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.
Equity and HIV/AIDS
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.
Highly Active Antiretroviral Therapy (HAART) has been available free of charge in Tanga, Tanzania since 2005, yet many women referred from prevention of mother-to-child transmission services to the Care and Treatment Clinics (CTC) for HAART never registered at the CTCs. In this study, researchers focused on the motivating and deterring factors to presenting for HAART, particularly in relation to women. A qualitative approach was used, including in-depth interviews and focus group discussions. Researchers found that the main deterrent to presenting for treatment appears to be fear of stigmatisation including fear of ostracism from the community, divorce and financial distress. Participants indicated that individual counselling and interaction with other people living with HIV would encourage women to present for HAART, to do so, and indicated that the entrance to the CTC should be placed to allow discreet access. Necessary steps towards encouraging HIV infected women to seek treatment include reducing self-stigma, assisting them to form empowering relationships and to gain financial independence and emphasising the beneficial effect of treatment for themselves and for their children by example.
In this study, researchers conducted a qualitative study to explore risk situations that can explain the high HIV prevalence among youth in Kisumu town, Kenya. They conducted in-depth interviews with 150 adolescents aged 15 to 20, held four focus group discussions, and made 48 observations at places where youth spend their free time. Porn video shows and local brew dens were identified as popular events where unprotected multipartner, concurrent, coerced and transactional sex occurs between adolescents. Forced sex, gang rape and multiple concurrent relationships characterised the sexual encounters of youth, frequently facilitated by the abuse of alcohol, which is available for minors at low cost in local brew dens. A substantial number of girls and young women engaged in transactional sex, often with much older, wealthier partners. The authors conclude that local brew dens and porn video halls facilitate risky sexual encounters between youth and should be regulated and monitored by the government. Young men should be targeted in prevention activities, to change their attitudes related to power and control in relationships, while girls should be empowered how to negotiate safe sex, and their poverty should be addressed through income-generating activities.
Are Uganda’s health systems are being strengthened to sustain access to antiretroviral therapy (ART)? This study applies systems thinking to assess supply chain management, the role of external support and whether investments create the needed synergies to strengthen health systems. The authors combined data from the literature and key informant interviews with observations at health service delivery level in a study district. Findings indicate that current drug supply chain management in Uganda is characterised by parallel processes and information systems that result in poor quality and inefficiencies. Less than expected health system performance, stock outs and other shortages affect ART and primary care in general. Poor performance of supply chain management is amplified by weak conditions at all levels of the health system, including the areas of financing, governance, human resources and information. Governance issues include the lack to follow up initial policy intentions and a focus on narrow, short-term approaches. In conclusion, the study indicates serious missing system prerequisites. The findings suggest that root causes and capacities across the system have to be addressed synergistically to enable systems that can match and accommodate investments in disease-specific interventions. The multiplicity and complexity of existing challenges require a long-term and systems perspective essentially in contrast to the current short term and programme-specific nature of external assistance.
According to this report, despite a broad awareness of HIV, comprehensive knowledge of HIV and how to prevent it is still low, even in countries that have been most affected by the epidemic. There are encouraging signs that HIV-prevention efforts are resulting in positive change in sexual behaviours, accompanied by declines in HIV prevalence among young people in the most-affected countries. This should not be cause for complacency, UNAIDS warns. Instead, these successful services and programmes should be built upon to further efforts to reverse the epidemic among young people. To effectively advance the response among young people, UNAIDS argues that there is a need to increase investments. However, it also cautions that simply directing more resources will not increase HIV testing and uptake of services among young people. Instead, empowering young people and particularly young women to exercise their rights to sexual and reproductive health, improve programmes for young people and repeal national laws and policies that restrict access to HIV services for young people is required to protect future generations from HIV. The report highlights that young people are a key resource to reverse the global AIDS epidemic and lead the response in decades to come, but it stresses that the legal and policy barriers that prevent young people from accessing HIV services must be addressed, and young people should be engaged more effectively in the response.