According to this UNAIDS report, the global rate of new HIV infections declined by nearly 25% between 2001 and 2009. In South Africa, the rate of new HIV infections fell by more than 35%, with above-average declines in new HIV infections recorded in sub-Saharan Africa. The report found that in the third decade of the epidemic, people were starting to adopt safer sexual behaviours, reflecting the impact of HIV prevention and awareness efforts. However, there are still important gaps – for example, young women are less likely to be informed about HIV prevention than young men. While the rate of new HIV infections has declined globally, the total number of HIV infections remains high, at about 7,000 per day. According to the report, investments in the HIV response in low- and middle-income countries rose nearly 10-fold between 2001 and 2009, from US$ 1.6 billion to US$ 15.9 billion. However, in 2010, international resources for HIV declined, despite the fact that many low-income countries remain heavily dependent on external financing.
Equity and HIV/AIDS
The Soweto Men’s Study assessed HIV prevalence and associated risk factors among men who have sex with men (MSM) in Soweto, South Africa. Using respondent-driven sampling (RDS) recruitment methods, researchers recruited 378 MSM over 30 weeks in 2008. All results were adjusted for RDS sampling design. Overall HIV prevalence was estimated at 13.2%, with 33.9% among gay-identified men, 6.4% among bisexual-identified men, and 10.1% among straight-identified MSM. In multivariable analysis, HIV infection was associated with being older than 25, gay self-identification, monthly income less than ZAR500, purchasing alcohol or drugs in exchange for sex with another man and reporting between six and nine partners in the prior six months, including a regular female partner. The results of the study confirm that MSM are at high risk for HIV infection, with gay men at highest risk. HIV prevention and treatment for MSM are urgently needed, the authors conclude.
Do orphaned children and adolescents have elevated risk for HIV infection? In this study, researchers examined the state of evidence regarding the association between orphan status and HIV risk in studies of youth aged 24 years and younger. Using systematic review methodology, they identified 10 studies reporting data from 12 countries comparing orphaned and non-orphaned youth on HIV-related risk indicators, including HIV serostatus, other sexually transmitted infections, pregnancy and sexual behaviours. Meta-analysis of HIV testing data from 19,140 participants indicated significantly greater HIV seroprevalence among orphaned (10.8%) compared with non-orphaned youth (5.9%). Trends across studies showed evidence for greater sexual risk behaviour in orphaned youth. In conclusion, studies on HIV risk in orphaned populations, which mostly include samples from sub-Saharan Africa, show nearly two-fold greater odds of HIV infection among orphaned youth and higher levels of sexual risk behaviour than among their non-orphaned peers. Interventions to reduce risk for HIV transmission in orphaned youth are needed to address the sequelae of parental illness and death that might contribute to sexual risk and HIV infection.
In June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. In this study, researchers assessed progress toward this UNGASS target in Manicaland, Zimbabwe, using repeated household-based population sero-survey data. Progress towards the target was measured by calculating the proportional change in HIV prevalence among youth and young ANC attendees over three survey periods (rounds 1 to 3). The researchers found that HIV prevalence among youth in the general population declined by 50.7% from round 1 to 3. Among young ante-natal care (ANC) attendees, the proportional decline in prevalence of 43.5% was similar to that in the population, although ANC data significantly underestimated the population prevalence decline from round 1 to 2 and underestimated the increase from round 2 to 3. Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines. In Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends.
The Health4Men Clinic at Baragwanath Hospital, South Africa, is an HIV and Aids advocacy network specifically devoted to the needs of men who have sex with men (MSM). Nthato Ramushu from the Clinic says that the term MSM is quite new for many people. Because same-sex sexuality is easily misunderstood, this group is often neglected in HIV prevention and treatment campaigns. He states that almost half of those men living in Soweto, Gauteng who are gay or are MSM are too afraid to identify themselves as gay or MSM, despite their needs for health services and higher risk of HIV infection and transmission. Ramushu noted that many MSM are married men who are not open about their sexuality, fearing rejection by their families and communities.
The authors of this study analysed demographic and contextual factors associated with sexual risk taking among HIV-infected patients on antiretroviral treatment (ART) in Africa's largest informal urban settlement, Kibera in Nairobi, Kenya. In the study, they included 515 consecutive adult patients on ART attending the African Medical and Research Foundation clinic in Kibera in Nairobi. Interviewers used structured questionnaires covering socio-demographic characteristics, time on ART, number of sexual partners during the previous six months and consistency of condom use. Twenty-eight% of patients reported inconsistent condom use. Female patients were significantly more likely than men to report inconsistent condom use. Shorter time on ART was significantly associated with inconsistent condom use. Multiple sexual partners were more common among married men than among married women. ART needs to be accompanied by other preventive interventions, the authors conclude, to reduce the risk of new HIV infections among sero-discordant couples and to increase overall community effectiveness.
This ethnographic study in Dzivaresekwa district, Harare, Zimbabwe, examines the issue of sexuality among the elderly and their challenges in accessing information, education, and communication (IEC) campaigns in the face of HIV and AIDS. The research depended heavily on collecting life histories through key informant interviews. The theory of structuration as proposed by Anthony Giddens was adopted as a framework to analyse the findings. The findings reveal that although the sample of elderly people in Dzivaresekwa district were sexually active, HIV/AIDS-related interventions in the form of IEC campaigns mainly focus on the age group of 14–49-year-olds, and otherwise consider the elderly only as a group indirectly affected by the epidemic and less at risk of HIV infection. This is mainly a result of society’s presumption that people withdraw from sexual life with advanced age. Thus, the elderly are incorrectly regarded as sexually inactive and not susceptible to contracting sexually transmitted infections. A fuller understanding of the sexuality of the elderly is important to increase the usefulness HIV/AIDS efforts, while IEC campaigns that target them are still needed.
In this study, the authors explored acceptability of child transmission (PMTCT) programme components and identified structural and cultural challenges to male involvement in pregnancy and childbirth in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used, including focus group discussions with fathers and mothers, in-depth interviews with fathers, mothers and health personnel, and a survey of 426 mothers bringing their four-week-old infants for immunisation at five reproductive and child health clinics. Routine testing for HIV of women at the antenatal clinic was found to be highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance. Very few men joined their wives for testing and thus missed out on PMTCT counselling. The main barriers reported were that women did not have the authority to request their husbands to test for HIV and that the arena for testing, the antenatal clinic, was defined as a typical female domain where men were out of place. The authors conclude that deep-seated ideas about gender roles and hierarchy are the major obstacles to male participation in the PMTCT programme. Empowering men to participate by creating a space within the PMTCT programme that is male friendly should be feasible and should be highly prioritised for the PMTCT programme to achieve its potential.
Three international organisations have negotiated reductions on key first- and second-line, and paediatric antiretrovirals (ARVs) that will help countries save at least US$600 million over the next three years: the Clinton Health Access Initiative (CHAI), the international drug purchasing facility UNITAID and the UK Department for International Development (DFID). The deal, expected to affect most of the 70 countries comprising CHAI's Procurement Consortium, features notable reductions in the prices of tenofovir (TDF), efavirenz, and the second-line ritonavir-boosted atazanavir (ATV/r) used in HIV patients who have failed initial, or "first-line", regimens. As part of the deal, the three bodies set price ceilings for more than 40 adult and paediatric ARVs with eight pharmaceutical manufacturers and suppliers, which account for most ARVs sold in countries with access to generic drugs. As a result, the cost of ATV/r is down by two-thirds from just three years ago. Meanwhile, a once-a-day fixed-dose combination (FDC) pill containing TDF and efavirenz will now cost countries less than US$159 per patient per year. In 2008, low-income countries paid about $400 per patient per year for the same pill.
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 dangerous.