A new model for determining the demographic impact of HIV and AIDS in South Africa has been designed by two researchers, Leigh Johnson of the Centre for Infectious Disease Epidemiology and Research and Rob Dorrington of the Centre for Actuarial Research at the University of Cape Town. The new model is to replace the ASSA 2003 model for estimating HIV prevalence, HIV-related deaths, the numbers of those in need of ARVs and the impact of HIV interventions to integrate new data emerging from South Africa’s antenatal HIV-prevalence survey. The new model includes the ARV rollout data for up to the end of 2008. Because data shows that two-thirds of people starting ARVs are females, the model allows for different rates of ARV initiation in males and females, as well as for children and adults. It also recognises that the variable attrition rate across provinces.
Equity and HIV/AIDS
Although loss to follow-up after antiretroviral therapy (ART) initiation is increasingly recognized, little is known about pre-treatment losses to care (PTLC) after an initial positive HIV test. The objective of this paper was to determine PTLC in newly identified HIV-infected individuals in South Africa. It examined records of patients presenting for HIV testing at two sites offering HIV and CD4 count testing and HIV care in Durban, South Africa. PTLC was defined as failure to have a test for CD4 count within eight weeks of HIV diagnosis. Infected patients were significantly more likely to have PTLC if they lived ≥10 kilometers from the testing centre, had a history of tuberculosis treatment or were referred for testing by a health care provider rather than self-referred. Patients with one, two or three of these risks for PTLC were 1.88, 2.50 and 3.84 times more likely to have PTLC compared to those with no risk factors. In conclusion, nearly half of HIV-infected persons at two high prevalence sites in Durban, South Africa, failed to have CD4 counts following HIV diagnosis. These high rates of pre-treatment loss to care highlight the urgent need to improve rates of linkage to HIV care after an initial positive HIV test.
According to new data presented in this update, new HIV infections have been reduced by 17% over the past eight years. Since 2001, when the United Nations Declaration of Commitment on HIV/AIDS was signed, the number of new infections in sub-Saharan Africa is approximately 15% lower, which is about 400,000 fewer infections in 2008. In East Asia new HIV infections declined by nearly 25% and in South and South East Asia by 10% in the same time period. In Eastern Europe, after a dramatic increase in new infections among injecting drug users, the epidemic has leveled off considerably. However, in some countries there are signs that new HIV infections are rising again. The report highlights that, beyond the peak and natural course of the epidemic, HIV prevention programmes are making a difference. ‘The good news is that we have evidence that the declines we are seeing are due, at least in part, to HIV prevention,’ said Michel Sidibé, Executive Director of UNAIDS. ‘However, the findings also show that prevention programming is often off the mark and that if we do a better job of getting resources and programmes to where they will make most impact, quicker progress can be made and more lives saved.’
Adolescents (aged 10–18) were systematically recruited from acute admissions to the two public hospitals in Harare, Zimbabwe, to answer a questionnaire and undergo standard investigations including HIV testing, with consent. Pre-set case-definitions defined cause of admission and underlying chronic conditions. Participation was 94%. In total, 139 (46%) of 301 participants were HIV-positive, but only four were herpes simplex virus-2 (HSV-2) positive. Age and sex did not differ by HIV status, but HIV-infected participants were significantly more likely to be stunted, have pubertal delay, and be maternal orphans or have an HIV-infected mother. In conclusion, HIV is the commonest cause of adolescent hospitalisation in Harare, mainly due to adult-spectrum opportunistic infections plus a high burden of chronic complications of paediatric HIV and AIDS. Low HSV-2 prevalence and high maternal orphanhood rates provide further evidence of long-term survival following mother-to-child transmission. Better recognition of this growing phenomenon is needed to promote earlier HIV diagnosis and care.
New national treatment guidelines are set to make the world's largest antiretroviral (ARV) programme even bigger as South Africa extends treatment to more HIV-positive infants, pregnant women and people battling HIV-tuberculosis (TB) co-infection. Dr Nono Simelela, CEO of the South African National AIDS Council (SANAC), confirmed that the revised guidelines were in the final stages of editing and would go to print in March, while implementation is scheduled to begin on 1 April 2010. Major changes to the guidelines include providing ARVs to all HIV-positive infants less than one year old regardless of their CD4 count – which measures immune system strength – without having an expensive polymerase chain reaction (PCR) test that is not widely available at clinics to confirm their HIV status. Pregnant HIV-positive women will be able to start treatment at a new, higher CD4 count of 350, as will all TB/HIV co-infected patients, rather than having to wait until their CD4 counts fell to 200 or below as was previously the case. TB remains the leading cause of death among people living with HIV. The shifts in treatment could significantly reduce infant and maternal mortality due to HIV, and lower the rate of new infections.
In 2006, the World Health Organization (WHO) recommended that all patients start anti-retroviral therapy (ART) when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms. WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives. The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.
World Health Organization (WHO) recommendations on infant feeding and HIV were last revised in 2006. Significant programmatic experience and research evidence regarding HIV and infant feeding have accumulated since then. In particular, evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding. This has major implications for how women living with HIV might choose to feed their infants, and how health workers should counsel mothers when making these choices. The potential of ARVs to reduce HIV transmission throughout the period of breastfeeding also highlights the need for guidance on how child health services should commu¬nicate information about ARVs to prevent transmission through breastfeeding, and the implications for feeding of HIV exposed infants through the first two years of life.
In 2006, the World Health Organization (WHO) recommended that ARVs be provided to HIV-positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother-to-child transmission of HIV. At the time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period. WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs during that period. This will reduce the risk of HIV transmission and improve the infant's chance of survival. ‘In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs,’ said Daisy Mafubelu, WHO's Assistant Director General for Family and Community Health. National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.
The need for empirical evidence on the state of HIV and AIDS in prisons in Kenya which can influence prison specific policy formulation nationally prompted this study. Its objectives included describing the level of knowledge of HIV among male inmates; describing the sexual health knowledge and practices among male inmates before and during imprisonment; determining the prevalence and predictors of HIV infection among male inmates; and examining policy, practice and legal frameworks around prevention of HIV infection in prisons. A cross sectional study design was utilised. Data was collected from inmates and stakeholders involved in HIV and AIDS policy formulation using quantitative and qualitative approaches respectively. Both the inmates and the key informants agreed that consensual and non-consensual sex occurs between inmates. Although not many inmates were found to be abusing drugs, those who were doing so were likely to be first timers in prison. Without underestimating the role played by condoms in HIV prevention, their provision in prisons is not a panacea to the consequences of sexual practice among inmates. There is therefore a need for a comprehensive approach in programming which will be fundamental in alleviating the HIV/AIDS scourge in prisons.
In this study, national antiretroviral therapy (ART) policy is examined over the period of 1999 to 2008, which coincided with the government of President Thabo Mbeki and his Minister of Health, Dr Manto Tshabalala-Msimang. The movement towards a national ART programme in South Africa was an ambitious undertaking, the likes of which had not been contemplated before in public health in Africa. One million AIDS-ill individuals were targeted to be enrolled in the ART programme by 2007/08. Fewer than 50% of eligible individuals were enrolled. This failure resulted from lack of political commitment and inadequate public health system capacity. The human and economic costs of this failure are large and sobering. The total lost benefits of ART not reaching the people who need it are estimated at 3.8 million life years for the period, 2000 to 2005. The economic cost of those lost life years over this period has been estimated at more than US$15 billion.