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.
Equity and HIV/AIDS
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.
The Zimbabwe Minister of Health and Child Welfare, Dr Henry Madzorera is reported to have announced plans to increase the number of people on anteretrovirals from the current 180,000 to 300,000 (or 60% of the 500,000 adults estimated to need treatment) using resouces from the Global Fund, the United States President's Emergency Plan for AIDS Relief (PEPFAR), and a basket funding mechanism to which donors contribute for various HIV and AIDS interventions, known as the Expanded Support Programme on HIV/AIDS (ESP).
Ten months after being re-launched, a new brand of female condom has proven popular among Ugandan women. FC2 was launched in February; the government stopped distributing the original female condom, FC1, in 2007 on the grounds that women had complained it was smelly and noisy during sex. 'The new condom has improved features and will enable women to have a procedure within their control to give them more choices for prevention [of HIV and unwanted pregnancies],' said Vashta Kibirige, the coordinator of the condom unit at the Ministry of Health. The UN Population Fund and the NGO, Programme for Accessible health Communication and Education, are spearheading the re-launch of the female condom, which is still in the sensitisation stage and will become available to the public in 2010. The women questioned said the new condom was less noisy, more comfortable and well lubricated, increasing their sexual pleasure. It also has no smell and can be inserted in the vagina at least eight hours before sex, which the women liked a lot.
Despite emerging evidence that HIV-positive mothers should breastfeed to maximise their babies’ health prospects, South African health workers face a battle to change attitudes and habits. The 2003 South African Demographic Health Survey found that fewer than 12% of infants are exclusively breastfed during their first three months and this drops to 1.5% for infants aged between three and six months. Some health workers themselves have yet to be convinced of the benefits of breastfeeding, even for mothers who aren’t HIV positive. 'There exists the general idea that it is not important, that there is no critical reason to breastfeed, especially when you can formula feed,' says Linda Glynn, breastfeeding consultant at Mowbray Maternity Hospital in Cape Town. 'Some [health workers] think breastfeeding is a waste of time and an inconvenience.' Yet, the risks of not breastfeeding often go unrecognised. Most children born to HIV-positive mothers and raised on formula do not die of AIDS but of under-nourishment, diarrhoea, pneumonia and other causes not related to HIV. The World Health Organization recommends that all new mothers, regardless of their HIV status, practise exclusive breastfeeding for a minimum of six months.
Highly active antiretroviral therapy (HAART) drastically reduces mother-to-child transmission of HIV, but where breastfeeding is the only safe infant feeding option, HAART for the prevention of mother-to-child transmission needs to be evaluated in relation to both HIV transmission and infant mortality. One hundred-and-two >=18-year old women on HAART in rural Uganda who delivered one or more live infants between 1 March 2003 and 1 January 2007 were enrolled in a prospective study to assess HIV transmission and infant survival. Of 118 infants born during follow-up, 109 were breastfed. In total, 23 infants died during follow-up at a median age of 3.7 months; 15 of whom with severe diarrhoea and/or vomiting in the week preceding their death. The study concludes that, in resource-constrained settings, HIV-infected pregnant women should be assessed for HAART eligibility and treated as needed without delay, and should be encouraged to breastfeed their infants for at least six months.