This study reports on a ten-step Nurse Initiation Management of Antiretroviral Treatment (NIMART) rollout intervention in which 45 nurses from 17 primary healthcare centres (PHCs) in Johannesburg, South Africa, were trained and mentored in NIMART to commence patients on antiretroviral treatment (ART). A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. By the end of September 2011, all 17 PHCs were initiating patients on ART. Total initiations significantly increased by 99 patients immediately after NIMART rollout and continued to increase by an average of 9 every month, while referral facility initiations decreased by 12 immediately after NIMART and then decreased by an average of 18 every month. In conclusion, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, the authors argue that it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients.
Equity and HIV/AIDS
In a study of prevention of mother-to-child transmission of HIV (PMTCT) by triple antiretroviral therapy (ART) in Dar es Salaam, Tanzania (the Mitra Plus study), retrospective viral load testing revealed a high and increasing frequency of detectable viral load during follow-up for two years postnatally in women given continuous ART for their own health suggesting poor adherence. This study explored women’s own perceived barriers to adherence to ART post-delivery so as to identify ways to facilitate better drug adherence. Semi-structured interviews were conducted with 23 of the 48 women who had detectable viral load at 24 months postnatally. Most women in the study did not acknowledge poor adherence until confronted with the viral load figures. Then they revealed multiple reasons for failing to adhere to ART, which included lack of motivation to continue ART after weaning the child, poverty and stigma. PMTCT and ART projects need to address these issues, as well as women’s lack of empowerment. The authors argue that the new World Health Organisation’s proposal to start all HIV-infected pregnant women on lifelong ART regardless of CD4 cell count needs to address the challenging realities of women in resource-poor contexts if it is to be successful.
While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing in sub-Saharan Africa (SSA), systematic reviews to provide a more comprehensive understanding are lacking. In this study, researchers synthesised 42 papers from 13 countries to investigate these factors. They found that predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as ‘opt-out’ provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers’ inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women’s decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing.
This cross-sectional study design was conducted among 753 students drawn from selected departments in Debre Markos University, Ethiopia, using multi-stage sampling technique. A self-administered questionnaire was used to estimate the prevalence of voluntary counseling and testing (VCT) service utilisation and to assess associated factors. A total of 711 students participated in the study, of whom 81.4% had heard about the government’s confidential VCT service, identifying their major sources of information as mass media (73.3%) and health workers (71.1%). Just over half (58.5%) of the study participants had undergone VCT. The researchers identified the major factors for increased VCT service utilisation as knowledge about the availability of antiretrovirals in the VCT site, information about confidentiality, absence of perceived stigma, higher risk perception and knowledge about HIV. Therefore, they argue, actions targeting on these predictors are necessary to effectively enhance the use of the VCT services utilisation.
The authors of this study examined the association between young people's interests in the consumption of modern goods and their sexual behaviour in Antananarivo and Antsiranana, Madagascar. Their survey included 2, 255 youth ages 15-24. Overall, 7.3% of women and 30.7% of men reported having had multiple partners in the last year; and 5.9% of women reported ever practising transactional sex. This was associated with perceptions concerning the importance of fashion and a series of activities associated with modern lifestyles. For transactional sex, results suggested perceptions around fashion, nightclub attendance and getting to know a foreigner were key determinants. The authors found that peri-urban residence was more associated with transactional sex than urban residence; and ethnic origin was the strongest predictor of both outcomes for women. While they found some evidence of an association between sexual behaviour and interest in modern goods, or modern lifestyles, they caution that such processes did not single-handedly explain risky sexual behaviour among youth: these behaviours were also shaped by culture and conditions of economic uncertainty. These determinants must all be accounted for when developing interventions to reduce risky transactional sex and vulnerability to HIV.
The aim of this study was to determine the proportion, characteristics and outcomes of patients who transfer-out from an antiretroviral therapy (ART) service in a South African township. Researchers included all patients aged ≥15 years who enrolled between September 2002 and December 2009. Follow-up data were censored in December 2010. A total of 4,511 patients received ART during the study period. Overall, 597 (13.2%) transferred out. The probability of transferring out by one year of ART steadily increased from 1.4% in 2002/2004 cohort to 8.9% for the 2009 cohort. Independent risk factors for transfer-out were more recent calendar year of enrolment, younger age (≤25 years) and being ART non-naïve at baseline (i.e., having previously transferred into this clinic from another facility). The proportions of patients transferred out who had a CD4 cell count <200 cells/µL and/or a viral load ≥1000 copies/mL were 19% and 20%, respectively. With scale-up of ART over time, an increasing proportion of patients are transferring between ART services and the authors argue that information systems are needed to track patients. Approximately one-fifth of these have viral loads >1000 copies/mL around the time of transfer, suggesting the need for careful adherence counselling and assessment of medication supplies among those planning transfer.
The objective for this study was to explore street children’s vulnerability to HIV and STIs infection. Researchers employed In-depth interviews with street children in the two main cities of Malawi, Blantyre and Lilongwe. A total of 23 street children were interviewed. Results of the study strongly suggest that street children could be vulnerable to HIV and other sexually transmitted infections (STIs). This is due to various factors which include low knowledge levels of STIs and HIV, high risk sexual practices, lack of safer place to spend their nights for both boys and girls rendering them vulnerable to sexual abuses and the use of sex as a tool to secure protection and to be accepted especially for the newcomers on the street. This study highlights street children’s vulnerability to sexual exploitation which predisposes them to risk of HIV and AIDS as well as STIs. Furthermore, the street environment offers no protection against such vulnerability. There is need to explore potential and context sensitive strategies that could be used to protect street children from sexual exploitation and HIV and STIs.
In this study, researchers synthesised published qualitative research to identify the factors enabling and deterring uptake of HIV testing in sub-Saharan Africa (SSA). A total of 42 papers from 13 countries were synthesised in the final analysis. Results indicated that the predominant factors enabling uptake of HIV testing were deterioration of physical health and/or death of sexual partner or child. Other enabling factors were the roll-out of various new HIV testing initiatives, such as ‘opt-out’ provider-initiated HIV testing and mobile HIV testing, availability of treatment and social network influence and support. Major barriers to uptake of HIV testing were perceived low risk of HIV infection, perceived health workers’ inability to maintain confidentiality and fear of HIV-related stigma. Other barriers were direct and indirect financial costs of accessing HIV testing, and gender inequality, which undermines women’s decision making autonomy about HIV testing. The authors conclude that improving uptake of HIV testing requires addressing perception of low risk of HIV infection and perceived inability to live with HIV. There is also a need to continue addressing HIV-related stigma, which is intricately linked to individual economic support.
This paper describes the development of a family-centred, structured intervention to support mothers to disclose their HIV status to their HIV-negative school-aged children in rural South Africa, an area with high HIV prevalence. The intervention was piloted with 24 Zulu families, all mothers were HIV-positive and had an HIV-negative child aged 6–9 years. Lay counsellors delivered the six session intervention over a six to eight week period. Qualitative data were collected on the acceptability, feasibility and the effectiveness of the intervention in increasing disclosure, health promotion and custody planning. All mothers disclosed something to their children: 11/24 disclosed fully using the words "HIV" while 13/24 disclosed partially using the word "virus". This pilot study found the intervention was feasible and acceptable to mothers and counsellors, and provides preliminary evidence that participation in the intervention encouraged disclosure and health promotion. The pilot methodology and small sample size has limitations and further research is required to test the potential of this intervention. A larger demonstration project with 300 families is currently underway.
At least 28% of schoolgirls across South Africa are HIV positive, with only 4% of boys at schools HIV positive in comparison, according to figures released by Health Minister Aaron Motsoaledi at a National Council of Provinces ‘taking Parliament to the people’ event. He added that 94,000 schoolgirls got pregnant in 2011 and about 77,000 girls had abortions at public facilities. The minister attributed the high figures to the sugar daddy phenomenon, a transactional sexual relationship between older men with money and schoolgirls, where sex is traded for physical goods, such as cell phones and accessories. Young women put themselves at risk because they don’t have the agency to be able to negotiate safe sex, he argued. There is the risk for considerable physical, psychological and emotional harm. In recognition of the growing problem, in January 2012 the KwaZulu-Natal department of health launched a campaign against sugar daddies with a call to action to ‘protect your loved ones from sugar daddies’.