Recent guidelines recommend that all HIV-infected women should receive highly active antiretroviral therapy throughout pregnancy and lactation, irrespective of whether or not they need it for their own health. This strategy for prevention of mother-to-child transmission (PMTCT) of HIV is more effective than the well-established use of single-dose nevirapine, but it is also a more costly alternative. In this economic evaluation, the researchers used a decision model to combine the best available clinical evidence with cost, epidemiological and behavioural data from Northern Tanzania. It found that a highly active antiretroviral therapy-based PMTCT Plus regimen is more cost effective than the current Tanzanian standard of care with single-dose nevirapine. Although PMTCT Plus is roughly 40% more expensive per pregnant woman than single-dose nevirapine, the expected health benefits are 5.2 times greater. The incremental cost effectiveness ratio of the PMTCT Plus intervention is calculated to be US$4,062 per child infection averted and $162 per disability-adjusted life year.
Equity and HIV/AIDS
The results of the Centre for the AIDS Programme of Research in South Africa (CAPRISA) 004 tenofovir gel trial showed a 39% reduction in new HIV infections, and are considered a critical first step to getting an effective HIV prevention method for women. Much more research still needs to be done, CAPRISA cautions. As a follow-up to the CAPRISA 004 tenofovir gel trial, the global microbicide community has yet to define the quickest route to getting tenofovir gel to the public. There was consensus among the community members that confirmatory trials and implementation studies are urgently needed. However, a key challenge is insufficient funding to undertake the critical next steps. The proposed research is expected to cost approximately US$100 million over three years, of which only $58 million has been committed so far.
A global shortage of funds for the fight against HIV means universal access to prevention, treatment and care is unlikely unless HIV programmes get better value for their investments, according to this report. It argues that there is a need to ‘enhance the impact of current investments by improving the efficiency, effectiveness and quality of programmes, strengthening links between programmes, and building systems for a sustainable response. Although 5.25 million people accessed life-prolonging antiretroviral medication in 2009 - up 1.2 million from 2008 - the report notes that funding shortages, limited human resources, weak procurement and supply management systems for HIV drugs and diagnostics, and other bottlenecks continued to hamper the scale-up of treatment. An estimated 53% of pregnant women worldwide in need of prevention of mother-to-child transmission services received them in 2009, but only 28% HIV-positive children received treatment in 2009, compared to 36% for adults, and just 15% of children born to HIV-positive mothers were given appropriate infant diagnostics.
The notion that concurrent sexual partnerships are especially common in sub-Saharan Africa and explain the region's high HIV prevalence is accepted by many as conventional wisdom. This paper’s findings contradict that belief. The paper evaluated the quantitative and qualitative evidence offered by the principal proponents of the concurrency hypothesis and analysed the mathematical model they use to establish the plausibility of the hypothesis. It found that research seeking to establish a statistical correlation between concurrency and HIV prevalence either finds no correlation or has important limitations. Furthermore, in order to simulate rapid spread of HIV, mathematical models require unrealistic assumptions about frequency of sexual contact, gender symmetry, levels of concurrency, and per-act transmission rates. The paper considers qualitative evidence offered by proponents of the hypothesis as irrelevant since, among other reasons, there is no comparison of Africa with other regions. It concludes that promoters of the concurrency hypothesis have failed to establish that concurrency is unusually prevalent in Africa or that the kinds of concurrent partnerships found in Africa produce more rapid spread of HIV than other forms of sexual behaviour. Policy makers should turn attention to drivers of African HIV epidemics that are policy sensitive and for which there is substantial epidemiological evidence.
This study looked at HIV prevalence in the higher education sector in South Africa. It reported both quantitative and qualitative data. Out of a total of 29,856 eligible participants available at testing venues, 79,1% participated fully by completing questionnaires and providing specimens. Because of a substantial amount of missing data in 230 questionnaires, the final database consisted of 23,375 individuals made up of 17,062 students, 1,880 academic staff and 4,433 administrative and service staff. The mean HIV prevalence for students was 3,4%. HIV was significantly more common among men (6,5%) and women (12,1%) who reported symptoms of a sexuallty transmitted infection (STI) in the last year compared to men (2,5%) and women (6%) who did not report an STI. First-year students appeared to lack the required experience to make good, risk-aware decisions, especially regarding sexual liaisons and the use of alcohol. Qualitative data pointed to underlying causes of HIV transmission on campus as including reported transactional sex, intergenerational sex (a young woman with an older wealthier man), poor campus leadership on HIV and AIDS, limited uptake of voluntary testing and counseling services, poor levels of security on campus and stigma surrounding the disease.
The objective of this study was to determine the incidence of loss to follow-up in a treatment programme for people living with human immunodeficiency virus (HIV) infection in Kenya and to investigate how loss to follow-up is affected by gender. Between November 2001 and November 2007, 50,275 HIV-positive individuals aged 14 years and older (69% female) were enrolled in the study. An individual was lost to follow-up when absent from the HIV treatment clinic for more than three months if on combination antiretroviral therapy (cART) or for more than six months if not. Overall, 8% of individuals attended no follow-up visits, and 54% of them were lost to follow-up. The overall incidence of loss to follow-up was high, at 25.1 per 100 persons annually. Among the 92% who attended at least one follow-up visit, the incidence of loss to follow-up before and after starting cART was respectively 27.2 and 14.0 per 100 persons annually. Baseline factors associated with loss to follow-up included younger age, a long travel time to the clinic, patient disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV disease, and rural clinic location. Men were at an increased risk overall and before and after starting cART. The study concluded that interventions designed separately for men and women could improve retention.
This study examined the utilisation of the prevention of mother to child transmission (PMTCT) services in five reproductive and child health clinics in 2007 and 2008 in Moshi, northern Tanzania, after the implementation of routine counselling and testing and explored the level of knowledge the postnatal mothers had about PMTCT. Researchers interviewed 446 mothers when they brought their four-week-old infants to five reproductive and child health clinics for immunization and conducted thirteen in-depth interviews with mothers and nurses, four focus group discussions with mothers, and four observations of mothers receiving counselling. The study found that nearly all mothers (98%) were offered HIV testing, and all who were offered accepted. However, the counselling was hasty with little time for clarifications. Mothers attending urban antenatal clinics tended to be more knowledgeable about PMTCT than the rural attendees. Compared with previous studies in the area, this study found that PMTCT knowledge had increased and the counsellors had greater confidence in their counselling. The study concludes that when the PMTCT programme has had time to get established, both its acceptance and the understanding of the topics dealt with during the counselling increases.
South Africa is trying to pull off the most extensive global HIV testing campaign but the ambitious initiative is facing some daunting realities. Launched in April 2010, the campaign aims to test 15 million South Africans over 12 months. But five months in, Health Minister Aaron Motsoaledi has admitted the initiative has stalled. The government is preparing to re-launch the campaign and expand its reach to schools and workplaces. With an adult HIV prevalence of about 18%, just over one million South Africans were on antiretroviral (ARV) treatment as of May 2010, according to National Health Council data. If the campaign is successful in diagnosing more people with HIV and referring them to care, an additional 590,000 people could be eligible for treatment by April 2011, according to health department estimates. However, Mark Heywood, vice-chairman of the South African National AIDS Council (SANAC), referred to government statistics that show that between April and July 2010, about 1.7 million people were tested for HIV as part of the campaign, but, of 300,000 people who tested positive, only half were referred to any related health services. A poor referral system may also explain why, despite a surge in the uptake of voluntary counselling and HIV testing, only an additional 3,000 people were put on ARVs in the campaign's first two months.
This paper sought to study the progress and challenges with regard to universal antiretroviral (ARV) access in Free State Province, South Africa. Data from the first four years of the public sector ARV roll-out and selected health system indicators was used. Data was collected from the public sector ARV database in Free State Province for new patients on ARVs, average waiting times and median CD4 counts at the start of treatment. Information on staff training, vacancy rates and funding allocations for the ARV roll-out was obtained from official government reports. Projections were made of expected new ARV enrolments for 2008 and 2009 and compared with goals set by the National Strategic Plan (NSP) to achieve universal access to ARVs by 2011. The researchers found that new ARV enrolments increased annually to 25% of the estimated need by the end of 2007. Average waiting times to enrolment decreased from 5.82 months to 3.24 months. Median CD4 counts at enrolment increased from 89 to 124 cells/mm3. There is a staff vacancy rate of 38% in the ARV programme and an inadequate increase in budget allocations. The paper concludes that current vertical model of ARV therapy delivery is unlikely to raise the number of new enrolments sufficiently to achieve the goals of universal access by 2011 as envisaged by the NSP. The Free State is implementing a project (STRETCH trial) to broaden the ARV roll-out in an attempt to increase access to ARVs.
This study’s aim was to assess the evidence for a differential effect of positive prevention interventions among individuals infected and not infected with human immunodeficiency virus (HIV) in developing countries, and to assess the effectiveness of interventions targeted specifically at people living with HIV. The researchers conducted a systematic review and meta-analysis of papers on positive prevention behavioural interventions in developing countries published between January 1990 and December 2006. Nineteen studies met the inclusion criteria. The meta-analysis showed that behavioural interventions had a stronger impact on condom use among HIV-positive (HIV+) individuals than among HIV-negative individuals. Interventions specifically targeting HIV+ individuals also showed a positive effect on condom use. However, interventions included in this review were limited both in scope (most were HIV counselling and testing interventions) and in target populations (most were conducted among heterosexual adults or HIV-serodiscordant couples). Current evidence suggests that interventions targeting people living with HIV in developing countries increase condom use, especially among HIV-serodiscordant couples. Comprehensive positive prevention interventions targeting diverse populations and covering a range of intervention modalities are needed to keep HIV+ individuals physically and mentally healthy, prevent transmission of HIV infection and increase the agency and involvement of people living with HIV.