In April, 2020, just months into the COVID-19 pandemic, an international group of public health researchers published three lessons learned from the HIV pandemic for the response to COVID-19, which were to: anticipate health inequalities, create an enabling environment to support behavioural change, and engage a multidisciplinary effort. The authors revisit these lessons in light of more than 2 years' experience with the COVID-19 pandemic. With specific examples, the article details how inequalities have played out within and between countries, highlight factors that support or impede the creation of enabling environments, and note ongoing issues with the scarcity of integrated science and health system approaches. The authors argue that to better apply lessons learned as the COVID-19 pandemic matures and other infectious disease outbreaks emerge, it will be imperative to create dialogue among polarised perspectives, identify shared priorities, and draw on multidisciplinary evidence.
Equity and HIV/AIDS
In South Africa, 60% of female sex workers (FSWs) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, the authors explored preferences for DTP among FSWs living with HIV in Durban, South Africa, using 39 semi-structured in-depth interviews. Respondents suggested that decentralized treatment provision should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. Antiretroviral therapy packaging and storage were important for community-based delivery, and participants suggested decentralized treatment provision should be implemented by sex work sensitized staff with discrete uniform and vehicle branding. The authors suggest the potential utility of decentralized treatment provision for female sex workers as a strategy to address those most marginalized from current antiretroviral therapy programs in South Africa.
This article analysed constructions of adolescents’ sexualities and sexual health and the consequences for adolescent exercise of their sexual reproductive health and rights in rural Zambia, using discourse analysis in interviews and focus group discussions. The authors identified three interpretative repertories that influenced youth sexual health, linked to adolescent 'immaturity'; and what was respectful behaviours for girls and for boys, that shape how adolescents negotiate, adopt and resist sexual reproductive health and rights interventions. Adolescents were conflicted between having and applying sexual reproductive health and rights knowledge. The authors suggest that interventions that target adolescents’ sexual reproductive health and rights must aim to address these perceptions and discourses that erect barriers against positive sexual behaviours, including access to services that promote safer sex.
This paper identified key stigma-related barriers to ART adherence and strategies used by adolescents in overcoming these barriers. Data were collected by LVCT Health, a Kenyan organization with a programmatic focus on HIV testing, prevention, and care, interviewing 122 participants in Nairobi, Kisumu, and Mombasa, and in focus group discussions with adolescents living with HIV (ALHIV), peer leaders, and adolescents receiving HIV services in community settings irrespective of HIV status. Four major themes emerged. Knowledge and future-oriented goals can drive motivation for ALHIV to remain healthy. Disclosure to others strengthens support systems for ALHIV, medication-taking strategies and can overcome adherence challenges. A supportive clinic environment promotes continuous adolescent engagement in HIV care. These concepts were used to develop a model moderating negative effects of stigma among ALHIV. Strengths-based interventions, focused on increasing positive features in ALHIV in Kenya, and more formal involvement of adolescent peers to bolster adolescent support, are argued to have the potential to improve ART adherence among ALHIV.
Despite the strict COVID-19 pandemic restrictions in Uganda, viral load testing and viral load suppression rates improved by 68% and 35% during the first lockdown, while mortality reduced by 25% among people living with HIV in Kampala, according to a presentation by Dr Izudi, Makerere University, at the INTEREST 2022 conference. In 2020, modelling studies of the COVID-19 pandemic’s impact on HIV estimated that interruptions in ART would have the largest effect on HIV-related mortality in Africa, with a three-month interruption of ART supply in 13 African countries estimated to translate to a 35 to 131% rise in mortality in 2021. Observational data from six large HIV clinics and 9952 participants in Kampala compared a pre-pandemic cohort from March 2018 to February 2019 of people with HIV who had not experienced the COVID-19 restrictions, and an exposed cohort from June 2020 to June 2021 of people with HIV who experienced the restrictions. Patients exposed to restrictions had a 68% increase in viral load testing and a 35% increase in viral load suppression compared to the comparison group. Their mortality was also 25% lower than the control group,
Older gay black men living with HIV and AIDS and their aging and health care concerns are reported to be invisible in research in South Africa, with the focus being on younger LGBTQI+ men. This qualitative study explored the aging and health-care experiences of older gay black men in a selected township in the Cape Metropole, with the purpose of finding strategies to deal with their real life concerns and also interviewed health professionals working at the local clinic. A key finding was that health-care professionals, particularly nurses at a local clinic, stigmatize older black men living with HIV and AIDS and that rejection by their families and the death of their life partners leads to isolation, loneliness and depression. The authors propose training of health-care professionals by social workers and workshops to educate families of older LGBTQI+ people on their aging concerns.
This paper describes how an adult HIV peer-support group in urban Zimbabwe enabled implementation research, and client recruitment and retention, with successes, challenges and lessons documented over eight years. The interventions involved psychosocial support, nutrition care and support, adherence education and income generating projects. More than 900 people participated in peer-support group activities every month and 400 were engaged in income generating activities. The support group provided a platform for identification of research priorities, patient recruitment and retention and for dissemination of research findings.
The authors describe the change in 12-24 year old peer leaders' knowledge and leadership of a peer youth led HIV curriculum applied during monthly Saturday adolescent HIV clinics at two clinical sites in Moshi, Tanzania. Peer leaders previously participated in a mental health and life skills intervention called Sauti ya Vijana and were recommended for leadership by Sauti ya Vijana facilitators and clinic staff. Peer leaders demonstrated high fidelity to activities in each lesson and participant feedback was positive for curriculum delivery. Participants’ knowledge improved in nine of ten sessions. Peer leaders reported improved leadership confidence and resilience, and their perception was that the curriculum helped normalize the HIV experience for Youth Living with HIV attending clinic. Nevertheless, anticipated stigma, difficulty disclosing HIV status, and teaching ability remained barriers. This study provides evidence to support efforts to scale and sustain peer youth led interventions for Youth Living with HIV.
As countries approach the UNAIDS 95-95-95 targets, there is a need for innovative and cost-saving HIV testing approaches that can increase testing coverage in hard-to-reach populations. The HIV Self-Testing Africa-Initiative distributed HIV self-test (HIVST) kits using unincentivised HIV testing counsellors across 31 public facilities in Malawi, South Africa, Zambia and Zimbabwe. HIVST was distributed either through secondary (partner’s use) distribution alone or primary (own use) and secondary distribution approaches. The authors evaluated the costs of adding HIVST to existing HIV testing from the providers’ perspective in the 31 public health facilities across the four countries between 2018 and 2019 using expenditure analysis and bottom-up costing approaches. They found that costs of integrating HIV self-testing in the public health facilities ranged from US$4.27-US$13.42 per kit distributed. Personnel and cost of test kits were important cost drivers.
This paper explored the health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. The authors conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, through interviews with district health team leaders, ART clinic managers, representatives of PEPFAR implementing organizations and focus group discussions with recipients of HIV care. Five broad strategies for distributing antiretrovirals during ‘lockdown’ emerged: (i) accelerating home-based delivery of antiretrovirals; (ii) extending multi-month dispensing from three to six months for stable patients; (iii) leveraging the Community Drug Distribution Points model for ART refill pick-ups at outreach sites in the community; (iv) increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings and (v) leveraging Covid-19 outbreak response funding to deliver ART refills to rural homesteads. While Covid-19 ‘lockdown’ restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.