyzed conditions affecting two outcomes: the type of technology transfer arrangement entered (voluntary license or imitation) and the affordability of ARVs. Data were collected and analyzed from documents, key-informant interviews, and observation. Chi-squared and phi correlation statistics were then conducted across developing countries to test the association of voluntary ARV licensure with TRIPS-compliant patents and domestic firm ownership (state or private). Results: Tanzania’s weak patent system and poorly-financed, partially state-owned firm dissuaded industry investment, but attracted a non-government organization to transfer technology through imitation. Donor-financed ARV tenders, however, restrict competition to international quality-accredited products not produced by the firm. Without large volumes and manufacturing capacity, it cannot achieve economies of scale to reduce prices below imported ARVs. In South Africa, civil society challenged the strong patent system and poor government commitment that inhibited an ARV rollout. This and a well-financed, publicly-traded firm leveraged voluntary licenses. With international quality approval, the firm increased first-line ARV affordability; however, limited domestic competition keeps treatment prices above those of neighbouring countries. A multi-country analysis found 321 generic ARV manufacturing initiatives in 86 firms across 25 developing countries. Voluntary ARV licenses had a strong positive association with TRIPS-patent compliance (ф=.56, p<.0001) and a weak negative association with state-ownership (ф=.19, p<.0001). Firms in South Africa and India were granted 77% of licenses and accounted for most quality accredited generic ARVs. Conclusion: Despite positive association, technology transfer does not readily result from patent protection, particularly to state-owned firms. Developing countries must enact policies to enable affordable ARVs; yet, they must be cautious using local production to increase ARV access, as most initiatives cannot compete with high-volume generic manufacturers.