There is no question that an effective and urgent response is needed to extend access to antiretroviral therapy (ART) in southern Africa. The efforts of treatment activists, national governments, the World Health Organisation and the Global Fund to highlight this unmet health need are commendable. However, after decades of under-investment, harmful structural adjustment programmes and de-skilling, many health systems face significant obstacles in rising to the challenge of meeting the treatment needs. Treatment activism now needs to join with broader public health activism to ensure that treatment can be extended in ways that are sustainable, effective and equitable. This paper draws on work carried out by EQUINET and others to discuss the threats and opportunities entailed with the expansion of ART access in Southern Africa- threats that must be managed and opportunities tapped to realise aspirations of treatment access for more than a minority.
Equity and HIV/AIDS
At the 2006 United Nations High Level Meeting on HIV/AIDS, world leaders reaffirmed that “the full realization of all human rights and fundamental freedoms for all is an essential element in the global response to the HIV/AIDS pandemic.” Yet, 25 years into the AIDS epidemic, this “essential element” remains the missing piece in the fight against AIDS. Now more than ever, law and human rights should occupy the center of the global HIV/AIDS struggle. This booklet, published by OSI's Law and Health Initiative, presents 10 reasons why.
The first draft of the political declaration was released on April 26, and is based on the outcomes of the regional consultations on Scaling Up for Universal Access. Amongst other important strengths, the draft declaration has quite a strong focus on women and girls, committing governments to increase women’s and girls’ capacity to protect themselves from the risk of HIV infection, to take measures that will promote women’s empowerment and to protect and promote women’s human rights. The text also calls for stronger policy and program linkages between sexual and reproductive health and HIV and AIDS.
This report from the World Health Organization (WHO) and UNAIDS contains revised estimates of the number of people with HIV globally. Estimates of the total number of people infected with HIV fell from 39.5m in 2006 to 33.2m in 2007, a reduction of 16 percent. This reduction was mainly due to a change in the method used to measure the size of the epidemic, rather than trends in prevalence or incidence. The biggest drop came from a reassessment of India’s epidemic, with other important revisions being made in Angola, Mozambique, Nigeria, Kenya and Zimbabwe.
According to new data presented in this update, new HIV infections have been reduced by 17% over the past eight years. Since 2001, when the United Nations Declaration of Commitment on HIV/AIDS was signed, the number of new infections in sub-Saharan Africa is approximately 15% lower, which is about 400,000 fewer infections in 2008. In East Asia new HIV infections declined by nearly 25% and in South and South East Asia by 10% in the same time period. In Eastern Europe, after a dramatic increase in new infections among injecting drug users, the epidemic has leveled off considerably. However, in some countries there are signs that new HIV infections are rising again. The report highlights that, beyond the peak and natural course of the epidemic, HIV prevention programmes are making a difference. ‘The good news is that we have evidence that the declines we are seeing are due, at least in part, to HIV prevention,’ said Michel Sidibé, Executive Director of UNAIDS. ‘However, the findings also show that prevention programming is often off the mark and that if we do a better job of getting resources and programmes to where they will make most impact, quicker progress can be made and more lives saved.’
By the end of 2004, 700 000 people living with AIDS in developing countries were receiving antiretroviral (ART) treatment thanks to the efforts of national governments, donors and other partners. This is an increase of approximately 75% in the total number receiving treatment from a year ago, and is up from 440 000 in July 2004. At a joint press conference at the World Economic Forum’s Annual Meeting, Switzerland, the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United States Government and the Global Fund to fight AIDS, Tuberculosis and Malaria revealed the results of their joint efforts to increase the availability of ART in poor countries. However all the organizations warned that major, continued efforts are needed in countries and internationally to continue working towards the goal of access to treatment for all who need it.
In this study, researchers evaluated the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting in western Kenya. The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High risk express care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of [less than or equal to]100 cells/mm3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of [less than or equal to]100 cells/mm3 were eligible for enrolment into HREC and for analysis. Between March 2007 and March 2009, 4,958 patients initiated cART. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality, and reduced loss to follow up compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up. The researchers conclude that frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.
This study took the form of a cluster randomised controlled trial to compare the use of routine viral load (VL) testing for antiretroviral therapy (ART) versus local standard of care (which uses immunological and clinical criteria to diagnose treatment failure, with discretionary VL testing when the two do not agree). Twelve ART clinics in Lusaka, Zambia were included. The study was powered to detect a 36% reduction in mortality at 18 months. From December 2006 to May 2008, the study completed enrolment of 1,973 participants. Measured baseline characteristics did not differ significantly between the study arms. Enrolment was staggered by clinic pair and truncated at two matched sites. A large clinical trial of routing VL monitoring was successfully implemented in a dynamic and rapidly growing national ART program. Close collaboration with local health authorities and adequate reserve staff were critical to success. Randomised controlled trials such as this will likely prove valuable in determining long-term outcomes in resource-constrained settings.
This compact argues that sexual and reproductive rights are a pivotal but neglected priority in HIV and AIDS policy, programming and resource allocation. It claims that universal access to sexual and reproductive health services and education, and the protection of sexual and reproductive rights, are essential to ending it. The compact draws on issues in equity in health by calling on HIV and AIDS decision makers to redefine 'high risk' by recognising that women and girls are at serious risk and have the right to all services related to the prevention, treatment, care and support as part of comprehensive sexual and reproductive health services.
This study compared national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. The authors also compared the national policies with WHO guidance. There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy. Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. It is proposed that future research assess the extent of policy implementation and link these findings with HIV outcomes.