This ethnographic study in Dzivaresekwa district, Harare, Zimbabwe, examines the issue of sexuality among the elderly and their challenges in accessing information, education, and communication (IEC) campaigns in the face of HIV and AIDS. The research depended heavily on collecting life histories through key informant interviews. The theory of structuration as proposed by Anthony Giddens was adopted as a framework to analyse the findings. The findings reveal that although the sample of elderly people in Dzivaresekwa district were sexually active, HIV/AIDS-related interventions in the form of IEC campaigns mainly focus on the age group of 14–49-year-olds, and otherwise consider the elderly only as a group indirectly affected by the epidemic and less at risk of HIV infection. This is mainly a result of society’s presumption that people withdraw from sexual life with advanced age. Thus, the elderly are incorrectly regarded as sexually inactive and not susceptible to contracting sexually transmitted infections. A fuller understanding of the sexuality of the elderly is important to increase the usefulness HIV/AIDS efforts, while IEC campaigns that target them are still needed.
Equity and HIV/AIDS
In this study, the authors explored acceptability of child transmission (PMTCT) programme components and identified structural and cultural challenges to male involvement in pregnancy and childbirth in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used, including focus group discussions with fathers and mothers, in-depth interviews with fathers, mothers and health personnel, and a survey of 426 mothers bringing their four-week-old infants for immunisation at five reproductive and child health clinics. Routine testing for HIV of women at the antenatal clinic was found to be highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance. Very few men joined their wives for testing and thus missed out on PMTCT counselling. The main barriers reported were that women did not have the authority to request their husbands to test for HIV and that the arena for testing, the antenatal clinic, was defined as a typical female domain where men were out of place. The authors conclude that deep-seated ideas about gender roles and hierarchy are the major obstacles to male participation in the PMTCT programme. Empowering men to participate by creating a space within the PMTCT programme that is male friendly should be feasible and should be highly prioritised for the PMTCT programme to achieve its potential.
Three international organisations have negotiated reductions on key first- and second-line, and paediatric antiretrovirals (ARVs) that will help countries save at least US$600 million over the next three years: the Clinton Health Access Initiative (CHAI), the international drug purchasing facility UNITAID and the UK Department for International Development (DFID). The deal, expected to affect most of the 70 countries comprising CHAI's Procurement Consortium, features notable reductions in the prices of tenofovir (TDF), efavirenz, and the second-line ritonavir-boosted atazanavir (ATV/r) used in HIV patients who have failed initial, or "first-line", regimens. As part of the deal, the three bodies set price ceilings for more than 40 adult and paediatric ARVs with eight pharmaceutical manufacturers and suppliers, which account for most ARVs sold in countries with access to generic drugs. As a result, the cost of ATV/r is down by two-thirds from just three years ago. Meanwhile, a once-a-day fixed-dose combination (FDC) pill containing TDF and efavirenz will now cost countries less than US$159 per patient per year. In 2008, low-income countries paid about $400 per patient per year for the same pill.
The authors of this paper studied how increased access to antiretroviral therapy affects sexual behaviour, using data collected in Mozambique in 2007 and 2008. They surveyed both HIV-positive individuals and households from the general population. The findings support the hypothesis of disinhibition behaviours, where individuals are more likely to engage in risky sexual behaviour when they believe that they will have greater access to better health care, such as antiretroviral therapy. The findings suggest that scaling up access to antiretroviral therapy without prevention programmes may lead to more risky sexual behaviour and ultimately more infections. The authors conclude that with increased antiretroviral availability, prevention programmes need to include educational messages so that individuals know that risky sexual behaviour is dangerous.
According to this paper, a growing number of studies highlight men's social disadvantage in making use of HIV services. Drawing on the perspectives of 53 ARV users and 25 healthcare providers, researchers examined qualitatively how local constructions of masculinity in rural Zimbabwe impact on HIV testing and treatment uptake. They found that informants reported a clear and hegemonic notion of masculinity that required men to be and act in control, to have know-how, be strong, resilient, disease free, highly sexual and economically productive. However, such traits were in direct conflict with the 'good patient' persona who is expected to accept being HIV positive, take instructions from nurses and engage in health-enabling behaviours such as attending regular hospital visits and refraining from alcohol and unprotected extra-marital sex. This conflict between local understandings of manhood and biopolitical representations of 'a good patient' can provide a possible explanation to why so many men do not make use of HIV services in Zimbabwe. The researchers urge HIV service providers to consider the obstacles that prevent many men from accessing their services.
The authors of this study aimed to increase case-finding of infection with human immunodeficiency virus (HIV) in Zambia and their referral to HIV care and treatment by supplementing existing client-initiated voluntary counselling and testing (VCT), the dominant mode of HIV testing in the country. Lay counsellors offered provider-initiated HIV testing and counselling (PITC) to all outpatients who attended primary clinics and did not know their HIV serostatus. After the addition of PITC to VCT, the number tested for HIV infection in the nine clinics was twice the number undergoing VCT alone. Over 30 months, 44,420 patients were counselled under PITC and 31,197 patients, 44% of them men, accepted testing. Of those tested, 21% were HIV+; 38% of these HIV+ patients enrolled in HIV care and treatment. The median time between testing and enrolment was 6 days. The acceptability of testing rose over time. In conclusion, the introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing. Moreover, PITC was incorporated rapidly into primary care outpatient departments. Maximizing the number of patients who proceed to HIV care and treatment remains a challenge and warrants further research.
The introduction of the South African government's HIV tests on schoolchildren has been delayed by legal and confidentiality concerns, but officials insist a pilot project will start later in the year. After the national Department of Health announced the planned testing in January 2011, a pilot project to test pupils, voluntarily, was due to start at several schools in February. But it was shelved because crucial ethical and legal questions had not been answered. A team was set up to test the feasibility of the project, but four months later it has still not completed its research and consultations. Most teachers' unions and parents' organisations supported the proposal in principle, saying HIV screening could help curb the spread of HIV and reduce teenage pregnancies. But some expressed misgivings about how it might affect pupils and the learning environment. Parents must consent to tests and counselling must be provided by the schools.
The authors of this study reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). They identified 19 articles published in nine journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings, as measured against accepted international benchmarks. The authors conclude that interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses should focus on local assessment of rapidly evolving HIV MTCT options, strategies to improve coverage and reach underserved populations, evaluation of a more comprehensive set of MTCT approaches, and the integration of HIV MTCT and other sexual and reproductive health services.
Since 2000, access to antiretroviral drugs to treat HIV infection has dramatically increased to reach more than five million people in developing countries. Essential to this achievement was the dramatic reduction in antiretroviral prices, the authors of this paper argue, which was a result of global political mobilisation that cleared the way for competitive production of generic versions of widely patented medicines. Despite these promising changes, a "treatment timebomb" awaits, the authors warn. First, increasing numbers of people need access to newer antiretrovirals, but treatment costs are rising since new ARVs are likely to be more widely patented in developing countries. Second, policy space to produce or import generic versions of patented medicines is shrinking in some developing countries. Third, funding for medicines is falling far short of needs. Expanded use of the existing flexibilities in patent law and new models to address the second wave of the access to medicines crisis are required. One promising new mechanism is the UNITAID-supported Medicines Patent Pool, which seeks to facilitate access to patents to enable competitive generic medicines production and the development of improved products. Such innovative approaches are possible today due to the previous decade of AIDS activism. However, the Pool is just one of a broad set of policies needed to ensure access to medicines for all; other key measures include sufficient and reliable financing, research and development of new products targeted for use in resource-poor settings, and use of patent law flexibilities. Governments must live up to their obligations to protect access to medicines as a fundamental component of the human right to health.
The objective of this paper was to quantify the deaths from human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) that are misattributed to other causes in South Africa’s death registration data and to adjust for this bias. Differences between global and South African relative death rates were used to identify the causes to which deaths from HIV and AIDS were misattributed in South Africa and quantify the HIV and AIDS deaths misattributed to each. These deaths were then reattributed to AIDS. In South Africa, deaths from HIV and AIDS are often misclassified as being caused by 14 other conditions. Whereas in 1996–2006 deaths attributed to HIV and AIDS accounted for 2.0–2.5% of all registered deaths in South Africa, the analysis shows that the true cause-specific mortality fraction rose from 19% to 48% over that period. More than 90% of HIV and AIDS deaths were found to have been misattributed to other causes during 1996–2006. In conclusion, adjusting for cause of death misclassification, a simple procedure that can be carried out in any country, can improve death registration data and provide empirical estimates of HIV and AIDS deaths that may be useful in assessing estimates from demographic models.