Equity and HIV/AIDS

‘Antwerp in Geneva’ workshop on the AIDS response and health systems strengthening in sub-Saharan Africa, 28 May 2008
Ford N, Ooms G, Laga M, Pirard M, van Damme W and Loewenson R

On 28 May 2008 the Institute of Tropical Medicine (Antwerp, Belgium) hosted a meeting at the World Health Organization (Geneva, Switzerland) to review the evidence on the effects of AIDS programmes on Health Systems, particularly in high HIV prevalence settings, and discuss the way forward. Over 30 participants attended from a range of backgrounds (implementers, activists, academics and funders) and HIV-affected countries. The report summarizes the main issues that were discussed at the workshop, including the harms and benefits of HIV programmes for health systems and primary health care, debates around continued AIDS exceptionalism, and considerations and policy options for HIV programmes
to maximise their potential to contribute to health systems strengthening.
The report is organised around the major issues/debates that have been raised around AIDS programmes and health systems, particularly the financing, organisation and delivery of health systems. The discussions were informed by country experiences presented from a number of high-burden countries in sub-Saharan Africa and evidence and experience from
meeting delegates.

‘It's her responsibility’: Partner involvement in prevention of mother to child transmission of HIV programmes, northern Tanzania
Falnes E, Moland K, Tylleskar T, de Paoli M, Msuya SE and Engebretsen IM: Journal of the International AIDS Society 14(21), 26 April 2011

In this study, the authors explored acceptability of child transmission (PMTCT) programme components and identified structural and cultural challenges to male involvement in pregnancy and childbirth in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used, including focus group discussions with fathers and mothers, in-depth interviews with fathers, mothers and health personnel, and a survey of 426 mothers bringing their four-week-old infants for immunisation at five reproductive and child health clinics. Routine testing for HIV of women at the antenatal clinic was found to be highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance. Very few men joined their wives for testing and thus missed out on PMTCT counselling. The main barriers reported were that women did not have the authority to request their husbands to test for HIV and that the arena for testing, the antenatal clinic, was defined as a typical female domain where men were out of place. The authors conclude that deep-seated ideas about gender roles and hierarchy are the major obstacles to male participation in the PMTCT programme. Empowering men to participate by creating a space within the PMTCT programme that is male friendly should be feasible and should be highly prioritised for the PMTCT programme to achieve its potential.

‘Just like fever’: A qualitative study on the impact of antiretroviral provision on the normalisation of HIV in rural Tanzania and its implications for prevention
Roura M, Wringe A, Busza J, Nhandi B, Mbata D, Zaba B and Urassa M: International Health and Human Rights, 9 September 2009

As part of a broader initiative to monitor the implementation of the national antiretroviral therapy (ART) programme, this qualitative study investigated the impact of ART availability on perceptions of HIV in a rural ward of north Tanzania and its implications for prevention. A mix of qualitative methods was used including semi-structured interviews with 53 ART clinic clients and service providers. Four group activities were conducted with persons living with HIV. People on ART often reported feeling increasingly comfortable with their status reflecting a certain ‘normalisation’ of the disease. Overcoming internalised feelings of shame facilitated disclosure of HIV status, helped to sustain treatment, and stimulated VCT uptake. However ‘blaming’ stigma – where people living with HIV were considered responsible for acquiring a ‘moral disease’ – persisted in the community and anticipating it was a key barrier to disclosure and VCT uptake. As long as an HIV diagnosis continues to have moral connotations, a de-stigmatisation of HIV paralleling that occurring with diseases like cancer is unlikely to occur.

‘SADC, put your money where your mouth is’
SATAMo: December 2008

The Treatment Barometer, a survey by SATAMo on access to AIDS treatment within Southern African Development Community (SADC) countries, calls on regional leaders to keep the promises they made towards the provision of HIV treatment by committing much-needed resources. It’s the first regional treatment monitoring research to be carried out by community-based treatment activists, who noted that more than 80% of SADC governments have not honoured the Abuja Declaration more than seven years after the commitment, barriers to treatment still exist, reports of stigma and discrimination by health care workers remain high, stock-outs of drugs are common in more than 80% of the countries surveyed and most countries are struggling to provide first-line treatment to those who need it, with eight countries in SADC below 35% coverage and only two exceeding 75% coverage.

‘The mercurial piece of the puzzle’: Understanding stigma and HIV/AIDS in South Africa
Gilbert L: Journal of Social Aspects of HIV/AIDS Research Alliance (SAHARA-J)13(1) 8-16

Although stigma and its relationship to health and disease is not a new phenomenon, it has not been a major feature in the public discourse until the emergence of HIV. The range of negative responses associated with the epidemic placed stigma on the public agenda and drew attention to its complexity as a phenomenon and concept worthy of further investigation. Despite the consensus that stigma is one of the major contributors to the rapid spread of HIV and the frequent use of the term in the media and among people in the street, the exact meaning of ‘stigma’ remains ambiguous. This paper re-visits some of the scholarly deliberations and further interrogates their relevance in explaining HIV-related stigma evidenced in South Africa. In conclusion a model is presented. Its usefulness – or explanatory potential – is that it attempts to provide a comprehensive framework that offers insights into the individual as well as the social/structural components of HIV-related stigma in a particular context. As such, it is argued by the authors to have the potential to provide more nuanced understandings as well as to alert us to knowledge-gaps in the process.

‘What if they ask how I got it?’ Dilemmas of disclosing parental HIV status and testing children for HIV in Uganda
Rwemisisi J, Wolff B, Coutinho A, Grosskurth H, Whitworth J: Health Policy and Planning 23: 36-42, 2008

Limited research has been conducted outside Western settings on how HIV-positive parents decide to test and disclose their own HIV status to children. This qualitative study was conducted in 2001 and 2005 to assess parent attitudes and current counselling policy and practice regarding child testing and parental disclosure in Uganda prior to the roll-out of antiretroviral therapy. Concerns over disclosure to children of parent's HIV status and testing children for HIV represent a major psychological burden for HIV-positive parents. Further research is reported to be needed, but current counselling practice could be improved now by adapting lessons learned from existing research.

“One-stop shop” brings life-saving HIV care, reproductive health to Botswana’s women
United Nations Population Fund (UNFPA), Geneva, September 2016

When Rose Matuulane was pregnant five years ago, she had to wait for a nurse to visit her small village, Otse in Botswana, to provide antenatal check-ups. When the nurse could not make it, Ms. Matuulane had to travel 84 km to the nearest clinic, in Shoghong, arriving the day before so that she could rise early and queue for hours. If she or any other woman additionally needed a family planning consultation, cervical cancer screening, HIV testing and counselling, or HIV treatment, they would have to come back another day, waiting again for hours. Ms. Matuulane, 24, is now a mother of two. The experience she had with her second pregnancy was worlds apart from the first. In 2011, shortly after she had her first baby, UNFPA helped to introduce integrated reproductive health care services at the Otse Health Post. It meant Ms. Matuulane no longer had to travel all the way to Shoshong. The new approach – called a “one-stop shop model” – also meant women no longer had to return time and again for different sexual and reproductive health services. The one-stop shop model is helping to increase women’s access to life-saving maternal health care and family planning. It is also a critical tactic in the fight against Botswana’s devastating HIV epidemic. The country has an HIV prevalence of 22 per cent among 15-to-49 year olds, according to 2015 UNAIDS estimates. A staggering 18 per cent of maternal deaths in the country are due to HIV-related causes. By integrating a full suite of reproductive health care together with a full range of HIV services – including prevention, testing and antiretroviral treatment – health workers have more opportunities to provide both kinds of care. The project – a partnership between the Ministry of Health, UNFPA and UNAIDS, with funding from the European Union, and the Swedish and Norwegian development agencies – is being piloted in seven countries in the East and Southern Africa Region. Botswana is the first of the pilot countries to implement the approach nationwide. Since the programme’s launch, the number of women visiting clinics for post-natal care, who are then able to simultaneously receive HIV and family planning services, has increased by 63 per cent, according to a recent report. The number of women seeking family planning, who are now able to access HIV services at the same time, has increased by 89 per cent.

“We cannot leave lives of nationals to development partners”
Gonzalez LL: Inter Press Services: 16 March 2011

As external funders retreat from funding HIV prevention and treatment, national programmes reliant on external funding have become exceedingly vulnerable. Activists from East and Southern Africa are calling on governments to take increased ownership of these programmes to ensure treatment continues after donor funds have gone. According to Dr Mbulawa Mugabe, UNAIDS deputy regional director for East and Southern Africa, the region has made considerable progress towards reaching the universal HIV treatment access target of 80% coverage among those in need of antiretrovirals (ARVs). He added that the region is performing above average for low and middle-income countries. However, he indicated that hardly any of the region’s governments are contributing financially to the treatment response. “We cannot leave the lives of nationals to development partners," he emphasised. According to researchers, governments need to bridge the gap between domestic and external spending for ARVs but, without accurate country-level data, this gap is difficult to estimate.

“You are wasting our drugs”: health service barriers to HIV treatment for sex workers in Zimbabwe
Mtetwa S; Busza J; Chidiya S; Mungofa S; Cowan F: BMC Public Health 13(698), July 2013,

In Zimbabwe, despite the existence of well-attended services targeted to female sex workers (SWs), fewer than half of women diagnosed with HIV took up referrals for assessment and ART initiation; just 14% attended more than one appointment. The authors conducted a qualitative study to explore the reasons for non-attendance and the high rate of attrition, through three focus group discussions (FGD) in Harare with HIV-positive SWs. SWs emphasised supply-side barriers, such as being demeaned and humiliated by health workers, reflecting broader social stigma surrounding their work. Sex workers were particularly sensitive to being identified and belittled within the health care environment. Demand-side barriers also featured, including competing time commitments and costs of transport and some treatment, reflecting SWs’ marginalised socio-economic position. Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. The authors suggest that programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.