The treatment-related experiences of parents, children and young people with regular prescribed medication.

Background Taking regular medication has been shown to have an impact on the daily lives of patients and their families. Objective To explore the medication-related experiences of patients and their families when a child or young person is prescribed regular medication. Setting A specialist U.K. paediatric hospital. Method Semi-structured face-to-face interviews of 24 parents/carers, children or young people, who had been taking two or more medications for 6 weeks or longer. The themes explored included the medication regimen, formulation, supplies, social aspects and adverse effects. The data was analysed using NVIVO version 11. Main outcome measure The experiences of patients, and their parents/carers, when a child/young person takes regular medication. Results Participants described a range of experiences associated with taking regular medication. Medication-related challenges were experienced around the timing of administration which was managed over 24 h rather than waking hours. Updating medication doses for administration at school was often delayed. Unintended nonadherence was cited as the biggest challenge with a range of strategies employed to manage this. The internet was commonly used as a source of additional information accessed for reassurance and adverse effects but there were varying experiences of using patient forums/help groups. Other challenges included the adequacy of information, travelling with medication, formulation issues, arranging supplies and adverse effects. Conclusion Patients and parents experience many challenges with children's medication. Individualised treatment options should be considered. Further research is required to determine how these experiences may be managed including the role of paediatric medication review.

Design and optimization of a multiplex anti-influenza peptide immunoassay.

Current flu vaccines are based on killed or attenuated virus vaccines that must be altered each year to include the hemagglutinin and neuraminidase genes from a strain of virus predicted to predominate in the coming year. A vaccine that could protect against multiple strains of influenza A and B would be a major asset in the fight against flu-related mortality and morbidity. To support development of such a vaccine, we have developed a Flu Multiplex Assay based on a Luminex platform to assess serum antibody levels to two conserved peptides derived from influenza A (M2 protein) and influenza B (hemagglutinin protein). The peptides were synthesized with a biotin label and subsequently coupled to two different LumAvidin microspheres. We then tested various sera against both types of peptide in the multiplex assay format. The data show that sera from Rhesus macaques immunized with a single peptide react only with the homologous peptide while Rhesus macaques immunized with both peptides respond well to both peptides. Additionally, we were able to specifically compete reactivity to both peptides. We have tested serial bleeds from 100 pediatric patients at ages ranging from 16 to 56 weeks as well as single bleeds from over 100 healthy adults. No overall trend in titer relative to pediatric age was detected. Both demographics exhibited a minimal response to either the A/M2 or B/HA0 peptides. However, the average titer for the pediatric serum samples was significantly lower than that found in the adult population. The adult population exhibited a higher prevalence of low reactive samples. Assay reagents and parameters have been optimized and the assay is shown to be repeatable and robust. The assay will be used to support clinical vaccine trials of a bivalent peptide vaccine.

Children/young people taking long-term medication: a survey of community pharmacists' experiences in England.

OBJECTIVES: To determine whether community pharmacists undertake medication reviews with children/their carers and to identify the type of medication-related experiences presented to them when a child is taking long-term medication. METHODS: A 13 question semi-structured survey was posted to 354 England-based community pharmacists with telephone follow-up/repeat mailing of non-responders. Participants were asked about their practice as a community pharmacist over the preceding 12 months to children/young people, or their carers, taking long-term medication. The questionnaire covered: medication review, reported adherence, information requests, adverse effects, administration and obtaining medication supplies. The data were analysed using SPSS version 22 and NVivo version 10. RESULTS: The response rate was 76/354 (21.5%). Eighteen (23.7%) respondents had undertaken a Medicines Use Review (MUR) and 22 (28.9%) a New Medicines Service (NMS) medication review with a child/their carer. Participants reported that patients/their carers had presented to them with non-adherence including stopping medication (24, 31.6%) and changing the dose (28, 36.8%). Respondents were directly asked about the indication (59, 77.6%), dose regimen (63, 82.9%), administration (64, 84.2%) and adverse effects (58, 76.3%) of prescribed medication. Respondents reported patients/carers experiencing difficulties obtaining medication from their community pharmacy (47, 61.8%) and patients' family doctors declining to prescribe a medication recommended by a specialist (27, 35.5%). CONCLUSIONS: Medicines Use Review and NMS reviews are utilised by community pharmacists in children/their carers. The medication-related experiences presenting to community pharmacists could fall within the purview of a medication review (MUR or NMS). There is scope to further extend this service to this group of patients/carers.

A telephone survey to determine the experiences of children and their parents/carers, following the initiation of a new medicine.

OBJECTIVE: To determine what issues are experienced during the first few weeks of therapy by patients, and their parents/carers, when a child/young person has been prescribed a new medicine. METHOD: One hundred patients aged ≤18 years of age prescribed a new medicine for ≥6 weeks were recruited from a single UK National Health Service specialist paediatric hospital outpatient pharmacy. Six weeks after the first dispensing of their new medicine the patient or their parent/carer received telephone follow-up by a researcher and verbally completed a questionnaire containing both open and closed questions. Patient or parent/carer experiences were identified and analysed using thematic analysis and descriptive statistics. RESULTS: Eighty-six participants were available for telephone follow-up. Six (7%) had not started their medicine. Paediatric patients and their parents/carers experienced a range of issues during the first few weeks after starting a new medicine. These included additional concerns/questions (24/80, 30%), administration issues (21/80, 26.3%), adverse effects (29/80, 36.3%) and obtaining repeat supplies (12/80, 15%). The Morisky Medication Adherence Scale indicated that 34/78 (43.6%) participants had a high adherence rating, 35/78 (44.9%) medium and 9/78 (11.5%) a low rating. CONCLUSIONS: Paediatric patients and their parents/carers experience a range of issues during the first few weeks after starting a new medicine. Further research is required to determine the type of interventions that may further support medicines use in this group of patients.

An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital.

AIMS: To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. METHOD: A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patient's preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor. The discrepancies were classified into intentional and unintentional discrepancies. The unintentional discrepancies were assessed for potential clinical harm by a team of healthcare professionals, which included doctors, pharmacists and nurses. RESULTS: Medicines reconciliation was conducted in 244 children admitted to hospital. 45% (109/244) of the children had at least one unintentional medication discrepancy between the PAM and admission medication order. The overall results indicated that 32% (78/244) of patients had at least one clinically significant unintentional medication discrepancy with potential to cause moderate 20% (50/244) or severe 11% (28/244) harm. No single source of information provided all the relevant details of a patient's medication history. Parents/carers provided the most accurate details of a patient's medication history in 81% of cases. CONCLUSIONS: This study demonstrates that in the absence of medicines reconciliation, children admitted to hospitals across England are at risk of harm from unintended medication discrepancies at the transition of care from the community to hospital. No single source of information provided a reliable medication history.

Hospital and Community Pharmacists' Perceptions of Which Competences Are Important for Their Practice.

The objective of the PHAR-QA (Quality assurance in European pharmacy education and training) project was to investigate how competence-based learning could be applied to a healthcare, sectoral profession such as pharmacy. This is the first study on evaluation of competences from the pharmacists' perspective using an improved Delphi method with a large number of respondents from all over Europe. This paper looks at the way in which hospital pharmacists rank the fundamental competences for pharmacy practice. European hospital pharmacists (n = 152) ranked 68 competences for pharmacy practice of two types (personal and patient care), arranged into 13 clusters. Results were compared to those obtained from community pharmacists (n = 258). Generally, hospital and community pharmacists rank competences in a similar way. Nevertheless, differences can be detected. The higher focus of hospital pharmacists on knowledge of the different areas of science as well as on laboratory tests reflects the idea of a hospital pharmacy specialisation. The difference is also visible in the field of drug production. This is a necessary competence in hospitals with requests for drugs for rare diseases, as well as paediatric and oncologic drugs. Hospital pharmacists give entrepreneurship a lower score, but cost-effectiveness a higher one than community pharmacists. This reflects the reality of pharmacy practice where community pharmacists have to act as entrepreneurs, and hospital pharmacists are managers staying within drug budgets. The results are discussed in the light of a "hospital pharmacy" specialisation.

Glyphosate tolerant canola meal is equivalent to the parental line in diets fed to rainbow trout.

Two separate studies were conducted to evaluate the utility of glyphosate tolerant canola (GTC) as a feed ingredient in diets fed to rainbow trout. In the first study, two forms of GTC were compared to a parental line, Westar. In the second study, one line of GTC was reevaluated to Westar. In each study, processed canola meals were incorporated at 5, 10, 15, or 20% of the dry diet and a diet containing no canola was fed for comparison. All diets were fed to triplicate groups of fish in each study. In the first study, weight gain, feed efficiency (FE), protein efficiency ratio (PER), and protein retention (PR) were not significantly different in fish fed either Westar or GT200 at any level of substitution. Fish fed GT73 exhibited a gradual reduction in weight gain, FE, and PER as the level of GTC increased. However, the only significant reduction was in weight gain of fish fed 20% GT73 as compared to fish fed 5% GT73. Because of an error in preparing samples prior to the experiment, samples GT200 and GT73 were essentially equivalent in composition. The differences were explained by differences in processing temperatures that occurred after the sample mixing error occurred. In the second study, mean weight gain, PR, and survival were not significantly different among forms of canola. FE and PER values were significantly lower in fish fed 15% Westar as compared to fish fed 10% Westar; other FE and PER values were not significantly different. On the basis of these results, GTC processed into a toasted meal and incorporated into diets for rainbow trout is equivalent to a parental line of canola.

One-stop health centres: what co-location means for pharmacy.

This paper examines the potential for the development of patient services that could arise from the co-location of pharmacies with medical practices in the new "one-stop" centres. A review of the pharmacy-specific literature shows limited understanding of influence of location upon service development and highlights a tension between the professional and commercial drives. The aim of the survey of health centre pharmacists was to describe the current patterns of integration in the primary health care team. The study demonstrates that co-location offers opportunities but that there are barriers linked to the loss of traditional commercial activity.

Clinical significance of medication reconciliation in children admitted to a UK pediatric hospital: observational study of neurosurgical patients.

BACKGROUND: In December 2007, the National Institute for Health and Clinical Excellence and the National Patient Safety Agency in the UK (NICE-NPSA) published guidance that recommends all adults admitted to hospital receive medication reconciliation, usually by pharmacy staff. A costing and report tool was provided indicating a resource requirement of 12.9 million pounds for England per year. Pediatric patients are excluded from this guidance. OBJECTIVE: To determine the clinical significance of medication reconciliation in children on admission to hospital. METHODS: A prospective observational study included pediatric patients admitted to a neurosurgical ward at Birmingham Children's Hospital, Birmingham, England, between September 2006 and March 2007. Medication reconciliation was conducted by a pharmacist after the admission of each of 100 consecutive eligible patients aged 4 months to 16 years. The clinical significance of prescribing disparities between pre-admission medications and initial admission medication orders was determined by an expert multidisciplinary panel and quantified using an analog scale. The main outcome measure was the clinical significance of unintentional variations between hospital admission medication orders and physician-prescribed pre-admission medication for repeat (continuing) medications. RESULTS: Initial admission medication orders for children differed from prescribed pre-admission medication in 39% of cases. Half of all resulting prescribing variations in this setting had the potential to cause moderate or severe discomfort or clinical deterioration. These results mirror findings for adults. CONCLUSIONS: The introduction of medication reconciliation in children on admission to hospital has the potential to reduce discomfort or clinical deterioration by reducing unintentional changes to repeat prescribed medication. Consequently, there is no justification for the omission of children from the NICE-NPSA guidance concerning medication reconciliation in hospitals, and costing tools should include pediatric patients.

The corporatization of community pharmacy: implications for service provision, the public health function, and pharmacy's claims to professional status in the United Kingdom.

BACKGROUND: Pharmacy has experienced both incomplete professionalization and deprofessionalization. Since the late 1970s, a concerted attempt has been made to re-professionalize pharmacy in the United Kingdom (UK) through role extension-a key feature of which has been a drive for greater pharmacy involvement in public health. However, the continual corporatization of the UK community pharmacy sector may reduce the professional autonomy of pharmacists and may threaten to constrain attempts at reprofessionalization. OBJECTIVES: The objectives of the research: to examine the public health activities of community pharmacists in the UK; to explore the attitudes of community pharmacists toward recent relevant UK policy and barriers to the development of their public health function; and, to investigate associations between activity, attitudes, and the type of community pharmacy worked in (eg, supermarket, chain, independent). METHODS: A self-completion postal questionnaire was sent to a random sample of practicing community pharmacists, stratified for country and sex, within Great Britain (n=1998), with a follow-up to nonresponders 4 weeks later. Data were analyzed using SPSS (SPSS Inc., Chicago, IL, USA) (v12.0). A final response rate of 51% (n=1023/1998) was achieved. RESULTS: The level of provision of emergency hormonal contraception on a patient group direction, supervised administration of medicines, and needle-exchange schemes was lower in supermarket pharmacies than in the other types of pharmacy. Respondents believed that supermarkets and the major multiple pharmacy chains held an advantageous position in terms of attracting financing for service development despite suggesting that the premises of such pharmacies may not be the most suitable for the provision of such services. CONCLUSIONS: A mixed market in community pharmacy may be required to maintain a comprehensive range of pharmacy-based public health services and provide maximum benefit to all patients. Longitudinal monitoring is recommended to ensure that service provision is adequate across the pharmacy network.

Science or practice? UK undergraduate experiences and attitudes to the MPharm degree.

OBJECTIVE: The debate surrounding the science/practice balance in the teaching of undergraduate pharmacy has been played out in the professional literature for years. The objective of this work was to explore the attitudes of pharmacy undergraduates on the practice-science debate. SETTING: The study was undertaken as part of a national study of teaching, learning and assessment methods in United Kingdom (UK) schools of pharmacy. METHOD: Six focus groups were carried out. The sample was 44 volunteer students from nine UK schools of pharmacy, representing all 4 years of the MPharm programme. Groups were tape recorded and transcribed. Analysis of the transcripts was theme based by topic. MAIN OUTCOME MEASURE: Qualitative data on student attitudes and experiences. RESULTS: Most students thought that there was too strong an emphasis placed on the science components of the course in the early part of their studies. Later in the course they realised that the majority of the science was necessary; it just had not been apparent to them at the time. There were strongly held attitudes across all 4 years that it would be beneficial to include more practice-related material at the beginning of their studies. This would be beneficial for three reasons: to make the course more interesting, to aid in the contextualisation of the science component and to assist the students in any early placement or vacational work. CONCLUSION: Internationally, changes to the role of the pharmacist from a traditional supply function to a more clinical role has resulted in differing educational needs for the pharmacist of the future. Pharmacy will remain a degree built on a strong scientific background, but students advise that the contextualisation and sequencing of material within the degree could make a considerable improvement to their learning. Consulting students helps us to understand the teaching, learning and assessment experience better by giving insights into ways of improving the delivery. In the case of the UK, there are legislative changes impending which may provide an opportunity to review the balance of practice-and science in the curriculum.

Hospital pharmacists' awareness of a new antibiotic guideline in the UK: implications for practice.

OBJECTIVES: Pharmacists play an important role in the review of local hospital guidelines. British Thoracic Society (BTS) guidelines for the management of patients with community-acquired pneumonia (CAP) were updated in 2001, and it is important that individual hospital recommendations are based upon this national guidance. The aim of this study was to identify UK Chief Pharmacists' awareness of these updated guidelines one year after their publication. Secondary aims were to identify whether pharmacists had subsequently initiated revision of institutional CAP guidelines, and what roles different professional staff had performed in this process. METHOD: A self-completion postal questionnaire was sent to the Chief Pharmacist (or their nominated staff) in 253 UK NHS hospitals in November 2002. This aimed to identify issues relating to their awareness of the 2001 BTS guidelines and subsequent revision of their hospital's guidelines. RESULTS: 188 questionnaires were returned (a response rate of 74%), of which 164 hospitals had local antibiotic prescribing guidelines. Respondents in 29% of these hospitals were unaware of the 2001 BTS publication and institutional guidelines had been revised in only 51% of hospitals where the Chief Pharmacist was purportedly aware of the new BTS guidance. Generally, more staff types were involved in revising guidelines than initiating revision. CONCLUSIONS: Variability existed in both Chief Pharmacists' awareness of new national guidance and subsequent review processes operating in individual hospitals. A lack of proactive reaction to new national guidance was identified in some hospitals, and it is hoped that the establishment of specialist "infectious diseases pharmacists" will facilitate the review of institutional antibiotic prescribing guidelines in the future.

Vectored Gag and Env but not Tat show efficacy against simian-human immunodeficiency virus 89.6P challenge in Mamu-A*01-negative rhesus monkeys.

Simian-human immunodeficiency virus (SHIV) challenge studies in rhesus macaques were conducted to evaluate the efficacy of adenovirus-based vaccines in the context of different major histocompatibility complex class I genetic backgrounds and different vaccine compositions. Mamu-A*01 allele-negative rhesus monkeys were immunized with one of the following vaccine constructs: (i) replication-defective recombinant adenovirus type 5 (Ad5) expressing human immunodeficiency virus type 1 (HIV-1) Tat (Ad5/HIVTat); (ii) Ad5 vector expressing simian immunodeficiency virus (SIV) Gag (Ad5/SIVGag); (iii) Ad5 vector expressing the truncated HIV-1(jrfl) Env, gp140 (Ad5/gp140_jrfl); (iv) Ad5 vector expressing the SHIV-89.6P gp140 (Ad5/gp140_89.6P); or (v) the combination of Ad5/SIVGag and Ad5/gp140_jrfl. Following intravenous challenge with SHIV-89.6P, only those cohorts that received vaccines expressing Gag or Env exhibited an attenuation of the acute viremia and associated CD4-cell lymphopenia. While no prechallenge neutralizing antibody titers were detectable in either Ad5/gp140-vaccinated group, an accelerated neutralizing antibody response was observed in the Ad5/gp140_89.6P-vaccinated group upon viral challenge. The set-point viral loads in the Ad5/SIVGag- and Ad5/gp140_jrfl-vaccinated groups were associated with the overall strength of the induced cellular immune responses. To examine the contribution of Mamu-A*01 allele in vaccine efficacy against SHIV-89.6P challenge, Mamu-A*01-positive monkeys were immunized with Ad5/SIVGag. Vaccine-mediated protection was significantly more pronounced in the Mamu-A*01-positive monkeys than in Mamu-A*01-negative monkeys, suggesting the strong contributions of T-cell epitopes restricted by the Mamu-A*01 molecule. The implications of these results in the development of an HIV-1 vaccine will be discussed.

Attenuation of simian immunodeficiency virus SIVmac239 infection by prophylactic immunization with dna and recombinant adenoviral vaccine vectors expressing Gag.

The prophylactic efficacy of DNA and replication-incompetent adenovirus serotype 5 (Ad5) vaccine vectors expressing simian immunodeficiency virus (SIV) Gag was examined in rhesus macaques using an SIVmac239 challenge. Cohorts of either Mamu-A*01(+) or Mamu-A*01(-) macaques were immunized with a DNA prime-Ad5 boost regimen; for comparison, a third cohort consisting of Mamu-A*01(+) monkeys was immunized using the Ad5 vector alone for both prime and boost. All animals, along with unvaccinated control cohorts of Mamu-A*01(+) and Mamu-A*01(-) macaques, were challenged intrarectally with SIVmac239. Viral loads were measured in both peripheral and lymphoid compartments. Only the DNA prime-Ad5-boosted Mamu-A*01(+) cohort exhibited a notable reduction in peak plasma viral load (sevenfold) as well as in early set-point viral burdens in both plasma and lymphoid tissues (10-fold) relative to those observed in the control monkeys sharing the same Mamu-A*01 allele. The degree of control in each animal correlated with the levels of Gag-specific immunity before virus challenge. However, virus control was short-lived, and indications of viral escape were evident as early as 6 months postinfection. The implications of these results in vaccine design and clinical testing are discussed.

Heterologous human immunodeficiency virus type 1 priming-boosting immunization strategies involving replication-defective adenovirus and poxvirus vaccine vectors.

We compared the human immunodeficiency virus type 1 (HIV-1)-specific cellular immune responses elicited in nonhuman primates by HIV-1 gag-expressing replication-defective adenovirus serotype 5 (Ad5) or poxvirus vectors, used either alone or in combination with each other. The responses arising from a heterologous Ad5 priming-poxvirus boosting regimen were significantly greater than those elicited by homologous regimens with the individual vectors or by a heterologous poxvirus priming-Ad5 boosting regimen. The heterologous Ad5 priming-poxvirus boosting approach may have potential utility in humans as a means of inducing high levels of cellular immunity.

Mamu-A*01 allele-mediated attenuation of disease progression in simian-human immunodeficiency virus infection.

Expression of several major histocompatibility complex (MHC) class I alleles is associated with a protective effect against disease progression in both human immunodeficiency virus type 1 and simian immunodeficiency virus infection. To understand the mechanism underlying this effect, we investigated the expression of the MHC class I allele Mamu-A*01 in simian-human immunodeficiency virus (SHIV) infection, one of the major models for evaluation of AIDS vaccine candidates. We found that disease progression was significantly delayed in Mamu-A*01-positive rhesus monkeys infected with the highly pathogenic SHIV 89.6P. The delay corresponded not only to a noted Mamu-A*01-restricted dominant cytotoxic T-lymphocyte (CTL) response but also to a lower viral load in lymph nodes (LN) and, importantly, to minimal destruction of LN structure during early infection. In contrast, Mamu-A*01-negative monkeys exhibited massive destruction of LN structure with accompanying rapid disease progression. These data indicate that MHC class I allele-restricted CTL responses may play an important role in preservation of lymphoid tissue structure, thereby resulting in attenuation of disease progression in immunodeficiency virus infection.

The impact of early immune destruction on the kinetics of postacute viral replication in rhesus monkey infected with the simian-human immunodeficiency virus 89.6P.

Set-point viral load is positively correlated with the extent of initial viral replication in pathogenic simian-human immunodeficiency virus (SHIV) infection. To elucidate the mechanisms underlying the correlation, we conducted a systematic investigation in rhesus monkeys infected with the highly pathogenic SHIV 89.6P. This model is widely used in the preclinical evaluation of AIDS vaccine candidates and a thorough understanding of the model's biology is important to the proper interpretation of these evaluations. We found that the levels of peak viremia were positively correlated not only with the levels of set-point viremia but, importantly, with the extent of initial overall immune destruction as indicated by the degree of CD4+ T cell depletion and lymph node germinal center (GC) formation. The extent of initial overall immune destruction was inversely correlated with subsequent development and maintenance of virus-specific cellular and humoral immune responses. Thus, these data suggest that the extent of early immune damage determines the development and durability of virus-specific immunity, thereby playing a critical role in establishing the levels of set-point viral replication in SHIV infection. Vaccines that limit both the initial viral replication and the extent of early immune damage will therefore mediate long-term virus replication control and mitigation of long-term immune destruction in this model of immunodeficiency virus infection.

Vaccine-induced immunity in baboons by using DNA and replication-incompetent adenovirus type 5 vectors expressing a human immunodeficiency virus type 1 gag gene.

The cellular immunogenicity of formulated plasmid DNA and replication-defective human adenovirus serotype 5 (Ad5) vaccine vectors expressing a codon-optimized human immunodeficiency virus type 1 gag gene was examined in baboons. The Ad5 vaccine was capable of inducing consistently strong, long-lived CD8(+)-biased T-cell responses and in vitro cytotoxic activities. The DNA vaccine-elicited immune responses were weaker than those elicited by the Ad5 vaccine and highly variable; formulation with chemical adjuvants led to moderate increases in the levels of Gag-specific T cells. Increasing the DNA-primed responses with booster doses of either Ad5 or modified vaccinia virus Ankara vaccines suggests a difference in the relative levels of cytotoxic and helper responses. The implications of these results are discussed.

Integrase inhibitors and cellular immunity suppress retroviral replication in rhesus macaques.

We describe the efficacy of L-870812, an inhibitor of HIV-1 and SIV integrase, in rhesus macaques infected with the simian-human immunodeficiency virus (SHIV) 89.6P. When initiated before CD4 cell depletion, L-870812 therapy mediated a sustained suppression of viremia, preserving CD4 levels and permitting the induction of virus-specific cellular immunity. L-870812 was also active in chronic infection; however, the magnitude and durability of the effect varied in conjunction with the pretreatment immune response and viral load. These studies demonstrate integrase inhibitor activity in vivo and suggest that cellular immunity facilitates chemotherapeutic efficacy in retroviral infections.