The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centres and hospitals, offers such a model, providing access to proximate HIV care and minimising structural barriers to retention. In this paper the authors first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralisation of ART services and long-term retention of patients in care. They then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organisation committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organisations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralisation and retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. The authors conclude that PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works.
Equity and HIV/AIDS
The first new trial of a potential vaccine against HIV in seven years has begun in South Africa, raising hopes that it will help bring about the end of the epidemic. Although fewer people are now dying from Aids because 18.2 million are on drug treatment for life to suppress the virus, efforts to prevent people from becoming infected have not been very successful. The infection rate has continued to rise and experts do not believe the epidemic will be ended without a vaccine. The vaccine being tested is a modified version of the only one to have shown a positive effect, out of many that have gone into trials. Seven years ago, the vaccine known as RV144 showed a modest benefit of about 31% in a trial in Thailand. The aspiration is to push the effectiveness up from 31% to between 50% and 60% for use in combination with other prevention tools, such as condoms, antiretroviral drugs and circumcision. According to Professor Linda-Gail Bekker, of the University of Cape Town, “We’ve never treated our way out of an epidemic. There’s no doubt we have to have primary prevention alongside treatment in order to get HIV control, but we are not going to get HIV eradication without a vaccine. That is very clear.”
Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. This study in 2015 identified facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. The authors found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed.
Within the HIV public health domain, interest is growing in universal test and treat (UTT) strategies. This refers to the expansion of antiretroviral therapy (ART) in order to reduce onward transmission and incidence of HIV in a population, through a “treatment as prevention” (TasP). This paper focuses on how masculinity influences engagement with HIV care in the context of an on-going TasP trial. Data were collected in January–November 2013 using 20 in-depth interviews, 10 of them repeated thrice, and 4 focus group discussions, each repeated four times. The accounts detailed men’s unwillingness to engage with HIV testing and care, seemingly tied to their pursuit of valued masculinity constructs such as having strength and control, being sexually competent, and earning income. Given fears regarding getting an HIV-positive diagnosis, men preferred traditional medicine. Further primary health centres were not seen to be welcoming to men discouraging their readiness to test for HIV. These tensions were amplified by masculinity norms. Men struggled with disclosing their HIV status, and used various strategies to avoid or postpone disclosing, or disclose indirectly. In contrast women were found to access care readily. The authors argue that UTT and TasP promotion should use health service delivery models that address these tensions.
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.
HIV-related mHealth interventions have demonstrable efficacy in supporting treatment adherence, although the evidence base for promoting HIV testing is inconclusive. Progress is constrained by a limited understanding of processes used to develop interventions and weak theoretical underpinnings. This paper describes a research project that informed the development of a theory-based mHealth intervention to promote HIV testing amongst city-dwelling African communities in the conditions. A community-based participatory social marketing design was adopted. Six focus groups (48 participants in total) were undertaken and analysed using a thematic framework approach, guided by constructs from the Health Belief Model. Key themes were incorporated into a set of text messages, which were pre-tested and refined. The focus groups identified a relatively low perception of HIV risk, especially amongst men, and a range of social and structural barriers to HIV testing. In terms of self-efficacy around HIV testing, respondents highlighted a need for communities and professionals to work together to build a context of trust through co-location in, and co-involvement of, local communities which would in turn enhance confidence in, and support for, HIV testing activities of health professionals. Findings suggested that messages should: avoid an exclusive focus on HIV, be tailored and personalised, come from a trusted source, allay fears and focus on support and health benefits. HIV remains a stigmatised and de-prioritised issue within African migrant communities in the UK, posing barriers to HIV testing initiatives. A community-based participatory social marketing design can be successfully used to develop a culturally appropriate text messaging HIV intervention. Key challenges involved turning community research recommendations into brief text messages of only 160 characters.
The successes of HIV treatment scale-up and the availability of new prevention tools have raised hopes that the epidemic can finally be controlled and ended. Reduction in HIV incidence and control of the epidemic requires high testing rates at population levels, followed by linkage to treatment or prevention. As effective linkage strategies are identified, it becomes important to understand how these strategies work. The authors use qualitative data from The Linkages Study, a recent community intervention trial of community-based testing with linkage interventions in sub-Saharan Africa, to show how lay counselor home HIV testing and counselling (home HTC) with follow-up support leads to linkage to clinic-based HIV treatment and medical male circumcision services. They conducted 99 semi-structured individual interviews with study participants and three focus groups with 16 lay counselors in Kabwohe, Sheema District, Uganda. The participant sample included both HIV+ men and women (N=47) and HIV-uncircumcised men (N=52). Interview and focus group audio-recordings were translated and transcribed. The transcripts were analysed to identify emergent themes. Trial participants expressed interest in linking to clinic-based services at testing, but faced obstacles that eroded their initial enthusiasm. Follow-up support by lay counselors intervened to restore interest and inspire action. Together, home HTC and follow-up support improved morale, created a desire to reciprocate, and provided reassurance that services were trustworthy. In different ways, these functions built links to the health service system. They worked to strengthen individuals’ general sense of capability, while making the idea of accessing services more manageable and familiar, thus reducing linkage barriers. Home HTC with follow-up support leads to linkage by building “social bridges,”, viz: interpersonal connections established and developed through repeated face-to-face contact between counselors and prospective users of HIV treatment and male circumcision services. Social bridges are found to link communities to the service system, inspiring individuals to overcome obstacles and access care.
There has been remarkable progress in the response to AIDS since the global HIV community last convened in Durban in 2000. Curbing the spread of HIV was the first step . Accelerating investment and action on a robust human rights and social justice agenda is the next. Despite significant scientific advancements, the authors argue that we continue to encounter structural barriers that impede real world progress. Realising the promise of scientific achievement requires a greater commitment to removing barriers between discovery and implementation. The 21st International AIDS Conference (AIDS 2016) must bring these pieces together – the key scientific advances needed to end the epidemic and the key structural barriers impeding progress – and secure greater political commitment including financial resources to get the job done. They argue that it is key to focus on five key scientific advances; ensuring access to antiretroviral therapy for all people living with HIV, scaling up modern combination HIV prevention packages, treating and managing co-infections and co-morbidities, amplifying research efforts for a vaccine and a cure, optimising implementation research. They argue that there is a need to address five key structural barriers; focusing on key populations within and across various HIV epidemic scenarios, addressing gender inequality and empowering young women and girls, challenging laws, policies and practices that stigmatise and discriminate against people living with HIV and key populations, increasing investment in civil society and community lead responses, and enhancing the capacity of front-line healthcare workers.
From 8 to 10 June 2016, heads and representatives of states and governments, along with other key stakeholders, assembled at the United Nations (UN) in New York, for the High-Level Meeting on Ending AIDS. There are three reasons why this meeting is an important milestone for the global response against human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). First, the meeting provides an opportunity to reflect on the extent of progress and unprecedented achievements that have been made in responding to the AIDS epidemic, as described in the UN Secretary-General’s report. Second, the meeting served as an occasion to galvanise support from the global community to scale up the AIDS response. The 90–90–90 treatment target calls for 90% of people living with HIV to know their status, 90% of people who know their HIV status to have access to treatment and 90% of people on treatment to achieve suppressed viral loads by 2020. Third, the meeting was an opportunity to reflect on specific challenges that need to be addressed going forward. Among them is a treatment gap and inadequate global investments in prevention. The UNAIDS 2016–2021 Strategy integrated efforts towards ending the AIDS epidemic fully into Transforming our world: the 2030 agenda for sustainable development. The strategy sets out the links between the HIV response and several sustainable development goals (SDGs), from SDG 1 on ending poverty to SDG 16 on promoting inclusive societies.
Pain has been reported as the second most commonly reported symptom in people living with HIV. In South Africa, there are more than five million people living with HIV. Approximately, two million belong to the Xhosa cultural group. A culturally appropriate, valid, and reliable instrument is required to measure pain and its impact in this population. This article documents the process of translation of the Brief Pain Inventory (BPI) into the BPI-Xhosa and presents the results of the validity and reliability testing of the instrument. The translated BPI-Xhosa, a demographic questionnaire and the European Quality of Life-5 Dimensions Xhosa version (EQ-5D-Xhosa) health-related quality of life instrument were administered to 229 amaXhosa women living with HIV in a resource-poor urban settlement in South Africa. A 74% prevalence of pain was recorded. The BPI-Xhosa had good concurrent validity when compared with the previously validated EQ-5D-Xhosa. The BPI-Xhosa was found to be a valid instrument to measure pain prevalence, severity, and interference in amaXhosa women living with HIV.