Equity and HIV/AIDS

Antenatal HIV testing in rural eastern Uganda in 2003: Incomplete rollout of the prevention of mother-to-child transmission of HIV programme?
BMC International Health and Human Rights 6(6), 3 May 2006: Karamagi CAS , Tumwine JK, Tylleskar T and Heggenhougen KH

Uganda began to implement the prevention of mother-to-child transmission (PMTCT) of HIV programme in 2000, and by the end of 2003 it had expanded to cover 38 of 56 districts including Mbale District. However, reports from Mbale Hospital showed that less than 10% of pregnant women accepted antenatal HIV testing. We therefore conducted a study to determine the proportion of pregnant women who tested for HIV and the gaps and barriers in PMTCT implementation.

Antiretroviral durability and tolerability in HIV-infected adults living in urban Kenya
Hawkins C, Achenbach C, Fryda W, Ngare D, Murphy R: Journal of Acquired Immune Deficiency Syndrome 45: 304-310, 1 July 2007

Frequent antiretroviral therapy (ART) switches in HIV-infected Kenyan urban adults might limit the efficacy of ART. The authors sound the alarm that this is a potentially serious threat to the sustainability of HIV treatment programmes in Kenya and other developing countries.

Antiretroviral outcomes in South African prisoners: A retrospective cohort analysis
Davies NECG and Karstaedt AS: PloS One 7(3), 7 February 2012

Little is known about antiretroviral therapy (ART) outcomes in prisoners in Africa. To address this gap, researchers conducted a retrospective review of outcomes of a large cohort of prisoners referred to a public sector, urban HIV clinic. A total of 148 inmates (133 male) initiated on ART were included in the study. By week 96 on ART, 73% of all inmates enrolled in the study and 92% of those still accessing care had an undetectable viral load. By study end, 96 (65%) inmates had ever received tuberculosis (TB) therapy with 63 (43%) receiving therapy during the study: 28% had a history of TB prior to ART initiation, 33% were on TB therapy at ART initiation and 22% developed TB whilst on ART. Nine (6%) inmates died, seven in the second year on ART. While inmates responded well to ART, there was a high frequency of TB/HIV co-infection. The authors recommend that attention should be directed towards ensuring eligible prisoners access ART programmes promptly and that inter-facility transfers and release procedures facilitate continuity of care. Institutional TB control measures should remain a priority.

Antiretroviral price cuts secured amid growing funding fears
Plus News: 19 May 2011

Three international organisations have negotiated reductions on key first- and second-line, and paediatric antiretrovirals (ARVs) that will help countries save at least US$600 million over the next three years: the Clinton Health Access Initiative (CHAI), the international drug purchasing facility UNITAID and the UK Department for International Development (DFID). The deal, expected to affect most of the 70 countries comprising CHAI's Procurement Consortium, features notable reductions in the prices of tenofovir (TDF), efavirenz, and the second-line ritonavir-boosted atazanavir (ATV/r) used in HIV patients who have failed initial, or "first-line", regimens. As part of the deal, the three bodies set price ceilings for more than 40 adult and paediatric ARVs with eight pharmaceutical manufacturers and suppliers, which account for most ARVs sold in countries with access to generic drugs. As a result, the cost of ATV/r is down by two-thirds from just three years ago. Meanwhile, a once-a-day fixed-dose combination (FDC) pill containing TDF and efavirenz will now cost countries less than US$159 per patient per year. In 2008, low-income countries paid about $400 per patient per year for the same pill.

Antiretroviral therapy and early mortality in South Africa
Boulle A, Bock P, Osler M, Cohen K, Channing L, Hilderbrand K, Mothibi E, Zweigenthal V, Slingers N, Cloete K and Abdullah F: Bulletin of the World Health Organisation 86, 2008

This paper describes province-wide outcomes and temporal trends of the Western Cape Province antiretroviral treatment (ART) programme five years since inception, to demonstrate the utility of the WHO monitoring system for ART. Data on patients starting ART was prospectively captured into facility-based registers, from which monthly cross-sectional activity and quarterly cohort reports were aggregated. Retention in care, mortality, loss to follow-up and laboratory outcomes were calculated at six-monthly durations. By the end of March 2006, 16,234 patients were in care. Adults starting ART with CD4 counts less than 50 cells/μl fell from 51.3% in 2001 to 21.5% in 2005, while mortality at six months fell from 12.7% to 6.6%, offset in part by an increase in loss to follow-up (reaching 4.7% at six months in 2005). Over 85% of adults tested had viral loads below 400 copies/ml at six-monthly durations until four years on ART. The paper concludes that the location of care in primary-care sites was associated with good retention in care, while scaling-up ART provision was associated with reduced early mortality.

Antiretroviral therapy awareness and risky sexual behaviours: Evidence from Mozambique
De Walque D and Kazianga H: Centre for Global Development Working Paper 239, 12 January 2011

The authors of this paper studied how increased access to antiretroviral therapy affects sexual behaviour, using data collected in Mozambique in 2007 and 2008. They surveyed both HIV-positive individuals and households from the general population. The findings support the hypothesis of disinhibition behaviours, where individuals are more likely to engage in risky sexual behaviour when they believe that they will have greater access to better health care, such as antiretroviral therapy. The findings suggest that scaling up access to antiretroviral therapy without prevention programmes may lead to more risky sexual behaviour and ultimately more infections. The authors conclude that with increased antiretroviral availability, prevention programmes need to include educational messages so that individuals know that risky sexual behaviour is still dangerous.

Antiretroviral therapy awareness and risky sexual behaviours: Evidence from Mozambique
De Walque D And Kazianga H: Centre For Global Development Working Paper 239, 12 January 2011

The authors of this paper studied how increased access to antiretroviral therapy affects sexual behaviour, using data collected in Mozambique in 2007 and 2008. They surveyed both HIV-positive individuals and households from the general population. The findings support the hypothesis of disinhibition behaviours, where individuals are more likely to engage in risky sexual behaviour when they believe that they will have greater access to better health care, such as antiretroviral therapy. The findings suggest that scaling up access to antiretroviral therapy without prevention programmes may lead to more risky sexual behaviour and ultimately more infections. The authors conclude that with increased antiretroviral availability, prevention programmes need to include educational messages so that individuals know that risky sexual behaviour is dangerous.

Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approach
World Health Organization: 2010

This 2010 update of the original 2006 publication by the World Health Organization (WHO) outlines a public health approach to the delivery of anti-retroviral therapy (ART) for adults and adolescents in settings with limited health systems capacity and resources. The recommendations encourage earlier HIV diagnosis and earlier antiretroviral treatment, and promote the use of less toxic regimens and more strategic laboratory monitoring. The guidelines identify the most potent, effective and feasible first-line, second-line and subsequent treatment regimens, applicable to the majority of populations, the optimal timing of ART initiation and improved criteria for ART switching, and introduce the concept of third-line antiretroviral regimens. The primary audiences are national treatment advisory boards, partners implementing HIV care and treatment, and organisations providing technical and financial support to HIV care and treatment programmes in resource-limited settings. WHO notes that it is critical that national ART programme and public health leaders consider these recommendations in the context of countries’ HIV epidemics, the strengths and weaknesses of health systems, and the availability of financial, human and other essential resources and adapt the guidelines carefully. It is similarly important to ensure that the adaptation of these guidelines do not stifle ongoing or planned research, since the new recommendations reflect the current state of knowledge and new information for sustainability and future modifications of existing guidelines will be needed.

Antiretroviral Therapy for Refugees and Internally Displaced Persons: A Call for Equity
Mendelsohn JB, Spiegel P, Schilperoord M, Cornier N, Ross DA: PLoS Med 11(6), 10 June 2014

Available evidence suggests that refugees and internally displaced persons (IDPs) in stable settings can sustain high levels of adherence and viral suppression. Moral, legal, and public health principles and recent evidence strongly suggest that refugees and IDPs should have equitable access to HIV treatment and support. Exclusion of refugees and IDPs from HIV National Strategic Plans suggests that they may not be included in future national funding proposals to major funders. Levels of viral suppression among refugees and nationals documented in a stable refugee camp suggest that some settings require more intensive support for all population groups. Detailed recommendations are provided for refugees and IDPs accessing antiretroviral therapy in stable settings.

Antiretroviral therapy in Africa

The experience of tuberculosis treatment in Africa shows that the potential short term gains from reducing individual morbidity and mortality may be far outweighed by the potential for the long term spread of drug resistance, says an article in the British Medical Journal. Given the high levels of HIV prevalence and the lack of resources and infrastructures, HIV/AIDS antiretroviral therapy is likely to be introduced to Africa in a random and haphazard way, with inconsistent prescribing practices and poor monitoring of therapy and adherence: this risks the rapid development and transmission of drug resistance.

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