HIV/AIDS treatment guidelines for South Africa's public health sector are out of sync not only with those of many other countries in the region, but also with the latest research on how to most effectively treat people living with HIV. Various studies indicating that patients who start antiretroviral therapy (ART) earlier respond better to treatment and are less likely to develop AIDS-related illnesses have led the United States, the United Kingdom and a number of countries in Africa to change their treatment protocols. Deciding when to start a patient on life-long ARV drugs is usually based on a combination of CD4 cell count test results [which indicate the strength of the immune system] and HIV disease progression, which the World Health Organisation (WHO) has defined according to four clinical stages, with stage four being AIDS. The WHO revised its guidelines in 2003 to recommend that a patient who has reached stage three of the disease and has a CD4 count of less than 350 should begin treatment. Most countries in the region have revised their guidelines accordingly, but South Africa's national ART guidelines are still based on earlier WHO recommendations that ART be prescribed only for patients with stage four disease, or a CD4 count of less than 200. In April, the Southern African HIV Clinicians Society published guidelines in the Southern African Journal of HIV Medicine recommending that people living with HIV begin ART when their CD4 cell count drops below 350, regardless of disease progression. These guidelines are endorsed by the region's leading HIV specialists but have no direct influence on the South African government's ART programme.
Equity and HIV/AIDS
Since the beginning of the HIV epidemic, governments have prevented people living with HIV from entering or residing in their countries based solely on their HIV status. Such restrictions have stopped HIV positive people from travelling for business, family visits, or tourism; and from entering a country for study, labour migration, and political asylum. Seldom is HIV testing linked to any treatment, heath care, counselling or support, either in country of origin or destination. Nor are the results necessarily kept confidential. Though countries focus on excluding HIV positive migrants, little is done to protect migrants from HIV infection while in destination countries – and indeed some do get infected. There have also been reports of HIV-positive migrants dying for lack of treatment while abroad, including in immigration detention facilities pending deportation. HIV-travel restrictions are anachronisms that are inappropriate in the age of globalisation, increased travel, increased access to treatment for HIV, and national and international commitments to universal access to HIV prevention, treatment, care and support. They are also discriminatory and contribute to stigmatisation. No evidence suggests that HIV-related travel restrictions protect the public health, and they may in fact impede efforts to stop the epidemic. UNAIDS recognizes that States impose immigration and visa restrictions as a valid exercise of their national sovereignty. However, in imposing any restrictions on entry and stay relating to HIV or health, UNAIDS calls upon States to adopt non-discriminatory laws and regulations which rationally achieve valid objectives through the least restrictive means possible.
UNAIDS, in collaboration the World Food Programme (WFP) and the World Health Organization (WHO), has developed a policy brief on HIV, food security and nutrition. This policy provides guidance for governments, civil society and other partners on how to address food and nutrition concerns in the context of HIV, keeping in mind the commitment made by all UN member states through the Millennium Development Goals both to reduce chronic hunger and halt and reverse the spread of HIV by 2015.
Based on interviews in two South African provinces and extensive consultation with South African agencies involved with the issue, this report provides a detailed portrait of the situation of rural women, and the interaction among violence, poverty, and the risk of HIV/AIDS. The overview has a concise survey of the development of the AIDS epidemic in South Africa including the debates about government policy and the active role of civil society.
Few sub-Saharan African countries have substantial analyses of the rural and agricultural situations in their Poverty Reduction Strategy Papers (PRSPs) and the link between agriculture and HIV and AIDS is therefore missed. Rural poverty is at the root of risky behavior (sexual services for food, cash or other resources), which can often lead to an HIV infection, hence the rate of HIV transmission can only be effectively reduced by reducing rural poverty. The report recommends improvements in agriculture, food supply, local social security networks (which provide information and behavioural advice) and access to assets that can be mobilised as alternatives to transactional sex. Gender issues also need to be addressed.
By 31 December 2006, Malawi had enrolled 82 000 patients in its free national antiretroviral treatment (ART) programme. Each quarter, data from all ART clinics are aggregated for national reporting on ART scale-up. This information is essential to monitoring site performance, guiding national planning and supporting sustained funding. Despite increasing reliance on sites to aggregate data, the completeness and accuracy of sites’ reports was unknown. The authors therefore conducted an operational study during regular supervisory visits to assess the quality of data in the site reports. Specific objectives were to: i) determine the completeness and accuracy of key case registration and outcome data compiled by ART clinics, ii) compare national data summarized from site reports versus supervision reports, and iii) analyse characteristics associated with sites’ capacity to compile quality data.
This paper describes the experience of Zimbabwe in establishing a baseline for its National Action Plan for Orphans and Other Vulnerable Children (NAP for OVC) using the 10 core indicators developed by the UNAIDS Global Monitoring and Evaluation Reference Group in 2004. Through a population-based household survey in rural and urban high-density areas and the OVC policy and planning effort index assessment tool, a baseline was established. The survey found that 43.6% of children under 18 years were orphaned or made vulnerable by HIV/AIDS. Half of all households with children care for one or more OVC. While the large majority of OVC continued to be cared for by the extended family, its capacity to care for these children appeared to be under pressure. OVC were less likely to have their basic minimum material needs met, more likely to be underweight, less likely to be taken to an appropriate health provider when sick and less likely to attend school. Medical support to households with OVC was found to be relatively high (26%). Other support, such as psychosocial support (2%) and school assistance (12%), was lower. The OVC Effort Index assessment indicates that serious efforts are being made. The increase in the effort index between 2001 and 2004 in the areas of consultative efforts, planning and coordinating mechanisms reflects the strengthened commitment. Monitoring and evaluation and legislative review are the weakest areas of the OVC response. The findings of the baseline exercise point to the need for continued and additional efforts and resources to implement the NAP for OVC, the priorities of which were confirmed by the survey as critical to improve the welfare of the OVC in Zimbabwe.
The diagnosis and management of childhood tuberculosis (TB) are major challenges in countries such as Malawi with high incidence of TB and human immunodeficiency virus (HIV) infection. Diagnosis of TB in children often relies only on clinical features but clinical overlap with the presentation of HIV and other HIV-related lung disease is common. The tuberculin skin test (TST), the standard marker of M. tuberculosis infection in immune competent children, has poor sensitivity in HIV-infected children and is not usually available in Malawi. HIV test should be routine in children with suspected TB as it improves clinical management. HIV-infected children are at increased risk of developing active disease following TB exposure which justifies the use of isoniazid preventive therapy (IPT) once active disease has been excluded but this is difficult to implement and appropriate duration of IPT is unknown. HIV-infected children with active TB experience higher mortality and relapse rates on standard TB treatment compared to HIV-uninfected children, highlighting the need for further research to define optimal treatment regimens. HIV-infected children should also receive appropriate supportive care including co-trimoxazole prophylaxis and anti-retroviral treatment (ART) if indicated. There are concerns about concurrent use of some anti-TB drugs such as rifampicin with some ARTs.
In 2004, South Africa had one of the highest rates of HIV infection in the world and the province of KwaZulu-Natal (KZN) reported the peak of 40.7% positivity among the antenatal population. The purpose of this study was to identify measures to improve the quality of an HIV prevention program targeted at reducing the rate of mother-to-child transmission of HIV infection (MTCT). A cross-sectional observational (non-experimental) study was conducted from Empangeni hospital (i) using antenatal clinic registers between May 2002 and April 2003 and (ii) applied a questionnaire survey to a randomly selected sample of 306 HIV infected women who delivered between April and June 2004. The results showed that among 3774 antenatal attendees, 2528 (67%) accepted pre-test counselling and 2390 (63%) HIV testing. Majority (95%) of those who had (2528) pre-test counselling accepted HIV testing, post test counselling and test results. The prevalence of HIV infection was 41% (980) (95% CI, 39%-43%). Among them (980 HIV positive), 73% (716) received nevirapine during the antenatal period yielding an overall antenatal nevirapine prophylaxis (uptake) rate of 46% (based on an estimate of 41% HIV prevalence rate for total antenatal population of 3774 during the study period). Between April to June 2004, 2393 women delivered at Empangeni hospital of which 39% (933) were HIV positive. The coverage of pretest counselling for HIV testing (67%) and nevirapine use (46%) was low. We found in the questionnaire survey that the participating women had adequate knowledge and compliance on the use of nevirapine. Strategies are needed to improve program uptake and effectiveness of the prevention of mother-to-child transmission of HIV infection (PMTCT) program in rural South Africa.
Ten per cent of individuals infected with TB develop the active disease but this is greatly increased in those whose immune systems have been weakened by HIV. This report from the Forum for Collaborative HIV Research highlights the difficulty in managing the co-epidemic of HIV and TB that is rapidly spreading in Sub-Saharan Africa. The report concludes that strategies for dealing with TB and HIV currently exist in isolation, often reinforced by vertical programme financing. Efforts must be made to integrate these disease treatment programmes that will involve stakeholders working together within an evidence-based collaborative framework.