Despite the successes in rolling out antiretroviral therapy in sub-Saharan Africa, treatment remains lifelong and systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programmes. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programmes in Africa. They interviewed 890 patients enrolled in HIV treatment programmes in Jos in Nigeria, Dar es Salaam in Tanzania and Mbarara in Uganda who had extended absences from care. Two-hundred-eighty-seven were located, and 91 took part in the study. Findings revealed unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Through the process of disengagement, patients who missed visits and felt reluctant to return over time lost their subjective sense of connectedness to care. The authors conclude that efforts to prevent missed clinic visits combined with moves to minimise barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.
Equity and HIV/AIDS
In this report, the United Nations Children’s Fund (UNICEF) and its partners note progress on preventing mother-to-child HIV transmission (PMTCT), with most women around the world getting anti-retroviral drugs to prevent transmission to newborns. However, globally, AIDS remains the leading cause of death amongst women of childbearing age and UNICEF’s goal now is to help eliminate vertical mother-to-child transmission so that fewer or no newborns will be infected, especially in Africa, where 1,000 babies acquire the virus every day. UNICEF notes general progress in four priority areas: prevention of mother-to-child transmission of HIV; paediatric treatment; prevention among adolescents and young people; and protection for orphans and vulnerable children. The report emphasises that reaching the poorest, most marginalised and least served has been at the core of successful AIDS programming. That imperative is even greater in an era of static resources and ever more complex competing priorities. The AIDS-free generation that is now in sight can be achieved – but only if governments accelerate the scale-up of proven measures, and only if they are viewed as part of a rights-based, results-focused drive to reach all those in need. Integrating interventions into existing systems without losing the capacity to address the specific needs of children affected by AIDS remains a significant challenge.
This global strategy is intended to guide the response of the health sector to HIV epidemics to achieve universal access to treatment, prevention, care and support, improve related health outcomes and strengthen health systems. In order to achieve the twin goals of no new HIV infections and long, healthy lives for all people living with HIV, the strategy takes four steps. First, it reaffirms global goals for the health-sector response to HIV. Second, it proposes four strategic directions to guide national responses and to provide a framework for action by the World Health Organization (WHO). Third, it prioritises five key contributions that underpin the strategic directions and that will be the focus of WHO’s efforts in the next five years. Fourth, it positions the health-sector response to HIV within the broader public health agenda and as part of a multisectoral response to HIV. The strategy is global in scope but recognises differences in types and stages of epidemics, contexts, needs and responses across regions and countries that require targeted and contextual approaches.
The World Health Organization released revised principles and recommendations for HIV and infant feeding in November 2009. The recommendations are based on programmatic evidence and research studies that have accumulated over the past few years within African countries. This document urges national or sub-national health authorities to decide whether health services should mainly counsel and support HIV-infected mothers to breastfeed and receive antiretroviral interventions, or to avoid all breastfeeding, based on estimations of which strategy is likely to give infants in those communities the greatest chance of HIV-free survival. South Africa has recently revised its clinical guidelines for prevention of mother-to-child HIV transmission, adopting many of the recommendations in the November 2009 World Health Organization’s rapid advice on use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. However, one aspect of the new South African guidelines gives cause for concern: the continued provision of free formula milk to HIV-infected women through public health facilities. This paper presents the latest evidence regarding mortality and morbidity associated with feeding practices in the context of HIV and provides suggestions for the modification of current policy to prioritise child survival for all South African children.
In this interview with Sheila Tlou, who took over as UNAIDS director for east and southern Africa in November 2010, Tlou notes that only two countries in east and southern Africa – Rwanda and Botswana – have achieved universal access to anti-retroviral treatment. In 2015, UNAIDS and other health governance bodies are expected to set more targets, according to Tlou. She believes that the region will reach Millennium Development Goal (MDG) 6 by 2015, namely to halt and reverse the spread of HIV. However, she emphasises that the region will not have reached its goals of zero new HIV infections, zero deaths and zero discrimination. She identifies the greatest barriers to achieving HIV and AIDS goals in the region as stigma and discrimination. Key populations have been criminalised, including men who have sex with men, sex workers, injecting drug users and transgender populations, despite statistics that indicate that, in Africa, 34% men who have sex with men also reported that they were married and 54% reported that they had had sex with both men and women in the past six months.
According to this report, projections indicate that new HIV infections will surpass the global community’s capacity to provide treatment. If the burden of HIV and AIDS does reach the projected levels, it will confront decision makers with tough choices about who receives life-saving treatment and who does not. The Institute of Medicine (IoM) argues that capabilities need to be expanded to enable professionals overseeing HIV and AIDS policies, programmes and resource allocation to receive ethical training and to carry out their responsibilities within the structures needed to ensure transparency and accountability in these life-altering decisions. No single strategy will offer a magic bullet to meet the challenge of HIV/AIDS, therefore coun¬tries will need to adopt multi-pronged approaches. In particular, African nations should plan now for how to respond to this rapidly growing epidemic. IOM concludes that shared responsibility between the United States and African nations will empower these nations to take ownership of the challenge of HIV and AIDS and to work together to address the issues. For African nations, the focus should be on strengthening health care systems by making the most of existing capacities, such as health care workers on the ground and local institutions.
HIV and AIDS treatment in developing countries is being dealt a double blow that will mean treatment recommendations cannot be implemented and the promise of new scientific research will remain unfulfilled, according to the international medical humanitarian organization, Médecins Sans Frontières (MSF). The prices of the newer anti-retrovirals (ARVs) are expected to be astronomical, while donors are retreating from their commitments to expand AIDS treatment. The World Health Organization’s (WHO) latest recommendations for treatment include treating people with better tolerated drugs, and earlier. The revised strategy calls for treating people before they become ill from opportunistic infections such as tuberculosis. MSF data from Lesotho shows the value of this new strategy: providing people with treatment earlier led to a 68% reduction in deaths, a 27% reduction in new diseases, a 63% reduction in hospitalisation and a 39% reduction in people defaulting from care. Even South Africa, a middle-income country with the largest ARV treatment programme in the world, is expected to struggle to implement the full WHO recommendations if its proposal to the Global Fund is not approved.
In this documentary, the stories of three ‘ordinary men' from South Africa, Kenya and Sierra Leone are presented as they deal with the realities of HIV. The producer of the documentary is a gender activist who deliberately avoided using experts and non-governmental organisation workers to provide facts and advice, instead relying on personal narrative to reveal the relevant social and economic issues surrounding condom use and to make the documentary more relatable to its intended audience – African men. The film was envisioned as a way to stimulate debate about the challenges and complexities these men face on condom use. It may be useful as a tool for local civil society organisations, which could use the film to aid discussions about condoms.
South African AIDS activist organisations, SECTION27 and the Treatment Action Campaign (TAC), have welcomed the government’s successful new anti-retroviral (ARV) tender, which covers the period 1 January 2011 to 31 December 2012 and will see the state procuring ARVs at the best prices available globally. This is in stark contrast to the previous tender, which resulted in South Africa paying significantly more than necessary for ARVs. For example, South Africa will now be paying – on average – about R115 per patient per month on standard combination treatment of three ARVs, compared to a previous cost of R110 for just one ARV. Also, the price of the paediatric version of abacavir has nearly halved since the last tender. SECTION27 notes, however, that the tender did not include any TDF-containing three-in-one fixed dose combinations, which would allow patients the convenience of taking all their medications in just one pill. The organisation calls for call for greater transparency in future tenders, with more autonomy for the Department of Health and less influence on the tendering process by the Treasury.
The aim of this study was to identify risk factors that could explain the large differences in HIV-1 prevalence among pregnant women in Harare, Zimbabwe, and Moshi, Tanzania. Cross-sectional data from a two-centre study that enrolled pregnant women in Harare and Moshi was used. Consenting women were interviewed about their socio-demographic background and sexual behaviour, and tested for presence of sexually transmitted infections and reproductive tract infections. The prevalence of HIV-1 among pregnant women was 26% in Zimbabwe and 7% in Tanzania. The HIV prevalence in both countries rises constantly with age up to the 25-30 year age group. After that, it continues to rise among Zimbabwean women, while it drops for Tanzanian women. Risky sexual behaviour was more prominent among Tanzanians than Zimbabweans. Mobility and such infections as HSV-2, trichomoniasis and bacterial vaginosis were more prevalent among Zimbabweans than Tanzanians. In conclusion, the higher HIV-1 prevalence among pregnant women in Zimbabwe compared with Tanzania could not be explained by differences in risky sexual behaviour: all risk factors tested for in the study were higher for Tanzania than Zimbabwe. Non-sexual transmission of HIV might have played an important role in variation of HIV prevalence.