Observational studies have reported an association between male circumcision and reduced risk of HIV infection in female partners. This study assessed whether circumcision in HIV-infected men would reduce transmission of the virus to female sexual partners. Nine-hundred and twenty-two uncircumcised, HIV-infected, asymptomatic men aged 15–49 years with CD4-cell counts 350 cells per μL or more were enrolled in this unblinded, randomised controlled trial in Rakai District, Uganda. HIV-uninfected female partners of the randomised men were concurrently enrolled and followed up at 6, 12 and 24 months to assess HIV acquisition by male treatment assignment (primary outcome). The trial was stopped early because of futility. Seventeen (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up. It appears circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months – longer-term effects could not be assessed.
Equity and HIV/AIDS
While efforts have been made to assess the costs of providing antiretroviral therapy (ART) via accredited service points, little information is available on its downstream costs, particularly in public secondary level hospitals. This paper aims to determine the cost of care for inpatients and outpatients at a dedicated antiretroviral referral unit, the GF Jooste Hospital, during March 2005. This prospective costing study on 48 outpatients and 25 inpatients was conducted from a health system perspective. Incremental cost per outpatient was found to be R1,280 and R5,802 per inpatient. Costs were dominated by medical staff costs (62% inpatient and 58% outpatient, respectively). As the costs of providing secondary level care for patients on or immediately preceding ART initiation can be significant, the study recommends that they should be included in the government’s strategic planning so that the service can be expanded to meet current and future needs and to avoid crowding out other secondary level health services.
This paper seeks to describe the associations between socio-demographic, behavioural and social characteristics and knowledge of HIV status among a nationally representative population in South Africa. A multistage, representative probability sample involving 16,395 male and female respondents, aged 15 years or older was selected. From the total sample 27.6% ever and 7.8% knew their HIV status in the past 12 months. In multivariate analyses, being female, the age group 25 to 34 years old, other than African Black population group (White, Coloured and Asian), higher educational level, being employed, urban residence, awareness of a place nearby where one could be tested for HIV, impact of HIV on the household and having had two of more sexual partners in the past year were associated with knowledge of HIV status. Education about HIV and AIDS and access to HIV counselling and testing in rural areas, in particular among the Black African population group needs to be improved, in order to enhance the uptake of HIV counselling and testing services, an essential step for the initiation of treatment.
This report on international AIDS assistance provides data from 2008, the most recent year available. As such, it represents funding levels reflecting budgets largely set in place before the acceleration of the current global economic crisis. The analysis is based on data provided by donor countries. It found that international AIDS assistance from the G8, the European Community and other donor governments reached its highest level to date – new commitments totalled US$8.7 billion, of which US$6.7 billion was through bilateral channels. Disbursements have increased by more than six-fold. In 2008, the United States was the largest donor in the world, accounting for 51.3% of disbursements by governments. The United Kingdom accounted for the second largest share (12.6%), followed by the Netherlands (6.5%), France (6.4%) and Germany (6.2%). Still, there was a gap of US$6.5 billion between resources available from all sources and resources needed in 2008, as estimated by UNAIDS.
The Global Fund to Fight AIDS, Tuberculosis and Malaria has granted Zimbabwe US$37.9 million, resuming support after getting assurances from the new unity government that the money would not be misused. The head of the Global Fund's Africa Unit, Fareed Abdullah, said the money, previously managed by the state-appointed National Aids Council, would now be overseen by the United Nations Development Programme (UNDP) in Zimbabwe. ‘We're glad that today marks a turning point in the relationship between Zimbabwe and the Global Fund, after the troubled history of the past 18 months,’ Abdullah said. Last year, the Fund alleged that Zimbabwe's central bank had confiscated US$7.3 million in 2007 meant for health programmes – the bank has returned the money since then. ‘The reason behind getting the UNDP as the principal recipient is to do with that history, no doubt.’ Apart from helping in the fight against HIV and AIDS, the money would also be committed to tuberculosis and malaria programmes.
This study in the Kenyan capital, Nairobi, noted reduced HIV risk when the male partner of a pregnant woman attended antenatal clinic visits and was also tested for HIV. The study enrolled 532 HIV-positive pregnant women, 140 of whom were accompanied by their male partners on antenatal visits. Results showed that the one-year-old children of women whose partners had attended the clinics had an HIV-free survival rate 59% higher than those whose partners did not attend. These findings indicate that promotion of programmes aimed at increasing male attendance in antenatal care could function to reduce the risk of vertical transmission and infant mortality. About 80% of antenatal clinics in Kenya offer prevention of mother-to-child HIV transmission (PMTCT) services, but the uptake of counselling and testing is below 50%. The government is considering various incentives, such as waiving maternity fees for couples who attend PMTCT sessions together, to boost male participation.
A large clinical trial of anti-retroviral therapy (ART) for people with HIV infection in Africa has found that regular laboratory tests offer little additional clinical benefit to populations when compared to careful clinical monitoring. The DART trial aimed to find out whether the lab-based strategies used to deliver ART to people with HIV infection in resource-rich countries were essential in Africa, where around four million people still need ART urgently and resources are limited. The trial was carried out in three locations: Entebbe and Kampala in Uganda, and Harare in Zimbabwe, from 2003 to 2008. The results suggest that many more people with HIV in Africa could be treated for the same amount of money as is currently spent if lab tests are not routinely used to monitor ART. ART can be delivered safely and effectively by trained and supervised health workers in remote communities where routine laboratory services are not available – good news for low-income or resource-poor countries that are prioritising ART access over investment in expensive laboratory facilities.
While a number of countries in southern Africa have made great strides in improving access to antiretroviral (ARV) treatment for HIV-infected adults, progress in rolling out treatment for HIV-positive infants and children has lagged behind. Namibia is a notable exception. Over 7,600 children are receiving ARV treatment – 100% of those estimated to be in need of the life-prolonging medicine. Mother-to-child HIV transmission (PMTCT) programmes are available at 202 health facilities. ‘We are meeting targets for children on ARVs, but they are starting late,’ said Dr Agostino Munyiri, chief of health and nutrition at the United Nations Children’s Fund. Children born to HIV-positive mothers should ideally be tested when they are six weeks old, but the median age for testing is currently 17 weeks. ‘Many present with malnutrition and only then are tested for HIV, and even then not all are tested,’ Munyiri added. ‘We know they come back for immunisation [against various diseases]; we need to catch them at that stage.’
By not preparing for the changing treatment needs of people living with HIV, the sustainability of treatment programmes in developing countries is doomed. Over the next decade, an increasing number of patients on inexpensive first-line antiretroviral (ARV) drugs in low-income countries will need second-line ARVs, which currently cost at least seven times more. Many patients will also need to be switched to newer, less toxic first-line drugs, which have fewer side-effects but are at least double the price. This report argues that action is needed now to bring down the price of second-line and less toxic first-line ARVs if a crisis is to be averted later. It supports an alternative approach that would see pharmaceutical companies putting their ARV patents into a single pool, from which manufacturers or researchers could draw in exchange for a royalty fee. Patent pools not only have the potential to reduce the price of existing ARVs, but can stimulate the production of urgently needed new medicines and formulations, such as paediatric ARVs and fixed-dose combinations.
The fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention, held in mid-July, was attended by almost 6,000 mostly scientists and researchers eager to deliver their latest studies to a predominantly American and European audience. ‘The gap between evidence and implementation is particularly apparent between North and South’, said IAS president Dr Julio Montaner, referring to inequities in health services and availability of drugs. One of the most talked-about presentations was that of Robert Granich of the World Health Organisation, who claims that HIV could theoretically be eliminated if all people were tested each year and given antiretrovirals straight away if they tested positive, regardless of whether they were actually sick or not. His model predicted a reduction in HIV prevalence to less than 1% within 50 years based on the premise that, when placed on ARV treatment soon after infection, a person’s chances of infecting their partners are reduced to almost zero.