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.
Equity and HIV/AIDS
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.
AIDS activists have reported that public health facilities in South Africa's Free State Province are experiencing serious shortages of condoms, with some clinics reporting complete stockouts. The Treatment Action Campaign (TAC), an AIDS lobby group, contacted 41 clinics in the province: four reported shortages of condoms and eleven said they had none at all. One clinic in the provincial capital, Bloemfontein, said the depot that normally supplied them with condoms had run out. Free State attracted controversy in November 2008 after the provincial health budget had been overspent to such an extent that the authorities stopped initiating HIV-positive patients on antiretroviral treatment. The national department of health blamed a countrywide shortage in December 2008 on a delay in awarding a new tender. TAC speculated that the delay might still be affecting supply, as it used to receive about one million condoms a month from the health department for distribution, but could now only get hold of about half that quantity.
In this study, the main objective was to estimate the impact of global strategies, such as pooled procurement arrangements, third-party price negotiation and differential pricing, on reducing the price of antiretrovirals (ARVs). Researchers estimated the impact of global strategies to reduce ARV prices using data on 7,253 procurement transactions from July 2002 to October 2007. They found that large purchase volumes did not necessarily result in lower ARV prices. Although current plans for pooled procurement will further increase purchase volumes, savings are uncertain and should be balanced against programmatic costs. Third-party negotiations by the Clinton HIV/AIDS Initiative resulted in lower generic ARV prices. Generics were less expensive than differentially priced branded ARVs, except where little generic competition exists. Alternative strategies for reducing ARV prices, such as streamlining financial management systems, improving demand forecasting and removing barriers to generics, should be explored.
This study set out to determine the incidence of HIV during pregnancy as defined by seroconversion using a repeat HIV rapid testing strategy during late pregnancy. It adopted a cross-sectional design within a prevention of mother-to-child transmission programme. Pregnant women were retested between 36 and 40 weeks of gestation, provided that they had been tested HIV negative at least three months prior. Single women were at 2.5 times higher risk of seroconverting during pregnancy. In general, HIV incidence during pregnancy was four times higher than in the non-pregnant population. Public health programmes need to continue to reinforce prevention strategies and HIV retesting during pregnancy. The latter also offers an additional opportunity to prevent mother-to-child transmission and further horizontal transmission. Further research is required to understand the cause of primary HIV infection in pregnancy.
Little is known about the stage at which those infected with HIV present for treatment in sub-Saharan Africa. This study conducted a cross-sectional analysis of initial visits to the Immune Suppression Syndrome Clinic of the Mbarara University Teaching Hospital, Uganda, totalling 2,311 patients with an initial visit between February 2007 and February 2008. The median age of the patients was 33 years and 64% were female. More than one third (40%) were categorised as late presenters (stage three or four, according to the World Health Organization disease levels). Late presentation was associated with a lower education level, unemployment, living in a household with others or being unmarried, whereas being pregnant, having young children and consuming alcohol in the prior year were associated with early presentation. Targeted public health interventions to facilitate earlier entry into HIV care are needed, as well as additional study to determine whether late presentation is due to delays in testing vs. delays in accessing care.