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.
Equity and HIV/AIDS
Researchers in this study investigated reasons for clinical follow-up and treatment discontinuation among HIV-infected individuals receiving antiretroviral therapy (ART) in a public-sector clinic and in a workplace clinic in South Africa. Participants in a larger cohort study who had discontinued clinical care by the seventh month of treatment were traced using previously provided locator information. Those located were administered a semi-structured questionnaire regarding reasons for discontinuing clinical follow-up. Participants who had discontinued antiretroviral therapy were invited to participate in further in-depth qualitative interviews. Fifty-one of 144 (35.4%) in the workplace cohort had discontinued clinical follow-up by the seventh month of treatment. The median age of those who discontinued follow-up was 46 years and median educational level was five years. By contrast, only 16.5% (44/267) of the public-sector cohort had discontinued follow-up. Among them the median age was 37.5 years and median education was 11 years. Qualitative interviews were conducted with 17 workplace participants and 10 public-sector participants. The main reasons for attrition in the workplace were uncertainty about own HIV status and above the value of ART, poor patient–provider relationships and workplace discrimination. In the public sector, these were moving away and having no money for clinic transport. The authors argue that, in the workplace, efforts to minimise the time between testing and treatment initiation should be balanced with the need to provide adequate baseline counselling taking into account existing concepts about HIV and ART. In the public sector, earlier diagnosis and ART initiation may help to reduce early mortality, while links to government grants may reduce attrition.
This is the first study to report malaria as a risk factor of concurrent HIV infection at the population level. The authors examined the association between malaria and HIV prevalence in east sub-Saharan Africa. They used large nationally representative samples of 19,735 sexually active adults from the 2003–04 HIV and AIDS indicator surveys conducted in Kenya, Malawi and Tanzania, as well as the Atlas Malaria Project, and analysed the relationship between malaria and HIV prevalence, adjusting for important socio-economic and biological cofactors. They found that individuals who live in areas with a high malaria parasite rate are about twice as likely to be HIV positive compared with individuals who live in areas with a low parasite rate. The authors argue that these findings emphasise the need for field studies focused on quantifying the interaction among parasitic infections and risk of HIV infection, as well as studies to explore the impact of control interventions. Public health programmes in the region should be focused on reducing malaria transmission, especially in HIV-infected individuals.
An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. The authors of this study evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region. Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills. The authors conclude that MEMS-bottle use was readily accepted by patients, but patients need to be more explicitly instructed to continue MEMS-use when travelling. In addition, even if HIV clinics have sufficient staff and free medication, supplying an insufficient amount of pills may impose adherence barriers on patients.
Botswana has said it is prioritising the prevention of new HIV infections as its number one HIV and AIDS strategy, since the cost of keeping people alive on treatment is no longer sustainable. National AIDS Council spokesperson, Lorato Mongatane, said there is need for a comprehensive public awareness campaign to ensure the nation is made aware of the cost of the national response to HIV and AIDS and its impact on economic growth. Mongatane said with over 150,000 people on treatment and HIV and AIDS budget for 2010/2011 exceeding US$500 million, the Botswana government is prioritising the prevention of new infections to ensure that the number of people living with HIV and AIDS stabilises to help contain the cost over time. She pointed out that HIV prevention knowledge has not translated into major behaviour changes that could ultimately reduce the number of new infections.
This study, conducted between May 2009 and January 2010, undertook to explore the social, economic and cultural factors related to engagement in multiple concurrent sexual partnerships in Zambia. In-depth interviews were conducted at seven geographically diverse sites across Zambia. Interviews were conducted with 301 men and women who perceived themselves to be in stable relationships. Researchers used structured interviews and careful probing to elicit detailed information on all sexual partnerships during the previous 12 months. They found that overlapping concurrency was frequent among both men (71%) and women (46%) who identified themselves as being in stable relationships. Men who reported overlapping concurrency averaged three partners compared with women who had approximately two partners over the 12-month recall period. Quantitative data indicated that a high degree of mobility, with more than three-quarters of the entire sample indicating some degree of travel in their daily lives. The study calls for more research into the role of mobility in HIV transmission, as well as more national surveillance (biological and behavioural) data on mobile and migrant populations in Zambia. Currently, there is no systematic framework for collecting behavioral or biomedical data from migrant/mobile populations, and numerous gaps exist in data with regard to these groups. In addition, HIV prevention efforts must reflect a better understanding of the social and cultural nuances of mobility and migration that affect decisions to engage in sexual concurrency.
Based on field experience in environments with limited resources, this paper aims to illustrate the various strategies developed by Medicins sans Frontiers (MSF) to simplify patient screening and follow-up in order to increase access to anti-retroviral treatment. These include decentralising and streamlining treatment protocols, transferring skills, beginning treatment earlier, using new biological monitoring tools, gaining access to new drugs with fewer side effects, and not leaving out patients with complicated cases. The new strategies tend to place more responsibility on patients and simplify their treatment. Medical teams can then focus on treating the most complicated cases. Decentralising medical care and delegating responsibilities to less-qualified personnel (task shifting) are crucial, the paper argues. By giving patients more autonomy and making them responsible for their health, this paper argues, health facilities can spread out their medical consultations to every six months and thus reduce their workload. Simplifying medical follow-up may be achieved by decentralising and streamlining patient care and ensuring that two essential blood tests are available to patients - measuring the CD4 cell count, and the viral load.
This study found that farm workers in South Africa's Limpopo and Mpumalanga provinces have the highest HIV prevalence among any working population in Southern Africa. Conducted from March to May 2010 on 23 commercial farms, the survey included 2,810 farm workers, who anonymously gave blood specimens for HIV testing. The survey found that an average of 39.5% of farm workers who tested were HIV positive, which is more than twice the UNAIDS estimated national prevalence for South Africa of 18.1%. HIV prevalence was significantly higher among female employees, with almost half of the women (46.7%) testing positive compared to just under a third (30.9%) of the male workforce. The study could not pin-point a single factor causing this high rate of HIV infection on these farms, but cites a combination of factors such as multiple and concurrent partnerships, transactional sex, irregular condom use, presence of sexually transmitted infections (STIs) and tuberculosis, and high levels of sexual violence. The authors of the study note that a major research gap exists with regard to HIV among farm workers in southern Africa and they call for more research. The report makes several recommendations including increasing farm worker access to healthcare and implementing prevention programmes that are goal driven and monitored. The programmes should address gender norms that increase risky behaviour and vulnerability to HIV, such as the belief that a man has to have multiple partners. Both permanent and seasonal farm workers should be included in workplace health and safety policies.
Adolescents continue to be at high risk for HIV infection, with young men who have sex with men and youth with drug abuse and/or mental health problems at particularly high risk, according to this study. Multiple factors may interact to confer risk for these youth. Engaging vulnerable youth in HIV prevention research can present unique challenges in the areas of enrollment, retention, and trial adherence. Examples of successful engagement with vulnerable youth offer encouraging evidence for the feasibility of including these youth in clinical trials. Ethical challenges must be taken into consideration before embarking on biomedical HIV prevention studies with vulnerable youth, especially in the global context. Given the many individual and contextual factors that contribute to their high-risk status, the study urges that vulnerable youth populations be included in HIV prevention clinical research studies.
This report evaluates the work that Medicins sans Frontiers (MSF) has done in HIV and AIDS in Mozambique over the past ten years. MSF’s HIV and AIDS programmes offer HIV testing and counseling, treatment and prevention of opportunistic infections, paediatric diagnosis and treatment, prevention of mother-to-child transmission, and the provision of anti-retroviral therapy. At the end of August 2010, more than 33,000 people in Mozambique were being treated for HIV and AIDS through MSF’s projects. However, the report cautions that MSF’s model of care is not a prescriptive cure, and significant challenges remain. More than 350,000 people in Mozambique are in need of ARV treatment but do not have access to it, which equates to two-thirds of all HIV-positive Mozambicans. After years of political willingness and financial commitment to combat HIV and AIDS, external funders are now either flatlining, reducing or withdrawing their funding for HIV, thus abandoning those who are still in dire need of lifesaving treatment. HIV-infected people continue to face major barriers in their access to services, even in a context of free treatment. A shortage of qualified health workers is also considered a major barrier to access in Mozambique, with only 3 doctors and 143 nurses per 100,000 people, one of the lowest workforce per population ratios in the world.