This study reports on HIV-free survival among nine- to 24-month-old children born to HIV-positive mothers in the national prevention of mother-to-child transmission (PMTCT) programme in Rwanda. Researchers conducted a national representative household survey between February and May 2009. Participants were mothers who had attended antenatal care at least once during their most recent pregnancy, and whose children were aged nine to 24 months. They found that out of 1,448 HIV-exposed children surveyed, 44 (3%) were reported dead by nine months of age. Of the 1340 children alive, 53 (4%) tested HIV positive. HIV-free survival was estimated at 91.9 % at nine to 24 months. Adjusting for maternal, child and health system factors, being a member of an association of people living with HIV improved by 30% HIV-free survival among children, whereas the maternal use of a highly active antiretroviral therapy (HAART) regimen for PMTCT had a borderline effect. HIV-free survival among HIV-exposed children aged nine to 24 months is estimated at 91.9% in Rwanda. The national PMTCT programme could achieve greater impact on child survival by ensuring access to HAART for all HIV-positive pregnant women in need, improving the quality of the programme in rural areas, and strengthening links with community-based support systems, including associations of people living with HIV.
Equity and HIV/AIDS
As external funders retreat from funding HIV prevention and treatment, national programmes reliant on external funding have become exceedingly vulnerable. Activists from East and Southern Africa are calling on governments to take increased ownership of these programmes to ensure treatment continues after donor funds have gone. According to Dr Mbulawa Mugabe, UNAIDS deputy regional director for East and Southern Africa, the region has made considerable progress towards reaching the universal HIV treatment access target of 80% coverage among those in need of antiretrovirals (ARVs). He added that the region is performing above average for low and middle-income countries. However, he indicated that hardly any of the region’s governments are contributing financially to the treatment response. “We cannot leave the lives of nationals to development partners," he emphasised. According to researchers, governments need to bridge the gap between domestic and external spending for ARVs but, without accurate country-level data, this gap is difficult to estimate.
The aim of this prospective study (20 months) was to assess HIV patients' use of Traditional, Complementary and Alternative Medicine (TCAM) and its effect on anti-retroviral (ARV) adherence at three public hospitals in KwaZulu-Natal, South Africa. Seven hundred and thirty-five (29.8% male and 70.2% female) patients who consecutively attended three HIV clinics completed assessments prior to ARV initiation, 519 after 6 months, 557 after 12 and 499 after 20 months on antiretroviral therapy (ART). Results indicate that following initiation of ARV therapy the use of herbal therapies for HIV declined significantly from 36.6% prior to ARV therapy to 8% after 6 months, 4.1% after 12 months and 0.6% after 20 months on ARVs. Faith healing methods (including spiritual practices and prayer) declined from 35.8% to 22.1%, 20.8% and 15.5%, respectively. In contrast, the use of micronutrients, such as vitamin supplements, significantly increased from 42.6% to 78.2%. Herbal remedies were mainly used for pain relief, as immune booster and for stopping diarrhea. As herbal treatment for HIV was associated with reduced ARV adherence, patient's use of TCAM should be considered in ARV adherence management, the authors conclude.
This intervention study aimed to assess the effectiveness of a rural community-based anti-retroviral therapy (ART) programme in a subcounty (Rwimi) of Uganda and compare treatment outcomes and mortality in a rural community-based ART programme with a well-established hospital-based programme. Successful treatment outcomes after two years in both the community and hospital cohorts were high. All-cause mortality was similar in both cohorts. However, community-based patients were more likely to achieve viral suppression and had good adherence to treatment. The community-based programme was slightly more cost-effective. The unpaid community volunteers showed high participation and low attrition rates for the two years that this programme was evaluated. Key successes of this study include the demonstration that ART can be provided in a rural setting, the creation of a research infrastructure and culture within Kabarole’s health system, and the establishment of a research collaboration capable of enriching the global health graduate programme at the University of Alberta.
Most prevention of mother-to-child transmission (PMTCT) programmes in Africa are still not following a comprehensive approach around the four pillars as recommended by the UN strategy, according to this paper, despite the evidence on how critical interventions such as improving access to family planning and HIV prevention knowledge and tools support the goal of ending vertical transmission of HIV. Many women in the developing world continue to receive sub-optimal drugs and confusing messages about infant feeding, undermining even the slow ‘progress’ made on pillar three. And far too many women and infants in need of treatment are leaving prevention of vertical transmission programmes without any follow-up treatment, care and support. Research conducted in a number of African countries has revealed several barriers to care, such as lack of involvement of men in PMTCT services, lack of implementation of WHO guidelines on prevention of vertical transmission and infant feeding, prohibitive costs of ANC, delivery, diagnostic tests, OI and STI treatment, and transportation to distant clinics, and stigma, combined with a shortage of trained health care workers, long waiting times and lack of integrated services under one roof.
Swaziland is still short of lab reagents needed for CD4 count testing, used to initiate and monitor patients on antiretroviral treatment. Shortages of HIV programme supplies in Swaziland were first reported in mid-2011. Although the stock-outs have been largely blamed on reduced revenues from the Southern African Customs Union (SACU), the country also opted not to apply for funding in Round 10 from the Global Fund to Fight AIDS, TB and Malaria. Instead, it chose to assume financial responsibility for HIV treatment itself, at a time when SACU revenues were already expected to decline. Health Minister Themba Xaba said in a statement that the government needed US$875,000 to purchase the CD4 machine reagents.
In this report, the UNAIDS Advisory Group strongly affirms that sex workers and their organisations play a crucial role in confronting HIV and in many places have an outstanding record in helping to achieve universal access. However, sex workers usually face human rights violations and struggle to access HIV and other health and social services. Stigma and discrimination within society results in repressive laws, policies and practices against sex work, as well as their economic disempowerment. Violence against sex workers is too often committed with impunity by state and civilian actors, exacerbating sex workers’ HIV vulnerability. They are often excluded from access to benefits and financial services available to the general population and prevented from forming organisations that enable economic empowerment and social inclusion. In this report, the Advisory Group argues it it necessary for sex workers to enjoy universal access to HIV services, highlighting good practices that enhance human rights protections for sex workers in the hope that the information presented here will help shape programmes and policies on HIV and sex work that are truly human rights-based.
The authors of this study set out to determine the relative roles of stigma versus health systems in non-uptake of prevention of mother to child transmission of HIV-1 interventions by conducting a cross-sectional assessment of all consenting mothers accompanying infants for six-week immunisations. Between September 2008 and March 2009, mothers at six maternal and child health clinics in Kenya's Nairobi and Nyanza provinces were interviewed regarding PMTCT intervention uptake during recent pregnancy. Among 2,663 mothers, 2,453 (92.1%) reported antenatal HIV-1 testing. Although internal or external stigma indicators were reported by between 12% and 59% of women, stigma was not associated with lower HIV-1 testing or infant HIV-1 infection rates; internal stigma was associated with modestly decreased antiretroviral uptake. Health system factors contributed to about 60% of non-testing among mothers who attended antenatal clinics and to missed opportunities in offering antiretrovirals and utilisation of facility delivery.
The recent rise of health systems strengthening as a policy priority suggests that a move away from single-disease approaches to global health may be occurring. As the largest attempt by far to tackle one disease, the global AIDS effort has acted as a lightning rod for criticisms of global health initiatives focused on single diseases, according to the author of this paper. Global AIDS institutions have sought to respond by broadening their mandates to incorporate some wider systemic interventions into their activities. However, as the debate over addressing particular diseases or investing in health systems continues, five important underlying political and ethical questions are being neglected, including whether there is an ideal health system, the timescales involved, the definition of sustainability, governance/structural capacity and political will. If a more sustained and coordinated effort to improve health outcomes is to become a reality, these difficult questions will need to be tackled, the author concludes.
Speakers at a session on stigma at the 16th International Conference on AIDS and Sexually Transmitted Infections in Africa, held in December 2011 in Ethiopia, noted that HIV patients in Africa frequently suffer shame and depression but the continent’s health systems were ill-equipped to handle the issue, which not only affected their quality of life, but could lead to poor adherence to HIV treatment regimens. They said while HIV programmes focus heavily on reducing externalised stigma and ill-treatment of HIV patients by society, little is done to deal with a patients’ self-perception and how that might deteriorate following an HIV diagnosis. Studies from Zambia and Uganda have shown that depression is the most common psychiatric disorder among people living with HIV, and is more prevalent among HIV-positive people than in the general population. The Mbabane Mental Health Support Group, an advocacy group from Swaziland, calls for the integration of mental health services into primary healthcare as well as that of HIV positive people.