Much of the progress in recent years in the fight against HIV may be attributed to increased use of antiretrovirals (ARVs), argues the World Health Organisation (WHO) in this short article to commemorate World AIDS Day on 1 December 2012. The latest global statistics suggest that, provided countries are able to sustain current efforts, the goal of getting 15 million HIV-infected people worldwide on ARVs will be reached by 2015. Currently eight million people in low- and middle-income countries are accessing the treatment they need, up from only 0.4 million in 2003. However, vulnerable and marginalised groups are still not able to access HIV prevention and treatment services, including adolescent girls, sex workers, men who have sex with men, drug users and migrants. And children are lagging badly behind: only 28% of children who need ARVs can obtain them. Some countries are considering initiating treatment at an even earlier stage in the course of HIV, as well as offering all HIV-positive pregnant women ARV therapy for life. WHO is currently reviewing new scientific research and country experiences in order to publish updated and consolidated guidance on the use of ARVs in mid-2013.
Equity and HIV/AIDS
In light of the emerging debate on what a post-2015 development agenda and accountability framework should look like, the authors of this paper call on policy makers and other stakeholders to look at the AIDS response for lessons in global health responses, where the most marginalised are at the centre of the debate, human rights are protected under the rule of law, strong accountability is in place for results for people, and community and participatory processes are the norm. These hard-won principles of the AIDS response should be incorporated into the post-2015 global health agenda, while at the same time acknowledging that a rapidly changing world, including a shifting geopolitical and economic landscape, requires policy responses that are context sensitive. Three years ago, UNAIDS articulated what was then considered to be an ambitious vision: zero new HIV infections and zero-AIDS related deaths by 2015, underpinned by zero discrimination. The authors argue that the post-2015 development agenda calls for the reconceptualision of this vision as a set of concrete goals. They discuss the Shared Responsibility-Global Solidarity agenda, as pioneered by the African Union in its recent Roadmap on AIDS, Tuberculosis, and Malaria, to illustrate ways in which global health can be re-thought to tackle twenty-first century challenges.
Doubts have been cast about the ability of Home-Based HIV Counseling and Testing (HBHCT) to adhere to ethical practices including consent, confidentiality, and access to HIV care post-test. This study explored client experiences in relation these ethical issues. Researchers conducted 395 individual interviews in Kumi district, Uganda, where teams providing HBHCT had visited 6–12 months prior to the interviews. They found that 95% of respondents had ever tested (average for Uganda was 38%). Among those who were approached by HBHCT providers, 98% were informed of their right to decline HIV testing. Most respondents were counseled individually, but 69% of the married/cohabiting were counseled as couples. Most respondents (94%) were satisfied with the information given to them and the interaction with the HBHCT providers. These findings show a very high uptake of HIV testing and satisfaction with HBHCT, a large proportion of married respondents tested as couples, and high disclosure rates. HBHCT can play a major role in expanding access to testing and overcoming disclosure challenges. However, access to HIV services post-test may require attention.
Trial sponsors and implementers are ethically obligated to refer HIV infected Individuals identified in a research study at screening for HIV care and treatment. Makerere University Walter Reed Project is conducting HIV surveillance among high risk uninfected female sex workers. This study describes patterns in participants’ receipt of HIV results and response to referral for HIV care and treatment. Results indicated HIV prevalence was 35% at screening. Out of the 221 prevalent cases, only 96 participants (43%) received HIV confirmatory results and were referred for care, while 9 (4%) declined referral. The majority did not return for either their initial or confirmatory HIV result; while a few declined a blood re-draw. Of the 96 participants referred, 58% are currently in care, 14% did not report for care predominately citing indecisiveness while 28% could not be tracked. Most of the acutely infected participants (6/8) are in care. The authors argue that, although trial implementers may fulfil their obligation in referring study participants for HIV care, participants have a key role to play in facilitating this process. The large number of HIV prevalent female sex workers who did not return for their HIV results and may not be aware of their status could be a potential driver of the epidemic in Uganda, the paper concludes.
This paper looks at the modes of transmission model, which has been widely used to help decision-makers target measures for preventing HIV infection. The model estimates the number of new HIV infections that will be acquired over the ensuing year by individuals in identified risk groups in a given population using data on the size of the groups, the aggregate risk behaviour in each group, the current prevalence of HIV infection among the sexual or injecting drug partners of individuals in each group, and the probability of HIV transmission associated with different risk behaviours. The strength of the model is its simplicity, which enables data from a variety of sources to be synthesised, resulting in better characterization of HIV epidemics in some settings. However, concerns have been raised about the assumptions underlying the model structure, about limitations in the data available for deriving input parameters and about interpretation and communication of the model results. The aim of this review was to improve the use of the model by reassessing its paradigm, structure and data requirements. The authors identified key questions to be asked when conducting an analysis and when interpreting the model results and make recommendations for strengthening the model’s application in the future.
This qualitative study set out to identify gaps between policy and practice of HIV and AIDS workplace interventions in the University of Malawi, in particular the College of Medicine, in line with University HIV and AIDS policy. The researchers randomly sampled 25 students and 15 members of staff for interviews. Results indicated that there are a number of activities relating to HIV and AIDS in place while others are still in the pipeline, however the majority of respondents did not know about the University HIV and AIDS policy or any HIV and AIDS activities that are guided by the policy. This is due to lack of interest on their part or lack of knowledge on the existence of the workplace programme. The authors recommend that the University’s HIV and AIDS committee should strive to fast track key programme areas such as the voluntary counseling and testing centre, and clinic and coordination of different activities to increase programme visibility and patronage.
In this paper, researchers describe the increase in the treatment of South African pediatric HIV-infected patients assisted by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) from 2004 to 2010. They reviewed routine programme data from PEPFAR-funded implementing partners among persons receiving antiretroviral treatment (ART) aged 15 years old and less. From October 2004 through September 2010, the number of children newly initiated on ART in PEPFAR-assisted programmes increased from 154 to 2,641 per month resulting in an increase from 2,412 children on ART in September 2005 to 79,416 children in September 2010. Of those children who initiated ART before September 2009, 0–4 year olds were 1.4 times as likely to transfer out of the programme or die as 5–14 year olds; males were 1.3 times as likely to stop treatment as females. Approximately 27,548 years of life were added to children under-five years old from PEPFAR-assisted antiretroviral treatment. While pediatric antiretroviral treatment in South Africa has increased substantially, the authors call for additional case-finding and a further acceleration in the implementation of pediatric care and treatment services to meet the current treatment need.
This report consolidates all known information about sex work and HIV in Namibia, and aims to provide an objective knowledge base that can inform programming and advocacy efforts. In Namibia, sex work is formally illegal and criminalised. The author found that sex workers are severely affected by HIV (reportedly, around 70-75% HIV prevalence), and they are vulnerable to different health problems. This is compounded by problems in accessing services (i.e. stigma and discrimination), the excessive costs of obtaining services, and the frequent non-availability of drugs and staff. While overall knowledge of HIV seems to be acceptable, problems arise in negotiating condom use with clients, whereas alcohol and violence play an important role in facilitating sexual risk taking.
In 2011, three international organisations and a number of Namibian sex worker organisations conducted a series of rapid assessments on sex work and HIV in five towns in Namibia. In the assessments, a number of issues were raised in case of most or all the towns. These include stigma from health care providers and the community, a preference for traditional medicine, violence from a number of sources, and extortion and abuse from police officers. Yet, the way these affect sex workers are different in each location. The authors note that much more support is required to help sex workers organise and collaborate more effectively and to tackle the problems they face. Active participation of sex workers, as well as addressing HIV through a framework of human rights, are essential to making HIV programmes aiming to reach sex workers more effective. Violence, stigma in access to services, and discrimination should be identified and addressed as a matter of course in any HIV programmes aiming to reach sex workers. At the same time, relevant ministries, NGOs, UN agencies and external funders should use the findings drawn in this paper to raise awareness and advocate for national level action.
The Cash Transfer for Orphans and Vulnerable Children programme (CT-OVC) is Kenya's flagship social protection programme, reaching 150,000 poor families with OVC aged 17 or below. Households are provided a flat unconditional cash transfer of US$25 per month. The objective of this study is to assess whether the CT-OVC has reduced HIV-related behavioral risk among adolescents. Researchers included 1,912 households in seven districts across Kenya and gathered data on sexual behaviour and other risk-related behaviours for residents aged 15-25. Main study findings indicated that the CT-OVC programme has reduced the probability of sexual debut by 6.73%. This result appears to be driven by males. The programme also reduced the proportion of adolescents with two or more partners in the last 12 months by 7.2%, and reduced the probability of two or more unprotected sex acts in the last three months for females. The authors urge government to consider establishing a large-scale, national cash transfer programme aimed at preventing HIV among adolescents by postponing sexual debut, reducing the number of partners and reducing the number of unprotected sex acts.