In 2006, the Society for Adolescent Medicine issued its second position paper on HIV/AIDS in adolescents. It noted that although great progress had been made in the scientific understanding, diagnosis and treatment of HIV, and the prevention of perinatal transmission, there was a growing HIV crisis in the developing world. At least half of all new infections in the developing world were amongst youth and young adults, and a substantial number of teenagers and young adults were already living with HIV and AIDS. As HIV epidemics mature, increasing numbers of children infected perinatally survive and will present with HIV-related symptoms in older childhood and adolescence. Whilst the epidemiology of sexually acquired HIV infection amongst 15–24 year olds is well described in southern Africa, few data on the prevalence and disease pattern of perinatally acquired HIV infection in older children and adolescence exist. Recent data from a household survey conducted in South Africa in 2008 estimated the prevalence of HIV in children aged 2–14 years to be 2.5%. The survey indicates the relatively high prevalence of HIV in children and adolescents in this region. Most of these infections are acquired early in life and are probably undiagnosed.
Equity and HIV/AIDS
Survival to older childhood with untreated, vertically acquired HIV infection, which was previously considered extremely unusual, is increasingly well described. However, the overall impact on adolescent health in settings with high HIV sero-prevalence has not previously been investigated. Adolescents (aged 10–18 y) systematically recruited from acute admissions to the two public hospitals in Harare, Zimbabwe, answered a questionnaire and underwent standard investigations including HIV testing, with consent. Pre-set case-definitions defined cause of admission and underlying chronic conditions. Participation was 94%. One hundred and thirty-nine (46%) of 301 participants were HIV-positive, but only four were positive for herpes simplex virus-2 (HSV-2). Case fatality rates were significantly higher for HIV-related admissions (22% versus 7%, p<0.001), and significantly associated with advanced HIV, pubertal immaturity, and chronic conditions. The paper concluded that 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/AIDS. Low HSV-2 prevalence and high rates of maternal orphanhood 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.
The Kenyan government is considering a policy of repeat HIV testing during pregnancy. 'Currently, the lack of it is a gap in our policies,' said Peter Cherutich, head of HIV prevention at the National AIDS and Sexually Transmitted Infections Control Programme. 'Testing should be done periodically, even after childbirth, because a mother can become infected even during the breastfeeding period.' At present, HIV-positive mothers and their babies in Kenya are given a combination of three antiretroviral drugs after a single test, usually carried in the early stages of the pregnancy. 'If a woman tests negative during her prenatal test, gets infected during the pregnancy, and is not given the necessary medication during labour to protect the child, she stands a chance of infecting her child at birth or even during breastfeeding and you go back to square one,' Cherutich said. Infants contracting HIV through their mothers account for about 20% of an estimated 166,000 annual HIV infections in Kenya.
Tuberculosis (TB) is the leading cause of morbidity and mortality in the HIV-infected African population. The need for improved integration of HIV and TB services was highlighted by the World Health Organization (WHO) several years ago, but implementation of recommendations has been slow. HIV testing for TB patients is the gateway for combined HIV and TB treatment, care and prevention yet, in 2007, only 37% of TB patients in the WHO African region were tested for HIV. While some countries reported testing rates above 75%, a testing rate of only 39% was reported in South Africa, the country with the largest burden of HIV/TB co-infection. This study describes efforts to ensure high HIV testing rates in TB patients via an integrated programme at primary health care level in rural KwaZulu-Natal.
In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest, which prompted this review to assess youth HIV-prevention interventions in the country since 2000. Eight interventions were included, all of which were similar in HIV prevention content and objectives, but varied in thematic focus, hypothesised causal pathways, theoretical basis, delivery method, intensity and duration. Interventions were school- or group-based, involving in- and out-of-school youth. Primary outcomes included HIV incidence, reported sexual risk behaviour alone, or with alcohol use. Interventions led to reductions in sexually transmitted infections and reported sexual or alcohol risk behaviours, although effect size varied. All but one targeted at least one structural factor associated with HIV infection: gender and sexual coercion, alcohol/substance use or economic factors. Delivery methods and formats varied, and included teachers, peer educators and older mentors. School-based interventions experienced frequent implementation challenges. Key recommendations include: address HIV social risk factors, such as gender, poverty and alcohol; target the structural and institutional context; work to change social norms; and engage schools in new ways, including participatory learning.
This study investigated whether or not antiretroviral therapy (ART) influences pregnancy rates. It analysed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multi-country HIV care and treatment programme for women, children and families. From eleven programmes in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals, while ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. The study found that ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioural or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services.
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.
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.