Adherence to antiretroviral medication in the treatment of HIV is critical, both to maximise efficacy and to minimise the emergence of drug resistance. The aim of this prospective study in three public hospitals in KwaZulu-Natal, South Africa, is to assess the use of traditional complementary and alternative medicine (TCAM) by HIV patients and its effect on antiretroviral (ARV) adherence 6 months after initiating ARVs. 735 (29.8% male and 70.2% female) patients who consecutively attended three HIV clinics completed assessments prior to ARV initiation and 519 after six months on antiretroviral therapy (ART) Results indicate that the use of herbal therapies for HIV declined significantly from 36.6% prior to antiretroviral treatment (ART) initiation to 7.9% after being on ARVs for six months. Faith healing methods, including spiritual practices and prayer for HIV declined from 35.8% to 22.1% and physical/body-mind therapy (exercise and massage) declined from 5.0% to 1.9%. In contrast, the use of micronutrients (vitamins, etc.) significantly increased from 42.6% to 87.4%. In multivariate regression analyses, ARV non-adherence (dose, schedule and food) was associated with the use of herbal treatment, not taking micronutrients and the use of over-the-counter drugs. The use of TCAM declined after initiating ARVs. As herbal treatment for HIV was associated with reduced ARV adherence, patients’ use of TCAM should be considered in ARV adherence management.
Equity and HIV/AIDS
In what is being hailed as a boost for African involvement in AIDS research, Uganda has been selected to host the African AIDS Vaccine Programme (AAVP), formerly based in Geneva, Switzerland. The AAVP, a network of African HIV vaccine stakeholders whose mission is to promote HIV vaccine development for Africa, has operated under the stewardship of the World Health Organization's department of immunization vaccines and biologicals since its formation in 2000. The transition to a fully functional African programme began more than a year ago and will be completed in 2010. The Uganda Virus Research Institute (UVRI), a leading research institute based in Entebbe, will be its new headquarters.
This annual report examines evidence of progress in four key areas in 2008: prevention of mother-to-child transmission (PMTCT), paediatric HIV care and treatment, prevention of HIV among adolescents and young people, and protection and support for children affected by HIV and AIDS. The most significant progress was in PMTCT, with 45% of HIV-positive pregnant women globally receiving antiretroviral (ARV) treatment to prevent them passing HIV to their children; up from 24% in 2006. Several countries with high HIV prevalence expanded PMTCT coverage to most pregnant women needing treatment: 73% in South Africa, 91% in Namibia and 95% in Botswana. Other countries lagged behind: for example, in Nigeria only 10% of pregnant women with HIV were tested and treated to prevent transmission to their babies. The countries most successful at scaling up PMTCT incorporated their programmes into existing maternal and child health services, the report noted. The authors conclude that in the near future, it is not impossible to envisage a generation of children who are free of HIV.
Thanks to the international recession, the author argues that external funders are either decreasing or opting not to increase their funding of AIDS treatment. Medecins Sans Frontieres (MSF) recently reported that two key international programmes supporting AIDS treatment in the developing world are not increasing their grants: For two successive years the Global Fund Against AIDS, Tuberculosis and Malaria has reduced funding for approved grants, while the American President’s Emergency Plan for AIDS Relief (PEPFAR) is now practicing what it calls ‘flat-funding’, which ‘basically means that you can only recruit when someone dies, when someone empties a seat or a treatment slot’, as explained by Dr Erci Goemaere, co-ordinator of MSF missions in South Africa and Lesotho. The authors warn that a funding crisis could lead to the reversal of gains made since the start of antiretroviral treatment in developing countries.
This study took the form of a systematic review and meta-analysis of randomised trials of directly observed versus self-administered antiretroviral treatment. Duplicate searches of databases were conducted, as well as searchable websites of major HIV conferences and lay publications and websites, to identify randomised trials assessing directly observed therapy to promote adherence to antiretroviral therapy in adults. Twelve studies met the inclusion criteria. Four of these were done in groups that were judged to be at high risk of poor adherence (drug users and homeless people). Ten studies reported on the primary outcome – the study calculated a pooled relative risk of 1.04, and noted moderate heterogeneity between the studies for directly observed versus self-administered treatment. The study found that directly observed antiretroviral therapy seems to offer no benefit over self-administered treatment, which calls into question the use of such an approach to support adherence in the general patient population.
Conflation of HIV and alcohol disease in African settings is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.
In a bid to reduce the rate of HIV transmission from mother to child, Uganda will now give all pregnant women highly active antiretroviral therapy (HAART). Second deputy Prime Minister, Kirunda Kivejinja, said the government was committed to scaling up interventions that prevent HIV infections in children by improving prevention of mother-to-child transmission (PMTCT) services. ‘We shall also ensure scale-up of access to services for early infant HIV testing and treatment, and for care and support for all children that are affected by HIV,’ he added. ’We have proven that when pregnant women receive HAART, the rate of transmission from mother to child is less than 2%; this should go full-scale in Uganda,’ Addy Kekitiinwa, executive director of the Baylor Uganda Children's Foundation, said. A recent Ugandan study of 1,829 women found a 1.67% infection rate among infants born to mothers who received HAART during pregnancy, compared with an 11.75% infection rate among infants whose mothers received single-dose Nevirapine, and 3.73% and 5.02% of those who received two types of combination therapy.
New data presented at the IAS Conference for 2009 is already having an impact on HIV policy and practice on a global scale. Results of several basic research studies provided the field with a better understanding of the elevated HIV infection risk among African women due to chronically activated T-cells in genital tract mucosa, how complex genetic variables may affect HIV acquisition and disease progression, and how early antiretroviral therapy (ART) can substantially reduce the size of latent HIV reservoirs, a significant clinical issue in chronic HIV infection. Findings demonstrating that maternal triple-drug ART used throughout pregnancy and breastfeeding reduced vertical transmission to 1% are expected to inform revised World Health Organization (WHO) and South African national guidelines on antiretroviral prophylaxis. Also, research delineating the impact of antiretroviral therapy on reducing coincident tuberculosis and malaria epidemics in HIV-prevalent regions argued for wider and earlier access to treatment.
The Kenyan government has launched an ambitious HIV campaign to test at least one million people across the country over a three-week period. The programme is the first step in a national campaign that intends to test 10 million people by June 2010. According to the 2007 Kenya AIDS Indicator Survey, 80% of HIV-positive adults in the country do not know their status. The initiative, dubbed ‘Jitambue leo, ni haki yako’, Swahili for ‘Know yourself today, it is your right’, was launched on 23 November in the Kenyan capital, Nairobi. ‘We want to target everybody in our campaigns...no group is safe; the youth are becoming increasingly vulnerable, the old initially thought of as safe are equally at risk, and those in marriage account for 50% of new infections,’ said Dr Nicholas Muraguri, head of the National AIDS and Sexually transmitted infection Control Programme. ‘Infants and unborn children benefit too when their parents are tested.’
The world needs a dramatic change in thinking – and action from external funders, policymakers, and programme managers in the public, private and nongovernmental (NGO) sectors – to focus on strengthening health systems in the countries most affected by HIV and AIDS. To meet the Millennium Development Goal of reversing the epidemic by 2015, stakeholders must change how services are designed and delivered. A lesson learned in the 1990s and 2000s was that a host of separate activities cannot be scaled up in a sustainable way and that strengthening health systems is essential for long-term sustainability. The time has come to take a systems approach to HIV & AIDS programming. This holistic approach will create a strong foundation by focusing all efforts on integration, effectiveness and sustainability.