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.
Equity and HIV/AIDS
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.
This study assessed the effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda on young people's sexual behaviour, HIV knowledge and attitudes. Fourteen schools were selected in two neighbouring districts, Bugesera (intervention group) and Rwamagana (control group), and 1,950 students participated. Researchers found that time trends in sexual risk behaviour (being sexually active, sex in last six months, condom use at last sex) were not significantly different in students from intervention and control schools, nor was the intervention associated with increased knowledge, perceived severity or perceived susceptibility. However, stigma was reported as significantly reduced. To explain the failure of the intervention, the authors argue that young people may prefer receiving HIV information from sources other than peers. In addition, outcome indicators were not adequate. They call for integration of peer-led prevention in holistic interventions, as well as redefining peer educators' role as focal points for sensitisation and referral to experts and services. Interventions with a narrow focus on sexual risks should be avoided.
The main aim of this study was to identify predictors of HIV testing and condom use in Mozambique. Researchers analysed nationally representative survey data collected in 2009 for two outcomes: HIV testing and condom use. Results indicated that women at a higher risk of HIV were less likely to be tested for HIV than women at a lower risk. Large wealth differentials were observed: compared to the poorest women, HIV testing was higher among the wealthiest women. Perceived quality of health services was an important predictor of HIV testing, as HIV testing was higher among women who rated health services as being of very good quality. In terms of condom use, condom use was higher among men with girlfriends or those who had casual sex. Interestingly, being tested for HIV more than two years ago was not associated with condom use, and frequent mass media exposure was neither associated with HIV testing nor with condom use. The authors argue that the focus of HIV testing should shift from married women (routinely tested during antenatal care visits) to unmarried women and women with multiple sexual partners. Although services are free, transport costs to health facilities prove a major financial barrier to HIV testing. Mechanisms should be developed to cover the cost of transport, and the cost can also be reduced by substantially increasing community-based counselling. Men should be encouraged to test for HIV periodically.
In this study, researchers aimed to identify the infant-feeding challenges that Malawian women with HIV faced when they were advised to wean their children at an early age of six months, and explore how the women adhered to their infant-feeding options while facing and managing these challenges. The study was conducted between February 2008 and April 2009 at two public health facilities in Malawi where services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were conducted with 20 HIV-positive women. Several interdependent factors including the conflicting pressures of sexual morality and the demands of nurturing and motherhood in conditions of abject poverty, impeded the participating women from following medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty maintaining their ascribed roles as respected wives, mothers and members of the society at large. Given that the infant-feeding dilemmas for women with HIV are complex, the integration of public health efforts with context-specific socio-cultural understanding is essential, the authors argue, pointing to the recent 2010 WHO guidelines on breastfeeding, which recommend breastfeeding for two years for HIV-positive Malawian mothers.
The objective of this study was to assess the extent to which children may be falsely diagnosed as HIV-infected, using data from an antiretroviral therapy (ART) site in Pretoria, South Africa, between April 2004 and March 2010. Researchers analysed 1,526 patient files, with a male-to-female ratio of 1.01:1 and median age at first visit of 20 months. Nearly half (47%) of the children were aged less than 18 months. Fifty-one children (3.3%) were found to be HIV-uninfected after repeated diagnostic tests. Incorrect laboratory results for children aged less than 18 months included 40 false-positive HIV DNA PCR tests (6.3%) and one false-positive HIV p24Ag test. An additional four children were inappropriately referred after being incorrectly labelled as HIV-infected and one child aged younger than 18 months was referred after an inappropriate diagnostic test for age was used. The authors acknowledge that urgency in ART initiation in HIV-infected children is life-saving, especially in infants, but HIV tests may produce false-positive results so health care workers should meticulously check a child’s HIV-positive status before committing them to lifelong ART.