In a bid to reduce the rate of HIV transmission from mother to child, Uganda will now give all pregnant women highly active antiretroviral therapy (HAART). Second deputy Prime Minister, Kirunda Kivejinja, said the government was committed to scaling up interventions that prevent HIV infections in children by improving prevention of mother-to-child transmission (PMTCT) services. ‘We shall also ensure scale-up of access to services for early infant HIV testing and treatment, and for care and support for all children that are affected by HIV,’ he added. ’We have proven that when pregnant women receive HAART, the rate of transmission from mother to child is less than 2%; this should go full-scale in Uganda,’ Addy Kekitiinwa, executive director of the Baylor Uganda Children's Foundation, said. A recent Ugandan study of 1,829 women found a 1.67% infection rate among infants born to mothers who received HAART during pregnancy, compared with an 11.75% infection rate among infants whose mothers received single-dose Nevirapine, and 3.73% and 5.02% of those who received two types of combination therapy.
Equity and HIV/AIDS
New data presented at the IAS Conference for 2009 is already having an impact on HIV policy and practice on a global scale. Results of several basic research studies provided the field with a better understanding of the elevated HIV infection risk among African women due to chronically activated T-cells in genital tract mucosa, how complex genetic variables may affect HIV acquisition and disease progression, and how early antiretroviral therapy (ART) can substantially reduce the size of latent HIV reservoirs, a significant clinical issue in chronic HIV infection. Findings demonstrating that maternal triple-drug ART used throughout pregnancy and breastfeeding reduced vertical transmission to 1% are expected to inform revised World Health Organization (WHO) and South African national guidelines on antiretroviral prophylaxis. Also, research delineating the impact of antiretroviral therapy on reducing coincident tuberculosis and malaria epidemics in HIV-prevalent regions argued for wider and earlier access to treatment.
The Kenyan government has launched an ambitious HIV campaign to test at least one million people across the country over a three-week period. The programme is the first step in a national campaign that intends to test 10 million people by June 2010. According to the 2007 Kenya AIDS Indicator Survey, 80% of HIV-positive adults in the country do not know their status. The initiative, dubbed ‘Jitambue leo, ni haki yako’, Swahili for ‘Know yourself today, it is your right’, was launched on 23 November in the Kenyan capital, Nairobi. ‘We want to target everybody in our campaigns...no group is safe; the youth are becoming increasingly vulnerable, the old initially thought of as safe are equally at risk, and those in marriage account for 50% of new infections,’ said Dr Nicholas Muraguri, head of the National AIDS and Sexually transmitted infection Control Programme. ‘Infants and unborn children benefit too when their parents are tested.’
The world needs a dramatic change in thinking – and action from external funders, policymakers, and programme managers in the public, private and nongovernmental (NGO) sectors – to focus on strengthening health systems in the countries most affected by HIV and AIDS. To meet the Millennium Development Goal of reversing the epidemic by 2015, stakeholders must change how services are designed and delivered. A lesson learned in the 1990s and 2000s was that a host of separate activities cannot be scaled up in a sustainable way and that strengthening health systems is essential for long-term sustainability. The time has come to take a systems approach to HIV & AIDS programming. This holistic approach will create a strong foundation by focusing all efforts on integration, effectiveness and sustainability.
The Scorecard rates countries on their reporting of six key elements in an AIDS response tuned to the needs of women, including the collection of HIV data specific to women; progress in ensuring that women have equal access to HIV services; and the impact of national responses on reducing infections among women and facilitating their access to treatment. The overall score reflects the extent of data provided on each element. Countries with the highest HIV burdens were doing the best job of reporting data detailing their female-centred AIDS efforts, with 67% earning a high rating. However, the authors noted that a high score for reporting did not necessarily reflect good performance in delivering HIV services for women. Relatively good reporting by South Africa, for example, contrasted with a poor record in improving the maternal mortality of HIV-positive women, or curbing high rates of violence against women. There was also a disturbing lack of data on the situation of young girls, and what countries were doing to address their particular vulnerabilities.
The main aims of PEPFAR are presented for information. PEPFAR seeks to ensure that HIV and AIDS programmes are sustainable, country-owned and country-driven. The programmes must address HIV/AIDS within a broader health and development context and must build on existing strengths and increase efficiencies. PEPFAR seeks to transit from an emergency response to promotion of sustainable country programmes, strengthening partner government capacity to lead the response to the epidemic and other health demands, expanding prevention, care and treatment in both concentrated and generalised epidemics, integrating and coordinating HIV and AIDS programmes with broader global health and development programmes to maximise impact on health systems, and investing in innovation and operations research to evaluate impact, improve service delivery and maximise outcomes. PEPFAR’s targets for the fiscal period 2010–2014 focus on prevention, care, support, treatment and sustainability, including supporting the training and retention of more than 140,000 new health care workers to strengthen health systems.
This community-based, qualitative study conducted in rural Kisesa District, Tanzania, explores perceptions and experiences of barriers to accessing the national antiretroviral programme among self-identified HIV-positive persons. Part of wider operations research around local introduction of HIV therapy, the study involved consultation with villagers and documented early referrals' progress through clinical evaluation and, if eligible, further training and drug procurement. Data collection consisted of 16 participatory group discussions with community members and 18 in-depth interviews with treatment-seekers. While simple measures to reduce perceived barriers improved initial access to treatment and helped overcome anxiety among early referrals, pervasive stigma remains the most formidable barrier. Encouraging successful referrals to share their positive experiences and contribute to nascent community mobilisation could start to address this seemingly intractable problem.
This study explored factors influencing attendance at HIV clinic appointments among patients in a rural ward in north-west Tanzania. Forty-two in-depth interviews (IDI) and four focus group discussions were conducted with HIV-infected persons who had been referred to a nearby antiretroviral therapy (ART) clinic, and IDI were undertaken with eleven healthcare workers involved in diagnosis, referral and care of HIV-positive patients. Barriers to clinic attendance frequently included health systems factors, while physical and social benefits encouraged regular clinic attendance. Self-confidence in being able to sustain clinic attendance was often determined by patients' expectations or experiences of family support. These findings suggest that multi-faceted interventions are required to promote regular HIV clinic attendance, including on-going education, counselling and support in both clinic and community settings. These interventions also need to recognise the evolving needs of patients that accompany changes in physical health, and should address local beliefs around HIV aetiology. Decentralisation of HIV services to rural communities should be considered.
More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care) must discuss links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate alcohol’s effects on unsafe sex, unintended pregnancy and HIV transmission.
There has been a renewed debate over whether AIDS deserves an exceptional response because of the amount of funding targeted to the disease and the belief that AIDS activists prioritise it above other health issues. The strongest detractors of exceptionalism claim that the AIDS response has undermined health systems in developing countries. This paper argues that AIDS should be normalised in countries with mid-level prevalence, except when life-long treatment is dependent on outside resources – as is the case with most African countries – because treatment dependency creates unique sustainability challenges. And AIDS must always require an exceptional response in countries with high prevalence (over 10%). In these settings there is substantial morbidity, filling hospitals and increasing care burdens, and increased mortality, which most visibly reduces life expectancy. The idea that exceptionalism is somehow wrong is an oversimplification. The AIDS response must be based on human rights principles, and it must aim to improve health and well-being of societies as a whole.