In recent years, the ways in which HIV and AIDS-focused programmes interact with the delivery of other health services is often discussed, but the evidence as to whether HIV and AIDS programmes strengthen or distort overall health services is limited. The aim of this study was to examine the effect of a PEPFAR-funded HIV and AIDS programme on six government-run general clinics in Kampala, Uganda. Longitudinal information on the delivery of health services was collected at each clinic. Monthly changes in the volume of HIV and non-HIV services were analysed, along with a cross-sectional survey utilising patient exit interviews to compare perceptions of the experiences of patients receiving HIV care and those receiving non-HIV care. All HIV service indicators showed a positive change after the HIV programme began. For non-HIV and AIDS health services, TB lab tests and diagnoses increased significantly, and malaria service indicators also improved. Patients’ overall impressions were positive in both the HIV and non-HIV groups, with more than 90% responding favourably about their experiences. This study shows that when a collaboration is established to strengthen existing health systems, in addition to providing HIV and AIDS services in a setting in which other primary health care is being delivered, there are positive effects not only on HIV and AIDS services, but also on other essential services.
Equity and HIV/AIDS
According to Peter Salama, head of the United Nations Children’s Fund (UNICEF) in Zimbabwe, between 6, 000 and 7,000 children die per year in Zimbabwe as a result of HIV and in most cases it is because these children have failed to access paediatric anti-retroviral therapy (ART). The lack of technology meant that many children were not being tested for HIV, Salama said at an AIDS conference in Harare in September 2011. ‘It is important to have an early infant diagnosis as 50% of those children not tested will not be able to reach the age of two,’ he added. About one in seven Zimbabweans is infected with HIV, and about 13% of pregnant women are HIV-positive in Zimbabwe. However, the relatively high costs of medical care and the poor economy means many women give birth at home or never return to hospital for post-natal checkups.
Uganda's longstanding campaigners in its 30-year fight against HIV have expressed discontent with the government's treatment and prevention approaches. Milly Katana, a long-term activist and one of the inaugural board members of the Global Fund to fight HIV, Tuberculosis and Malaria, said that while the injection of millions of dollars had saved lives through treatment, it had also commercialised the industry, leaving it open to abuse by those not truly interested in defeating the epidemic. For Rubaramira Ruranga, executive director of the National Guidance and Empowerment Network of People Living with HIV/AIDS in Uganda, the lack of proper co-ordination at the top of the HIV response has led to disorganisation in the rest of the sector. He noted that Uganda has strong policies to fight HIV, that are not fully implemented. Gideon Byamugisha, founder member of the International Network of Religious Leaders Living with and Personally Affected by HIV/AIDS, argued that the focus on prevention through safe sex has meant that the 21% of new infections that occur through mother-to-child transmission are being overlooked.
Researchers in this study investigated sub-optimal patient adherence to antiretroviral therapy in 18 clinical sites in rural Zambézia Province, Mozambique. They conducted 18 community and clinic focus groups in six rural districts, interviewing 76 women and 88 men, of whom 124 were community participants (CPs) and 40 were health care workers (HCWs) who provide care for those living with HIV. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff, doubt as to the benefits of antiretroviral therapy and sharing medications with family members. Men expressed a greater concern about poor treatment by HCW than women and health care workers blamed patient preference for traditional medicine and the side effects of medication for poor adherence. In conclusion, perspectives of CP and HCW likely reflect differing socio-cultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.
The objective of this study was to investigate whether in utero exposure to highly active antiretroviral therapy (HAART) is associated with low birth weight and/or preterm birth in a population of South African women with advanced HIV disease. A retrospective observational study was performed on women with CD4 counts ≤250 cells/mm3 attending antenatal antiretroviral clinics in Johannesburg between October 2004 and March 2007. Effects of different HAART regimen and duration were assessed. Among HAART-unexposed infants, 27% were low birth weight compared with 23% of early HAART-exposed and 19% of late HAART-exposed infants. In the early HAART group, a higher CD4 cell count was protective against low birth weight and preterm birth. HAART exposure was associated with an increased preterm birth rate, with early nevirapine and efavirenz-based regimens having the strongest associations with preterm birth. The authors conclude that in utero HAART exposure was not significantly associated with low birth weight.
In a long-standing general population cohort in rural Uganda researchers assessed the prevalence of concurrency and investigated its association with socio-demographic and behavioural factors and with HIV prevalence, using the new recommended standard definition and methodological approaches. Among those eligible, 3,291 (66%) males and 4,052 (72%) females participated in the survey. Among currently married participants, 11% of men and 25% of women reported being in a polygynous union. Among those with a sexual partner in the past year, the proportion reporting at least one concurrent partnership was 17% in males and 0.5% in females. Polygyny accounted for a third of concurrency in men and was not associated with increased HIV risk. Among men there was no evidence of an association between concurrency and HIV prevalence (but too few women reported concurrency to assess this after adjusting for confounding). Regarding sociodemographic factors associated with concurrency, females were significantly more likely to be younger, unmarried, and of lower socioeconomic status than males. Behavioural factors associated with concurrency were young age at first sex, increasing lifetime partners, and a casual partner in the past year (among men and women) and problem drinking (only men). These findings are intended to provide a baseline for measuring changes in concurrency and HIV incidence in future surveys, and a benchmark for other studies.
This study aimed at exploring determinants of HIV testing and counselling in two Nairobi informal settlements. Data are derived from a cross-sectional survey nested in an ongoing demographic surveillance system. A total of 3,162 individuals responded to the interview and out of these, 82% provided a blood sample which was tested using rapid test kits. Approximately 31% of all respondents had ever been tested for HIV through client-initiated testing and counselling (CITC), 22% through provider-initiated testing and counselling (PITC) and 42% had never been tested but indicated willingness to test. Overall, 62% of females and 38% of males had ever been tested for HIV. Males were less likely to have had CITC and also less likely to have had PITC compared to females. Individuals aged 20-24 years were more likely to have had either CITC or PITC compared to the other age groups. Although the proportion of individuals ever tested in the informal settlements is similar to the national average, it remains low compared to that of Nairobi province especially among men. Key determinants of HIV testing and counselling include; gender, age, education level, HIV status and marital status. These factors need to be considered in efforts aimed at increasing participation in HIV testing, the authors conclude.
HIV and AIDS has always been one of the most thoroughly global of diseases. In the era of widely available anti-retroviral therapy (ART), it is also commonly recognised as a chronic disease that can be successfully managed on a long-term basis. This article examines the chronic character of the HIV and AIDS pandemic and highlights some of the changes we might expect to see at the global level as HIV is increasingly normalised as ‘just another chronic disease’. The article also addresses the use of this language of chronicity to interpret the HIV and AIDS pandemic and calls into question some of the consequences of an uncritical acceptance of concepts of chronicity.
The objective of this paper was to describe the long-term virological, immunological and mortality outcomes of providing highly active antiretroviral therapy (HAART) with strong adherence support to African HIV-infected female sex workers (FSWs) and contrast outcomes with those obtained in a cohort of regular HIV-infected women. FSWs and non-FSWs initiated on HAART between August 2004 and October 2007 were included in the study. Patients were followed monthly for drug adherence (interview and pill count), and at six-monthly intervals for monitoring CD4 counts and HIV-1 plasma viral loads (PVLs) and clinical events. Results showed no statistical differences between outcomes of FSWs and non-FSWs. The authors conclude that clinical and biological benefits of HAART can be maintained over the long term among FSWs in Africa and could also lead to important public health benefits.
The experiences of the past ten years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings. Achieving the levels of antiretroviral (ARV) coverage necessary to impact the course of the HIV epidemic remains a challenge and ARV coverage in most nations remains short of even current recommendations. Though treatment as prevention and seek, test, treat and retain strategies are attractive, the authors of this article argue that realising the benefits of these strategies means that they must cover hard to reach populations such as sex workers. While evidence on reach of these populations in research settings is encouraging, there are questions on the sustainability of these efforts as patients are transitioned back into national HIV control programmes, many of which are struggling even to maintain the current coverage in the face of declining external funding. The authors conclude that advocacy from both medicine and public health providers will be critical to sustain and enhance the necessary HIV and AIDS treatment and prevention programmes worldwide.