Life-prolonging antiretroviral (ARV) medication is reaching more HIV-positive Ugandans than ever before, but health workers are concerned about how they will deal with the inevitable rise in drug resistance. An estimated 400 accredited facilities are providing about 218,000 Ugandans with ARVs, and more than 300,000 have enrolled on HIV treatment, but many patients have died and some have simply abandoned treatment. Although studies show that ARV adherence is generally high, frequent drug stock-outs as a result of funding shortages and supply-chain problems as well as food insecurity mean that patients have experienced interruptions in their treatment regimens, predisposing them to resistance. The Europe-Africa Research Network for Evaluation of Second-line Therapy (EARNEST) trial is trying to determine the best option for resource-limited settings at the Infectious Disease Institute (IDI), part of the Mulago Hospital Complex in the capital, Kampala. Currently, about 3% of adults and 4.6% of children on ARVs are taking second-line drugs. According to the previous World Health Organization's CD-4 count cut-off of 200, the Ministry of Health has estimated that 379,551 more people would require ARVs.
Equity and HIV/AIDS
This report shows that the AIDS epidemic is beginning to change course as the number of people newly infected with HIV is declining and AIDS-related deaths are decreasing. Together, these are contributing to the stabilisation of the total number of people living with HIV in the world. Data from the report indicates that an estimated 2.6 million people became newly infected with HIV, nearly 20% fewer than the 3.1 million people infected in 1999. In 2009, 1.8 million people died from AIDS-related illnesses, nearly one-fifth lower than the 2.1 million people who died in 2004. At the end of 2009, 33.3 million people were estimated to be living with HIV, up slightly from 32.8 million in 2008. This is in large part due to more people living longer as access to antiretroviral therapy increases, the report argues. From 2001 to 2009, the rate of new HIV infections stabilised or decreased by more than 25% in at least 56 countries around the world, including 34 countries in sub-Saharan Africa. Of the five countries with the largest epidemics in the region, the report notes that four countries - Ethiopia, South Africa, Zambia and Zimbabwe - have reduced rates of new HIV infections by more than 25%, while Nigeria’s epidemic has stabilised. Sub-Saharan Africa continues to be the region most affected by the epidemic, with 69% of all new HIV infections.
In light of increasing access to antiretroviral therapy in sub-Saharan Africa, the authors conducted a longitudinal study to assess the impact of antiretroviral therapy on sexual risk behaviours among HIV-infected South Africans in urban and rural primary care clinics. This prospective observational cohort was conducted at rural and urban primary care HIV clinics, consisting of 1,544 men and 4,719 women enrolled from 2003 to 2010, and representing 19,703 clinic visits. The primary outcomes were being sexually active, unprotected sex and more than one sex partner and were evaluated at six-monthly intervals. Generalised estimated equations assessed the impact of antiretroviral therapy on sexual risk behaviours. Among 6,263 HIV-infected men and women, over a third (37.2%) initiated antiretroviral therapy (ART) during study follow-up. In comparison to pre-ART follow-up, visits while receiving antiretroviral therapy were associated with a decrease in those reporting being sexually active. Unprotected sex and having more than one sex partner were reduced at visits following ART initiation compared to pre-ART visits. Sexual risk behaviour significantly decreased following antiretroviral therapy initiation among HIV-infected South African men and women in primary care programmes. The study concludes that further expansion of ART programmes could enhance HIV prevention efforts in Africa.
This short film argues that many more people living with HIV in sub-Saharan Africa could be treated if laboratory tests were used in a targeted rather than routine way. Trial participants, practitioners and investigators explain how maintaining and scaling up access to antiretroviral therapy (ART) in low- and middle-income countries could be possible on current funding levels, even in the midst of a global economic crisis. The principal message from Developing Antiretroviral Therapy in Africa (DART) is that ART saves lives, and that it can be delivered safely and successfully without the use of routine laboratory testing for drug toxicity and side effects. Use of routine CD4 testing for monitoring disease progression is argued to offer only a small benefit to patients after the second year of therapy. Trial investigators believe that priority should be given to widening access to first- and second-line drugs to treat HIV, with resources focused on strengthening healthcare systems and training well-supervised healthcare workers to deliver quality care in rural areas.
This study assessed differences in access to antiretroviral treatment (ART) and patient outcomes across public sector treatment facilities in the Free State province, South Africa. It took the form of a prospective cohort study with retrospective database links. Data on patients enrolled in the treatment programme was analysed across 36 facilities between May 2004 and December 2007. Of 44,866 patients enrolled, 15,219 initiated treatment within one year, 8,778 died within one year (7,286 before accessing ART). Outcomes at one year varied greatly across facilities and more variability was explained by facility-level factors than by patient-level factors. The odds of starting treatment within one year improved over calendar time. Patients were less likely to start treatment if they were male, severely immunosuppressed, or underweight. Men were also more likely to die in the first year after enrolment. Although increasing numbers of patients started ART between 2004 and 2007, many patients died before accessing ART. Patient outcomes could be improved by decentralisation of treatment services, fast-tracking the most immunodeficient patients and improving access, especially for men.
The authors of this study assessed symptom prevalence, general health, ability to perform normal activities, and employment status among adult antiretroviral therapy (ART) patients in South Africa over three full years following ART initiation. A cohort of 855 adult pre-ART patients and patients on ATY for <6 months was enrolled and interviewed an average of 4.4 times each during routine clinic visits for up to three years after treatment initiation using an instrument designed for the study. The probability of pain in the previous week fell from 74% before ART initiation to 32% after three years on ART, fatigue from 66% to 12%, nausea from 28% to 4%, and skin problems from 55% to 10%. The probability of not feeling well physically yesterday fell from 46% to 23%. Before starting ART, 39% of subjects reported not being able to perform their normal activities sometime during the previous week; after three years, this proportion fell to 10%. Employment rose from 27% to 42% of the cohort. Improvement in all outcomes was sustained over three years and, for some outcomes, increased in the second and third year. Improvements in adult ART patients' symptom prevalence, general health, ability to perform normal activities and employment status were large and were sustained through the first three years on treatment. These results suggest that some of the positive economic and social externalities anticipated as a result of large-scale treatment provision, such as increases in workforce participation and productivity and the ability of patients to carry on normal lives, may indeed be accruing.
This study sought to quantify the number of cases and prevalence of human immunodeficiency virus (HIV) infection among older adults in sub-Saharan Africa. It reviewed data from Demographic and Health Surveys (DHS), of which 8 surveys contained data on HIV infection among men aged ≥ 50 years. Data was also extrapolated from the Joint United Nations Programme on HIV/AIDS on the estimated number of people living with HIV and on HIV infection prevalence among adults aged 15–49 years. The study found that, in 2007, approximately 3 million people aged ≥ 50 years were living with HIV in sub-Saharan Africa. The prevalence of HIV infection in this group was 4.0%, compared with 5.0% among those aged 15–49 years. Of the approximately 21 million people in sub-Saharan Africa aged ≥ 15 years that were HIV+, 14.3% were ≥ 50 years old. The study concludes that to better reflect the longer survival of people living with HIV and the ageing of the HIV+ population, indicators of the prevalence of HIV infection should be expanded to include people > 49 years of age. Little is known about comorbidity and sexual behaviour among HIV+ older adults or about the biological and cultural factors that increase the risk of transmission. HIV services need to be better targeted to respond to the growing needs of older adults living with HIV.
Much of the debate as to whether or not the scaling up of HIV service delivery in Africa benefits non-HIV priority services has focused on the use of nationally aggregated data. This paper analyses and presents routine health facility record data to show trend correlations across priority services. The authors conducted a review of district office and health facility client records for 39 health facilities in three districts of Zambia, covering four consecutive years (2004-2007). Intra-facility analyses were conducted, service and coverage trends assessed and rank correlations between services measured to compare service trends within facilities. Voluntary counselling and testing, antiretroviral therapy and prevention of mother-to-child transmission client numbers and coverage levels were found to have increased rapidly during the period. There were some strong positive correlations in trends within facilities between reproductive health services (family planning and antenatal care) and antiretroviral therapy and prevention of mother-to-child transmission. Childhood immunisation coverage also increased. Stock-outs of important drugs for non-HIV priority services were significantly more frequent than were stock-outs of antiretroviral drugs. The analysis shows scale-up in reproductive health service numbers in the same facilities where HIV services were scaling up. While district childhood immunisations increased overall, this did not necessarily occur in facility catchment areas where HIV service scale-up occurred. The paper demonstrates an approach for comparing correlation trends across different services, using routine health facility information. Larger samples and explanatory studies are needed to understand the client, facility and health systems factors that contribute to positive and negative synergies between priority services.
Delayed test results often mean HIV patients in Mozambique fail to get timely treatment, but new technology is reducing the need to send tests to far away laboratories, and speeding up test results and HIV treatment. After a successful 2009 pilot, the country has nationally rolled out SMS or text message printers, which transmit the results of infant HIV tests electronically from two central reference laboratories in Maputo and the northern provincial capital, Nampula, to more than 275 health centres. Previously, test samples and results would have taken on average three weeks and up to several months to be transported to and from clinics via car, plane and even kayak in remote parts of the country. According to research conducted by the Ministry of Health and the Clinton Health Access Initiative (CHAI), who developed the technology, the time it took for clinics to receive test results dropped from an average of about three weeks to about three days after the printers were introduced. This, in turn, reduced the time it took to start infants on antiretroviral (ARV) treatment as part of national prevention of mother-to-child (PMTCT) HIV transmission services by about four months. The number of infants starting treatment also increased by 60%.
This study is based on a one-week integrated multi-disease prevention campaign in Lurambi, Western Kenya. The aim was to offer services to at least 80% of those aged 15-49. Thirty-one temporary sites in strategically dispersed locations offered: HIV counselling and testing, 60 male condoms, an insecticide-treated bed net, a household water filter for women or an individual filter for men, and, for those testing HIV+, a three-month supply of cotrimoxazole and referral for follow-up care and treatment. Over seven days, 47,311 people attended the campaign with a 96% uptake of the multi-disease preventive package. Of these, 99.7% were tested for HIV (80% had previously never tested), of whom 4% tested positive. Three-hundred and eighty-six certified counsellors attended to an average of 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age and tended to correlate with an ended marriage and unemployment. Always using condoms with a non-steady partner was more common among HIV-infected women participants who knew their status compared to those who did not. The study concludes that integrated campaigns can efficiently cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services to help achieve various national and international health development goals.