Access to antiretroviral treatment in developing countries: Which financing strategies are possible?

BACKGROUND: In low- and middle-income countries, access to combination antiretroviral therapy for all people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in need of treatment is a major public health challenge. The objective of this paper was to provide an overview of the different financing modalities of HIV/AIDS care at the microeconomic level and an analysis of their advantages and limitations. METHODS: A review of the published literature using mainly the Medline and Science Direct databases for the 1990-2008 period in English and French made it possible to explore different financing strategies for the access to combination antiretroviral therapy using as case studies specific countries from different regions: Ivory Coast, Uganda, Senegal, and Rwanda for sub-Saharan Africa, Brazil and Haiti in the Latin America/Caribbean region, and Thailand for Asia. RESULTS: In these settings, direct payment through user fees is the most frequent financing mechanism in place for HIV/AIDS care and treatment, including combination antiretroviral therapy. Nevertheless, other mechanisms are being implemented to improve access to treatment such as community-based health insurance schemes with free care for the poor and vulnerable households and public-private partnerships. CONCLUSION: The type of financing strategy for HIV/AIDS care and treatment depends on the context. As direct payment through user fees limits access to care and does not enable program sustainability, national and donor agencies are introducing alternative strategies such as community financing systems (mutual health organizations, micro insurance, community health funds) and public-private partnerships. Finally, access to combination antiretroviral therapy has improved in resource-limited settings; however, there is a need to introduce alternative financial mechanisms to ensure long-term universal and equitable access to treatment and care, including combination antiretroviral therapy.

Cell cycle regulation by plant growth regulators: involvement of auxin and cytokinin in the re-entry of Petunia protoplasts into the cell cycle.

In order to understand the mode of action of auxins and cytokinins in the induction of cell division, the effects of the two plant growth regulators 2,4-dichlorophenoxyacetic acid (2,4-D) and N6-benzyladenine (BA) were investigated using mesophyll protoplasts of Petunia hybrida, cultivated in either complete medium or in medium deficient in cytokinin, auxin or both. Firstly we studied DNA synthesis, using 5-bromodeoxyuridine/bisbenzimide Hoechst/propidium iodide flow cytometry analyses and by the monitoring of histone H4 transcript levels. Roscovitine, a cyclin-dependent kinase (CDK) inhibitor, was found to block the cell cycle prior to entry into the S and M phases in the cultured P. hybrida protoplasts. This suggests that in Petunia cell there is a requirement for CDK activity in order to complete the G1 and G2 phases. Further experiments using roscovitine showed that neither 2,4-D nor BA were individually able to induce cell cycle progression beyond the roscovitine G1 arrest. We also monitored the phytohormonal induction of S phase by studying variations in transcript levels of the gene for mitogenactivated protein kinase (PMEK1) and transcript levels of the cell division cycle gene cdc2Pet. Only 2,4-D, and not BA, was able to stimulate PMEK1 gene transcription; thus, the more rapid S-phase induction in 2,4-D-treated protoplasts may be attributable to the activation of this transduction pathway. In contrast, both plant growth regulators were required to induce the appearance of cdc2Pet mRNA transcripts prior to S-phase engagement.

Roscovitine, a novel cyclin-dependent kinase inhibitor, characterizes restriction point and G2/M transition in tobacco BY-2 cell suspension.

Although the developmental programs of plants and animals differ, key regulatory components of their cell cycle have been conserved. Particular attention has been paid to the role of the complexes between highly conserved cyclin and cyclin-dependent kinases in regulating progression through the cell cycle. The recent demonstration that roscovitine is a potent and selective inhibitor of the animal cyclin-dependent kinases cdc2 (CDK1), CDK2 and CDK5 prompted an investigation into its effects on progression through the plant cell cycle. Roscovitine induced arrests both in late G1 and late G2 phase in BY-2 tobacco cell suspensions. Both block were fully reversible when roscovitine was used at concentrations similar to those used in the animal system. Stationary-phase cells subcultured in the presence of roscovitine were arrested at a 2C DNA content. This arrest was more efficient without exogenous addition of plant growth regulator. Roscovitine induced a block in G1 earlier than that induced by aphidicolin. S-phase synchronized cells treated with roscovitine were arrested at a 4C DNA content at the G2/ M transition. The expression analysis of a mitotic cyclin (NTCYC1) indicated that the roscovitine-induced G2 block probably occurs in late G2. Finally, cells in metaphase were insensitive to roscovitine. The purified CDK/cyclin kinase activities of late G1 and early M arrested cells were inhibited in vitro by roscovitine. The implications of these experimental observations for the requirement for CDK activity during progression through the plant cell cycle are discussed.

Cloning of upstream sequences responsible for cell cycle regulation of the Nicotiana sylvestris CycB1;1 gene.

To understand the mechanisms involved in the regulation of the mitotic cyclin B Nicta; CycB1;1 expression, we have cloned the Nicotiana sylvestris cyclin gene, Nicsy; CycB1;1, whose coding sequence is homologous to that of Nicta;CycB1;1 cDNA. The structure and the function of its 5'-flanking region, 1149 bp upstream of the first start codon, was analysed. By producing stably transformed cells of a synchronized culture with the Nicsy;CycB1;1 promoter/beta-glucuronidase (gus) reporter gene fusion, we demonstrate that the 1149 bp promoter fragment mediates a gus transcriptional oscillation, indistinguishable from that of endogenous Nicsy;CycB1;1 cyclin B transcripts. Transient GUS activity in BY-2 protoplasts reveals that promoter activity is considerably reduced by shortening the 5'-flanking region to 538 or 320 bp. Furthermore, the 320 bp fragment no longer mediates the observed transcriptional regulation of the 1149 bp Nicsy;CycB1;1 promoter in BY-2 protoplasts isolated from synchronized cells.

G2-and early-M-specific expression of the NTCYC1 cyclin gene in Nicotiana tabacum cells.

We have previously reported the isolation of a cDNA encoding a mitotic cyclin, NTCYC1, from a tobacco cell suspension library. Here we describe the expression patterns of NTCYC1 and of Ntsuc1, a suc 1 plant homologue, in synchronized tobacco cell suspensions. Furthermore, the expression pattern of this cyclin is compared to that of Ntcdc2-1, a Nicotiana tabacum homologue of cdc2. While no NTCYC1 transcript was detected in cells synchronized in the G1 and S phases, NTCYC1 expression was observed in late G2 and early M phases, disappearing in the G1' of a new cell cycle. On the other hand, Ntsuc1 and Ntcdc2-1 exhibited a constitutive expression during the cell cycle. A functional analysis performed by microinjecting NTCYC1 mRNA into immature Xenopus oocytes, indicates that NTCYC1 could participate in the control of the G2/M transition in plant cells. Subsequently NTCYC1 expression was used to assess the status of mesophyll cells in expanded leaves of N. tabacum. Depending on leaf position along the shoot axis, a large population of mesophyll cells appeared with a 4C DNA content, suggesting a G2 arrest. It was found that leaves with such a population also contained high levels of NTCYC1 transcripts. With respect to these results concerning a naturally occurring G2-arrested cell population, the regulation of NTCYC1 expression in planta is discussed.

Olomoucine, an inhibitor of the cdc2/cdk2 kinases activity, blocks plant cells at the G1 to S and G2 to M cell cycle transitions.

The cdc2/cdk2 protein kinases play key roles in the cell cycle at two control points: the G1/S transition and the entry into mitosis. Olomoucine, a specific inhibitor of these kinases, was tested in two plant cell systems: Petunia mesophyll protoplasts induced to divide and Arabidopsis thaliana cell suspension cultures. The cell cycle status was analysed from DNA histograms or through continuous labelling of cells with 5-bromodeoxyuridine (BrdUrd) followed by double staining with bis-benzimide (Hoechst 33258) and propidium iodide (PI). Such analyses resolve cells from several generations according to the extent of their DNA replication. Olomoucine was shown to reversibly arrest differentiated Petunia cells induced to divide at G1 phase and cycling Arabidopsis cells in late G1 and G2. A comparison of the effects of aphidicolin, oryzalin and olomoucine suggests that in the Arabidopsis cell suspension culture, a cdc2/cdk2-like kinase is activated at a restriction point in late G1.