Male-to-female transgender individuals, or transgender women (TW), are at high risk for HIV infection and face multiple barriers to HIV care. This article examines how a community-based clinic that offers free or low-cost care addresses the health care needs of TW. A total of twenty TW who attended a health care clinic dedicated to community-based health were interviewed regarding best practices for HIV prevention and primary care. In-depth interviews were conducted, transcribed, coded, and analysed. Factors reported to be effective for HIV prevention and primary care included access to health care in settings not dedicated to serving transgender and/or gay communities, a friendly atmosphere and staff sensitivity, and holistic care, including hormone therapy. Community-based health care settings can be ideal locales for HIV prevention and primary care for TW.
Equity and HIV/AIDS
The re-use of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalised HIV epidemics. Several African governments have taken steps to control injecting equipment, including banning syringes that can be reused. However, injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region, having become increasingly common among young adults in sub-Saharan Africa and also associated with high-risk sex. Demand-reduction programmes based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services. Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm-reduction programmes. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia and North America.
Multiple partnerships may not be as common in South Africa as previously thought, according to a study presented at the recent AIDS Research Symposium at the University the Witwatersrand, in Johannesburg. Saul Johnson, managing director of Health & Development Africa (HDA), a health consultancy which conducted the research, said findings from four sites across the country showed about 26% of men and 5% of women reported having had more than one partner in the past year. ‘The perception out there is that [having multiple partners] is more common than it really is,’ he said. The reason may be that men tend to inflate their partner counts. Johnson and his team found that when men were asked to write down a figure for the number of partners they had had in the last twelve months they exaggerated, but when asked to plot their sexual encounters in more detail, using a sexual partner calendar, they often revised the number down slightly. Women's responses were more likely to be consistent.
In South Africa a generation of children who were born HIV-positive is reaching young adulthood, but they are not getting the type of message or psychosocial support they need from the public sector. ‘These kids are getting older on treatment and surviving on treatment; they're becoming sexually active, they want to get married,’ HIV paediatrician Dr Harry Moultrie told the annual University of the Witwatersrand AIDS Research Symposium in Johannesburg at the end of August. We’re seeing a lot of teen pregnancies, sexually transmitted diseases and poor developmental outcomes.’ Studies in the United States have shown that HIV-positive teens may be more likely to engage in risky behaviour. Similar studies have yet to be carried out in South Africa, but Moultrie noted that if the findings were similar, many doctors in South Africa would not be ready to deal with the challenge. Only 12 clinics in the country are offering specialised services to HIV-positive youth. Moultrie called on the government to re-examine the guidelines that sent children aged 14 years or older away from paediatric clinics and into adult facilities, which might not be able to offer them the services they needed. ‘You have to realise that a lot of these children have gone through multiple childhood traumas, including multiple changes in caregivers,’ he said.
Non-governmental organisations have raised concern over the lack of female condoms claiming that it undermines efforts to curb new infections. The health department is looking for donors to finance the procurement and distribution of female condoms, citing lack of funds. Meanwhile, a tender has been issued. Tian Johnson, Advocacy Officer of the Thohoyandou Victim Empowerment Programme (TVEP), raised concern over the awarding of the tender for the manufacture of female condoms. ‘The current situation pertaining to the inadequate access to the female condom in South Africa today is a violation of the rights of women and men of this country. The tender for female condom supply has been awarded to a company called the Female Health Company. That means there are no options for competition, there are no options for bringing prices down. That enables us to use the excuse that we have been using for far too long, the excuse that female condoms are too expensive. It’s an excuse with no basis and with no merit’, he said.
A new government initiative to boost local HIV and AIDS research has been launched. The South African HIV/AIDS Research (and Innovation) Platform (SHARP), with backing from the Department of Science and Technology (DST), will support the development of new treatment options and prevention approaches such as microbicides, vaccines, and the role of genetics in controlling HIV infection. ‘The South African government had to revisit its expectations of HIV vaccine research in the light of growing national and international deliberations on the need to modify basic HIV/AIDS research and development strategies,’ the DST noted. So far SHARP has committed R45 million (US$5.8 million) to fund nine research projects over the next three years. One of the projects will validate a method for testing resistance to antiretroviral drugs that is cheaper and more accurate than the current method; another will investigate the role of natural ‘killer’ cells that prevent HIV transmission.
Observational studies have reported an association between male circumcision and reduced risk of HIV infection in female partners. This study assessed whether circumcision in HIV-infected men would reduce transmission of the virus to female sexual partners. Nine-hundred and twenty-two uncircumcised, HIV-infected, asymptomatic men aged 15–49 years with CD4-cell counts 350 cells per μL or more were enrolled in this unblinded, randomised controlled trial in Rakai District, Uganda. HIV-uninfected female partners of the randomised men were concurrently enrolled and followed up at 6, 12 and 24 months to assess HIV acquisition by male treatment assignment (primary outcome). The trial was stopped early because of futility. Seventeen (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up. It appears circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months – longer-term effects could not be assessed.
While efforts have been made to assess the costs of providing antiretroviral therapy (ART) via accredited service points, little information is available on its downstream costs, particularly in public secondary level hospitals. This paper aims to determine the cost of care for inpatients and outpatients at a dedicated antiretroviral referral unit, the GF Jooste Hospital, during March 2005. This prospective costing study on 48 outpatients and 25 inpatients was conducted from a health system perspective. Incremental cost per outpatient was found to be R1,280 and R5,802 per inpatient. Costs were dominated by medical staff costs (62% inpatient and 58% outpatient, respectively). As the costs of providing secondary level care for patients on or immediately preceding ART initiation can be significant, the study recommends that they should be included in the government’s strategic planning so that the service can be expanded to meet current and future needs and to avoid crowding out other secondary level health services.
This paper seeks to describe the associations between socio-demographic, behavioural and social characteristics and knowledge of HIV status among a nationally representative population in South Africa. A multistage, representative probability sample involving 16,395 male and female respondents, aged 15 years or older was selected. From the total sample 27.6% ever and 7.8% knew their HIV status in the past 12 months. In multivariate analyses, being female, the age group 25 to 34 years old, other than African Black population group (White, Coloured and Asian), higher educational level, being employed, urban residence, awareness of a place nearby where one could be tested for HIV, impact of HIV on the household and having had two of more sexual partners in the past year were associated with knowledge of HIV status. Education about HIV and AIDS and access to HIV counselling and testing in rural areas, in particular among the Black African population group needs to be improved, in order to enhance the uptake of HIV counselling and testing services, an essential step for the initiation of treatment.
This report on international AIDS assistance provides data from 2008, the most recent year available. As such, it represents funding levels reflecting budgets largely set in place before the acceleration of the current global economic crisis. The analysis is based on data provided by donor countries. It found that international AIDS assistance from the G8, the European Community and other donor governments reached its highest level to date – new commitments totalled US$8.7 billion, of which US$6.7 billion was through bilateral channels. Disbursements have increased by more than six-fold. In 2008, the United States was the largest donor in the world, accounting for 51.3% of disbursements by governments. The United Kingdom accounted for the second largest share (12.6%), followed by the Netherlands (6.5%), France (6.4%) and Germany (6.2%). Still, there was a gap of US$6.5 billion between resources available from all sources and resources needed in 2008, as estimated by UNAIDS.