This study found that farm workers in South Africa's Limpopo and Mpumalanga provinces have the highest HIV prevalence among any working population in Southern Africa. Conducted from March to May 2010 on 23 commercial farms, the survey included 2,810 farm workers, who anonymously gave blood specimens for HIV testing. The survey found that an average of 39.5% of farm workers who tested were HIV positive, which is more than twice the UNAIDS estimated national prevalence for South Africa of 18.1%. HIV prevalence was significantly higher among female employees, with almost half of the women (46.7%) testing positive compared to just under a third (30.9%) of the male workforce. The study could not pin-point a single factor causing this high rate of HIV infection on these farms, but cites a combination of factors such as multiple and concurrent partnerships, transactional sex, irregular condom use, presence of sexually transmitted infections (STIs) and tuberculosis, and high levels of sexual violence. The authors of the study note that a major research gap exists with regard to HIV among farm workers in southern Africa and they call for more research. The report makes several recommendations including increasing farm worker access to healthcare and implementing prevention programmes that are goal driven and monitored. The programmes should address gender norms that increase risky behaviour and vulnerability to HIV, such as the belief that a man has to have multiple partners. Both permanent and seasonal farm workers should be included in workplace health and safety policies.
Equity and HIV/AIDS
This report evaluates the work that Medicins sans Frontiers (MSF) has done in HIV and AIDS in Mozambique over the past ten years. MSF’s HIV and AIDS programmes offer HIV testing and counseling, treatment and prevention of opportunistic infections, paediatric diagnosis and treatment, prevention of mother-to-child transmission, and the provision of anti-retroviral therapy. At the end of August 2010, more than 33,000 people in Mozambique were being treated for HIV and AIDS through MSF’s projects. However, the report cautions that MSF’s model of care is not a prescriptive cure, and significant challenges remain. More than 350,000 people in Mozambique are in need of ARV treatment but do not have access to it, which equates to two-thirds of all HIV-positive Mozambicans. After years of political willingness and financial commitment to combat HIV and AIDS, external funders are now either flatlining, reducing or withdrawing their funding for HIV, thus abandoning those who are still in dire need of lifesaving treatment. HIV-infected people continue to face major barriers in their access to services, even in a context of free treatment. A shortage of qualified health workers is also considered a major barrier to access in Mozambique, with only 3 doctors and 143 nurses per 100,000 people, one of the lowest workforce per population ratios in the world.
The author argues in this paper that United States government policy has violated the rights of African people living with HIV and AIDS through its ‘moral’ restrictions prioritising abstinence-only sex education, restricting condom distribution and stigmatising sex workers. The author argues that the focus on technocratic approaches such as biomedical quick fixes, like the recent emphasis on male circumcision, ignores the deeply gendered, racial and sexual dimensions of the disease or its social, economic and cultural pathology in Africa.
In this article, the authors consider a neglected aspect of AIDS and HIV treatment – pain management. With enormous progress in preventing and treating HIV, more people than ever before now live with HIV as a chronic disease, especially in countries like Kenya, where, over the past year, the number of people receiving anti-retroviral (ARV) therapy has risen by 25%. But HIV patients can suffer from various types of chronic pain – and this includes those on ARVs who are living otherwise healthy, active lives – and pain management is usually overlooked, the authors note. They argue that palliative care, which requires caregivers to improve a patient's quality of life by treating pain and other symptoms, should become an essential element of comprehensive HIV care. It can also help patients to keep taking their antiretroviral drugs. Curative and palliative treatment should work side by side for any patient with a life-threatening disease, the authors state. A major barrier is unavailability of essential pain drugs in Kenya's health facilities. Oral morphine, the mainstay medication for moderate-to-severe chronic pain, is available in just seven of Kenya's 250 public hospitals, and even these facilities sometimes run out, even though oral morphine is inexpensive. However, because of a lack of training, healthcare workers often fear giving an overdose or causing addiction, which can be avoided with proper medical practice. The authors argue for greater, monitored use of morphine for pain management in children.
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.
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.