This Letter to Partners coincides with the 10th anniversary of the 2001 Declaration of Commitment on HIV/AIDS and five years since the world committed to achieve universal access to HIV prevention, treatment, care and support. In the letter, Michel Sidibé outlines a set of six new frontiers to move the global AIDS response forward. He calls for the democratisation of the response: political promises must be realised in the form of improved resources and services, and the communities that are served must be included in decision-making. Also, he notes that the law must work for not against AIDS: for example, national laws must stop discrimination against people living with HIV, men who have sex with men, lesbians, people who inject drugs, sex workers and transgender people. Sidibé calls on stakeholders to reduce the upward trajectory of programme costs, and make funding for AIDS a shared responsibility, as well as help build the AIDS movement as a bridge to development and foster scientific innovation for HIV prevention and treatment. According to Sidibé, each of the six new frontiers supports the other, and he cautions that a singular advancement in only one will not be sufficient to move the entire global AIDS response forward.
Equity and HIV/AIDS
The authors of this study assessed retention in HIV care for individuals not yet eligible for antiretroviral therapy (ART) and explored factors associated with retention in a rural, public health HIV programme in South Africa. During the period January 2007 to December 2007, HIV-infected adults (≥16 years) who were not yet eligible for ART, with a CD4 count of >200, were included in the analysis. Retention was defined by repeat CD4 count within 13 months. A total of 4,223 participants were included in the analysis, of whom 83.9% were female. Overall retention was 44.9%, with 201 days as median time to return to the clinic. Males were independently associated with lower odds of retention, and older participants with higher odds of retention. The authors conclude that retention in HIV care before eligibility for ART is poor, particularly for younger individuals and those at an early stage of infection. Further work to optimise and evaluate care and monitoring strategies is required to realise the full benefits of the rapid expansion of HIV programmes in sub-Saharan Africa.
The South African government has announced that it will soon launch a controversial step in its national campaign to test 15 million people for HIV by June 2011. Under the plans, children and adolescents will be offered voluntary HIV testing and counselling in high schools. This editorial addresses some of the major obstacles it predicts the campaign will face. Under South African law, children aged 12 years and older can give consent to a HIV test. But some issues remain problematic, such as how a health worker should determine whether consent provided by a 12-year-old or adolescent is sufficiently informed or not, and how to ensure confidentiality of test results. It is also not clear whether children who test positive will receive anti-retroviral therapy, or if parental or peer pressure might be applied on children to divulge their test results. The Lancet editors call on the task team that is planning the intervention to consider whether schools are the best place for children to learn their HIV status. Problems in the national HIV testing and counselling campaign, launched in April 2010, heed a cautionary warning, the editors note. Monitoring and evaluation of the campaign has so far been poor and there have been reports of HIV-positive people not being referred for treatment, clinics not complying with national testing and counselling protocols, and anecdotal reports of coercive testing.
The authors of this study reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). They identified 19 articles published in nine journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings, as measured against accepted international benchmarks. The authors conclude that interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses should focus on local assessment of rapidly evolving HIV MTCT options, strategies to improve coverage and reach underserved populations, evaluation of a more comprehensive set of MTCT approaches, and the integration of HIV MTCT and other sexual and reproductive health services.
A US$45 million five-year grant has been awarded to the Elizabeth Glaser Paediatric Foundation (EGPAF) to fund various child HIV interventions in Zimbabwe. Some of this funding is intended for the country’s prevention of mother-to-child transmission (PMTCT) programme, which, according to this article, is performing poorly, as more 150,000 children are estimated to be HIV positive and more than 90% of childhood HIV infections can be attributed to mother-to-child transmission. USAID blamed the high figure on the fact that most children were ‘getting lost in the system’ because their mothers did not return to clinics for additional maternal and child health services after the initial visit to the antenatal clinic. Financial constraints and lack of knowledge about the importance of registering for antenatal services were identified as major barriers, while long distances from health facilities prevented many women from accessing treatment for their infants. In the article, Plus News argues that the government should implement the 2010 World Health Organisation guidelines on PMTCT, which recommend that all HIV-positive pregnant women begin anti-retroviral treatment at 14 weeks of pregnancy and continue until they stop breastfeeding.
In the context of growing recognition that primary prevention, including behavioural change, must be central in the fight against HIV and AIDS, the authors of this study conducted an extensive multi-disciplinary synthesis of the available data on the causes of the remarkable HIV decline that has occurred in Zimbabwe (29% estimated adult prevalence in 1997 to 16% in 2007) despite severe social, political, and economic disruption in the country. The behavioral changes associated with HIV reduction - mainly reductions in extramarital, commercial and casual sexual relations, and associated reductions in partner concurrency - appear to have been stimulated primarily by increased awareness of AIDS deaths and secondarily by the country's economic deterioration. These changes were probably aided by prevention programs utilising both mass media and church-based, workplace-based, and other inter-personal communication activities, the authors surmise. They conclude that focusing on partner reduction, in addition to promoting condom use for casual sex and other evidence-based approaches, is crucial for developing more effective prevention programmes, especially in regions with generalised HIV epidemics.
The authors of this paper studied how increased access to antiretroviral therapy affects sexual behaviour, using data collected in Mozambique in 2007 and 2008. They surveyed both HIV-positive individuals and households from the general population. The findings support the hypothesis of disinhibition behaviours, where individuals are more likely to engage in risky sexual behaviour when they believe that they will have greater access to better health care, such as antiretroviral therapy. The findings suggest that scaling up access to antiretroviral therapy without prevention programmes may lead to more risky sexual behaviour and ultimately more infections. The authors conclude that with increased antiretroviral availability, prevention programmes need to include educational messages so that individuals know that risky sexual behaviour is still dangerous.
Researchers in this study investigated reasons for clinical follow-up and treatment discontinuation among HIV-infected individuals receiving antiretroviral therapy (ART) in a public-sector clinic and in a workplace clinic in South Africa. Participants in a larger cohort study who had discontinued clinical care by the seventh month of treatment were traced using previously provided locator information. Those located were administered a semi-structured questionnaire regarding reasons for discontinuing clinical follow-up. Participants who had discontinued antiretroviral therapy were invited to participate in further in-depth qualitative interviews. Fifty-one of 144 (35.4%) in the workplace cohort had discontinued clinical follow-up by the seventh month of treatment. The median age of those who discontinued follow-up was 46 years and median educational level was five years. By contrast, only 16.5% (44/267) of the public-sector cohort had discontinued follow-up. Among them the median age was 37.5 years and median education was 11 years. Qualitative interviews were conducted with 17 workplace participants and 10 public-sector participants. The main reasons for attrition in the workplace were uncertainty about own HIV status and above the value of ART, poor patient–provider relationships and workplace discrimination. In the public sector, these were moving away and having no money for clinic transport. The authors argue that, in the workplace, efforts to minimise the time between testing and treatment initiation should be balanced with the need to provide adequate baseline counselling taking into account existing concepts about HIV and ART. In the public sector, earlier diagnosis and ART initiation may help to reduce early mortality, while links to government grants may reduce attrition.
This is the first study to report malaria as a risk factor of concurrent HIV infection at the population level. The authors examined the association between malaria and HIV prevalence in east sub-Saharan Africa. They used large nationally representative samples of 19,735 sexually active adults from the 2003–04 HIV and AIDS indicator surveys conducted in Kenya, Malawi and Tanzania, as well as the Atlas Malaria Project, and analysed the relationship between malaria and HIV prevalence, adjusting for important socio-economic and biological cofactors. They found that individuals who live in areas with a high malaria parasite rate are about twice as likely to be HIV positive compared with individuals who live in areas with a low parasite rate. The authors argue that these findings emphasise the need for field studies focused on quantifying the interaction among parasitic infections and risk of HIV infection, as well as studies to explore the impact of control interventions. Public health programmes in the region should be focused on reducing malaria transmission, especially in HIV-infected individuals.
An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. The authors of this study evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region. Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills. The authors conclude that MEMS-bottle use was readily accepted by patients, but patients need to be more explicitly instructed to continue MEMS-use when travelling. In addition, even if HIV clinics have sufficient staff and free medication, supplying an insufficient amount of pills may impose adherence barriers on patients.