Three South Africans are part of a special group of HIV positive people that may provide valuable clues to scientists searching for a vaccine. Scientists call them ‘elite controllers’, as they have virtually undetectable levels of HIV in their blood and normal immune systems (CD4 counts), despite the fact that some have been infected for a number of years. Harvard University’s Professor Bruce Walker heads an international study of about 1,300 controllers that is trying to unravel how they control HIV so that this knowledge can be used to help boost the immunity of ordinary people. Over two-thirds of the controllers have a gene called B57 that is able to process antigens (foreign substances such as viruses that enter the body). A range of studies presented at the international AIDS Vaccine conference in Paris in October identified this gene as being able to protect against HIV. But not all controllers have B57. Another small clue is that the controllers’ immune systems seem to target a particular HIV gene called Gag more than the other HIV proteins, when it enters their cells, indicating that Gag may be more dangerous than other viral genes. Finally, the elite controllers have abnormally active dendritic cells, which are the key cells that ‘conduct’ the body’s immune response.
Equity and HIV/AIDS
Swaziland not only has the world's highest HIV prevalence rate, it now also has the highest tuberculosis (TB) rate, but health officials warn that not enough is being done to integrate TB and HIV services. One in four adults is infected with HIV. By the end of 2007, an estimated 170,000 people were living with HIV, and every year an estimated 13,000 people develop TB, the primary opportunistic disease in HIV-positive people. Themba Dlamini, manager of Swaziland's National TB Control Programme, said 80% of Swaziland's TB cases were also HIV-positive. But with governments focused on HIV/AIDS, TB has not been getting enough attention. Swaziland's Health Minister, Benedict Xaba, said that, although the country provided free TB medicines, other costs, such as hospital fees and transport, made it difficult for many people to access health services. About 58% of TB patients completed their six-month course of treatment last year, falling far short of the 85% target recommended by the World Health Organization. International guidelines also set a 70% detection target for TB, but in Swaziland the case detection rate is below 60%.
This paper reviews published quantitative research on the mental health of HIV-infected adults in Africa. Twenty-seven articles published between 1994 and 2008 reported the results of 23 studies. Most studies found that about half of HIV-infected adults sampled had some form of psychiatric disorder, with depression the most common individual problem. People living with HIV or AIDS (PLHIV) tended to have more mental health problems than non-HIV-infected individuals, with those experiencing less problems less likely to be poor and more likely to be employed, educated and receiving antiretroviral treatment (ART). While some key findings emerged from the studies, the knowledge base was diverse and the methodological quality uneven, so studies lacked comparability and findings were not equally robust. Priorities for future research should include replicating findings regarding common mental health problems among PLHIV, important issues among HIV-infected women, and the longer-term mental health needs of those on ART. Research is also needed into predictors of mental health outcomes and factors associated with adherence to ART, which can be targeted in interventions.
This paper sought to determine whether individuals’ risk perceptions and efficacy beliefs could be used to meaningfully segment audiences to assist interventions that seek to change HIV-related behaviours. A household-level survey of 968 individuals was conducted in four districts in Malawi. Cluster analysis was used to create four groups within the risk perception attitude framework: responsive, avoidant, proactive, and indifferent. The researchers ran analysis of covariance models (controlling for known predictors) to determine how membership in the risk perception attitude framework groups would affect three variables: knowledge about HIV, HIV-testing uptake and condom use. A significant association was found between membership in one or more of the four Risk Perception Attitude Framework groups and the three variables. In conclusion, the Risk Perception Attitude Framework can serve as a theoretically sound audience segmentation technique to determine whether messages should augment perceptions of risk, beliefs about personal efficacy or both.
This paper explored the extent to which public sector roll-out has met the estimated need for paediatric treatment in a rural South African setting. Local facility and population-based data were used to compare the number of HIV infected children accessing HAART before 2008, with estimates of those in need of treatment from a deterministic modeling approach. The impact of programmatic improvements on estimated numbers of children in need of treatment was assessed in sensitivity analyses. It found that, if PMTCT uptake were extended to reach 100% coverage, the annual number of infected infants could be reduced by 49.2%. Despite progress in delivering decentralised HIV services to a rural sub-district in South Africa, substantial unmet need for treatment remains. In a local setting, very few children were initiated on treatment under one year of age and steps have now been taken to successfully improve early diagnosis and referral of infected infants.
This study set out to assess paediatric antiretroviral treatment (ART) outcomes and their associations from a collaborative cohort representing 20% of the South African national treatment programme. It took the form of a multi-cohort study of 7 public sector paediatric ART programmes in Gauteng, Western Cape and KwaZulu-Natal provinces. The subjects were ART-naïve children (≤16 years) who commenced treatment with ≥3 antiretroviral drugs before March 2008. The study found that the median (IQR) age of 6,078 children with 9,368 child-years of follow-up was 43 months, with 29% being <18 months. Most were severely ill at ART initiation. More than 75% of children were appropriately monitored at 6-monthly intervals with viral load suppression (<400 copies/ml) being 80% or above throughout 36 months of treatment. Mortality and retention in care at 3 years were 7.7% (95% confidence interval 7.0 - 8.6%) and 81.4% (80.1 - 82.6%), respectively. Dramatic clinical benefit for children accessing the national ART programme is demonstrated. Higher mortality in infants and those with advanced disease highlights the need for early diagnosis of HIV infection and commencement of ART.
HIV and AIDS will slow Africa’s economic growth, but most important it will deplete human capital. Investment is declining as households, businesses and governments increase their recurrent expenditure to compensate for losses and disruptions because of sick or dead individuals. The health system – usually at the forefront in absorbing the impact of HIV and AIDS-related illnesses – is being eroded through the loss of many skilled personnel. Health staff are retiring, leaving for the private sector or other countries and succumbing to AIDS. In high-prevalence countries the epidemic is adversely affecting popular participation through attrition among the politically active age groups. The attrition among government officials and civil service personnel is compromising the state’s ability to implement decisions and policies. The epidemic is also likely to affect popular political opinion and levels of activism by reshaping political priorities and loyalties. But these challenges can be met if governance continues to improve across Africa.
This article summarises the challenges, opportunities and lessons learned from presentations, discussions and debates addressing major policy and programmatic responses to HIV in six geographical regions, including sub-Saharan Africa. It draws from AIDS 2008 Leadership and Community Programmes, particularly the six regional sessions, and Global Village activities. While the epidemiological, cultural and socio-economic contexts in these regions vary considerably, several common, overarching principles and themes emerged: advancing basic human rights, particularly for vulnerable and most at risk populations; ensuring the sustainability of the HIV response through long-term, predictable financing; strengthening health systems; investing in strategic health information; and improving accountability and the involvement of civil society in the response to AIDS. Equally important is the need to address political barriers to implementing evidence-based interventions such as opioid substitution therapy (OST), needle and syringe programmes (NSPs), comprehensive sexuality education for youth, and sexual and reproductive rights.
In this study, 202 isiXhosa speaking older caregivers from Motherwell in the Eastern Cape Province of South Africa were trained to provide care for grandchildren and adult children living with HIV or AIDS. Based on a community needs assessment, a health education intervention comprising four modules was designed to improve skills and knowledge which would be used to assist older people in their care-giving tasks. Some topics were HIV and AIDS knowledge, effective intergenerational communication, providing home-based basic nursing care, accessing social services and grants, and relaxation techniques. Structured one-on-one interviews measured differences between pre-intervention and post-intervention scores among those who attended all four modules vs. those that missed one or more of the sessions. The results demonstrated that older people who participated in all four workshops perceived themselves more able and in control to provide nursing care. The participants also showed a more positive attitude towards people living with HIV or AIDS and reported an increased level of HIV and AIDS knowledge.
More than four million people in low- and middle-income countries were receiving antiretroviral therapy (ART) at the close of 2008, representing a 36% increase in one year and a ten-fold increase over five years, according to this report. It highlights other gains, including expanded HIV testing and counselling and improved access to services to prevent HIV transmission from mother to child. Access to antiretroviral therapy continues to expand at a rapid rate. Of the estimated 9.5 million people in need of treatment in 2008 in low- and middle-income countries, 42% had access, up from 33% in 2007. The greatest progress was seen in sub-Saharan Africa, where two-thirds of all HIV infections occur. Prices of the most commonly used antiretroviral drugs have declined significantly in recent years, contributing to wider availability of treatment. The cost of most first-line regimens decreased by 10–40% between 2006 and 2008. However, second-line regimens continue to be expensive. Despite recent progress, access to treatment services is falling far short of need and the global economic crisis has raised concerns about their sustainability. Many patients are being diagnosed at a late stage of disease progression resulting in delayed initiation of ART and high rates of mortality in the first year of treatment.