The recent rise of health systems strengthening as a policy priority suggests that a move away from single-disease approaches to global health may be occurring. As the largest attempt by far to tackle one disease, the global AIDS effort has acted as a lightning rod for criticisms of global health initiatives focused on single diseases, according to the author of this paper. Global AIDS institutions have sought to respond by broadening their mandates to incorporate some wider systemic interventions into their activities. However, as the debate over addressing particular diseases or investing in health systems continues, five important underlying political and ethical questions are being neglected, including whether there is an ideal health system, the timescales involved, the definition of sustainability, governance/structural capacity and political will. If a more sustained and coordinated effort to improve health outcomes is to become a reality, these difficult questions will need to be tackled, the author concludes.
Equity and HIV/AIDS
Speakers at a session on stigma at the 16th International Conference on AIDS and Sexually Transmitted Infections in Africa, held in December 2011 in Ethiopia, noted that HIV patients in Africa frequently suffer shame and depression but the continent’s health systems were ill-equipped to handle the issue, which not only affected their quality of life, but could lead to poor adherence to HIV treatment regimens. They said while HIV programmes focus heavily on reducing externalised stigma and ill-treatment of HIV patients by society, little is done to deal with a patients’ self-perception and how that might deteriorate following an HIV diagnosis. Studies from Zambia and Uganda have shown that depression is the most common psychiatric disorder among people living with HIV, and is more prevalent among HIV-positive people than in the general population. The Mbabane Mental Health Support Group, an advocacy group from Swaziland, calls for the integration of mental health services into primary healthcare as well as that of HIV positive people.
Published data on adherence to antiretroviral therapy (ART) in Kenya is limited. This study assessed adherence to ART and identified factors responsible for non-adherence in Nairobi. This is a multiple facility-based cross-sectional study, where 416 patients aged over 18 years were systematically selected and interviewed using a structured questionnaire about their experience taking ART. Additional data was extracted from hospital records. Overall, 403 patients responded: 35% males and 65% females, of whom 18% were non-adherent, and the main (38%) reasons for missing therapy were being busy and forgetting. Accessing ART in a clinic within walking distance from home and difficulty with dosing schedule predicted non-adherence. The study found better adherence to HAART in Nairobi compared to previous studies in Kenya. However, the authors argue that adherence can be improved further by employing fitting strategies to improve patients' ability to fit therapy into their lifestyles and implementing cue-dose training to impact forgetfulness. Further work to determine why patients accessing therapy from ART clinics within walking distance from their residence did not adhere is recommended.
A meeting to address issues around HIV and men who have sex with men went ahead as scheduled in Addis Ababa, Ethiopia, on 3 December 2011, despite protests and calls for its cancellation by local religious leaders. The meeting - held a day before the opening of the 16th International Conference on AIDS and Sexually transmitted infections in Africa (ICASA) - was organized by the South African-based NGO, African Men for Sexual Health and Rights (AMSHeR). Originally due to be held at a local hotel, the venue quietly shifted to the UN compound in Addis Ababa. According to participants, it attracted more than 150 participants from 25 African countries, and focused on addressing the problems MSM faced in accessing HIV services. Speakers included UNAIDS executive director, Michel Sidibe. Before the meeting, four religious leaders had called a press conference to denounce it. Ethiopia's Minister of Health, Tedros Adhanom Ghebreyesus, persuaded them to cancel the press conference. Even at the new venue, there were hundreds of protesters outside for half the day, said one participant, Homosexuality is illegal in Ethiopia and punishable by between three and 10 years in prison. While the government allowed the meeting to go ahead, gay rights activists doubt it will lead to a positive change for MSM in Ethiopia.
This National Strategic Plan (NSP) has four strategic objectives, which will form the basis of the HIV, STI and TB response: address social and structural barriers to HIV, sexually transmitted infection (STI) and TB prevention, care and impact; prevent new HIV, STI and TB infections; sustain health and wellness; and increase protection of human rights and improve access to justice. The NSP is driven by a long-term 20-year vision for the country with respect to the HIV and TB epidemics, adapting the Three Zeros advocated by UNAIDS, and additional one for discrimination: zero new HIV and TB infections; zero new infections due to vertical transmission (mother-to-child); zero preventable deaths associated with HIV and TB; and zero discrimination associated with HIV and TB. In line with this 20-year vision, the NSP has the following broad goals: reduce new HIV infections by at least 50% using combination prevention approaches; initiate at least 80% of eligible patients on antiretroviral treatment (ART), with 70% alive and on treatment five years after initiation; reduce the number of new TB infections as well as deaths from TB by 50%; ensure an enabling and accessible legal framework that protects and promotes human rights to support implementation of the NSP; and reduce self-reported stigma related to HIV and TB by at least 50%.
On 1 December 2011, World AIDS Day, United States (US) President, Barack Obama, pledged to provide antiretroviral treatment to some six million people globally by 2013, an increase of two million on the previous target. However, there will still be no increase in funding from the US President's Emergency Plan for AIDS Relief (PEPFAR), which pledged US$48 billion in 2008 for five years. Consequently, although costs of HIV and AIDS programmes have come down, PEPFAR is having to look at smarter programming and greater efficiencies to increase roll out. PEPFAR noted that the US was also working to persuade other wealthy countries, such as China, Germany and Sweden, to take greater responsibility in the fight against HIV and AIDS. Obama's announcement has been welcomed with cautious optimism in developing countries, who are concerned that the rich countries of the North may not keep their pledges to the Global Fund – the main HIV and AIDS funder for many poor countries – in the current global recession.
On 3 December 2011, a meeting was held at the All-Africa AIDS Conference (ICASA) addressing the health and human rights of African men who have sex with men (MSM) and the lesbian, gay, bi and intersex (LGBTI) community in general. The meeting was attended by global agencies, including UNAIDS and the African Commission on Human Rights, but by few international non government organisations. Speakers from the United States (US) President’s Fund for Emergency AIDS Relief (PEPFAR) and the African Commission outlined the health needs of MSM in Africa regarding their vulnerability to HIV and AIDS. They made commitments to scale up efforts in this area. Participants called for public health and human rights approaches to be more inclusive, to take into account the full spectrum of LGBTI health issues, including violence, victimisation, psychiatric disorders and substance abuse.
Although South Africa is committed to providing anti-retroviral treatment (ART) to all South Africans who need it, there are insufficient pharmacists working in public sector facilities to dispense ART to all these patients, according to this policy brief, which means that dispensing tasks must be shifted to pharmacists assistants and/or nurses. The Health Economics Unit (HEU) argues that the pharmacists assistant pharmaceutical care model has the lowest cost to the health system and would support a more integrated primary health care service. Patients getting their ART by attending facilities staffed by pharmacists assistants and nurses experienced relatively better geographic access to facilities and lower transport costs, compared to those attending more central facilities that employ pharmacists. Patients prefer a nurse to dispense their ARTs as this reduces the risk of being identified by other patients as being HIV-positive. The pharmacists assistant model can be made more acceptable to patients by ensuring that there are no differences between patient folders (e.g. those on ART should not have differently coloured folders) and dispensing all medication (not only anti-retrovirals) in brown paper bags.
In this study researchers explored the level of awareness and practice on HIV prevention among married couples from selected communities in Malawi. They carried out the study from October to December 2008 in four communities, two each from Chiradzulu and Chikhwawa districts of Malawi. They conducted face-to-face in-depth interviews with 30 couples in each district using a semi-structured interview guide. The couples’ ages ranged from 20 to 53 years, most (52%) being in the 20-31 year-old age group. All couples were aware of HIV prevention methods and talked about them in their marriages. For most couples (54) there was mutual trust between husbands and wives, and members of only a few couples (six) doubted their partners’ ability to maintain mutual fidelity, but researchers detected infidelity among 25 couples. A few couples (5) had been tested for HIV. No couples favoured the use of condoms with a marriage partner as an HIV prevention method. The researchers conclude that the level of HIV prevention awareness among couples in Malawi is high and almost universal. However, there is low adoption of the HIV prevention methods among the couples because they are perceived to be couple unfriendly due to their incompatibility with the socio-cultural beliefs of the people. There is a need to target couples as units of intervention in the adoption of HIV prevention methods by rural communities.
This policy brief draws on evidence from a recent study that investigated the factors influencing the choices of infant feeding of HIV-positive mothers in Ghana through an assessment of the perspectives of HIV-positive mothers and family members (i.e., fathers and grandmothers) in two districts in Ghana. Results from the study showed that HIV-positive mothers had good knowledge and understanding of exclusive breastfeeding and exclusive replacement feeding, however adherence to these feeding options was poor and mixed feeding was common. HIV-positive mothers had access to counseling on replacement infant feeding options but there was an emphasis on exclusive breastfeeding and exclusive replacement feeding and not on other replacement options. HIV-positive mothers faced various obstacles (socio-economic, familial and stigma) in carrying out replacement feeding. Family members and communities have a strong influence on mothers’ infant feeding practices. The authors of the study recommend introducing a multi-dimensional behaviour change strategy which involves mothers, family members and significant community members in order to change perceptions, understanding and attitudes to exclusive replacement feeding and exclusive breastfeeding and at the same time, explicitly deal with the risk in terms of infant survival associated with mixed feeding. Male partners should be involved and counselors should explore why the full range of feeding options (like heat-treated breast milk, animal milk and wetnursing) are not discussed.