Little is known about antiretroviral therapy (ART) outcomes in prisoners in Africa. To address this gap, researchers conducted a retrospective review of outcomes of a large cohort of prisoners referred to a public sector, urban HIV clinic. A total of 148 inmates (133 male) initiated on ART were included in the study. By week 96 on ART, 73% of all inmates enrolled in the study and 92% of those still accessing care had an undetectable viral load. By study end, 96 (65%) inmates had ever received tuberculosis (TB) therapy with 63 (43%) receiving therapy during the study: 28% had a history of TB prior to ART initiation, 33% were on TB therapy at ART initiation and 22% developed TB whilst on ART. Nine (6%) inmates died, seven in the second year on ART. While inmates responded well to ART, there was a high frequency of TB/HIV co-infection. The authors recommend that attention should be directed towards ensuring eligible prisoners access ART programmes promptly and that inter-facility transfers and release procedures facilitate continuity of care. Institutional TB control measures should remain a priority.
Equity and HIV/AIDS
In March 2012, the World Bank issued a report: ‘The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda’. The report, the author of this article argues, is not new because it represents a recurrent theme in the World Bank approach from the earliest days of the global AIDS pandemic – it’s not fiscally sustainable to treat people living with HIV in high-impact, low-resource countries – instead the world must focus on prevention measures. The author disagrees, and points out a number of significant flaws in the report. First, the report is already out of date since it relies almost exclusively on pre-2009 data and fails to take into account increased efficiencies in AIDS programming, which have been significant in the past several years. The World Bank has also ignored the exciting new research that shows that suppressive anti-retroviral therapy reduces the risk of onward transmission of HIV by at least 96%. Second, there is growing evidence, again ignored by the Bank, that even a moderate expansion of investments now in treatment scale-up and in diffusion of scaleable prevention methods like condoms and needle-exchange can have significant impacts on new infections and thus future treatment costs. Third, the Bank fails to use evidence to rally support for (unspecified) “prevention” activities and does not call for innovative global financing, like a financial transaction tax. Fourth, the report appears to neglect the economic and social benefits of a healthier population and to ignore some of the costs of premature deaths by focusing on fiscal costs of treatment, while ignoring the huge social and economic benefits of the survival of the vital age 25-45 cohort.
In November 2011, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) announced that its next scheduled funding round was cancelled. This report draws on recently collected field data from numerous countries where the International HIV/AIDS Alliance operates to explain why AIDS funding crisis requires urgent action. The authors note that countries like Zambia and Zimbabwe have so far been making strong progress towards reducing HIV infections and AIDS-related deaths but this progress is now under threat. The cancellation of funds will seriously affect the scale-up of the worldwide HIV response and important existing services will be reduced or eliminated in the absence of urgent measures. They argue that the Global Fund is the best mechanism the world has for realising the possibility of a world without AIDS but can only do so with sufficient investment. They recommend that external funders and other stakeholders must act very quickly to maintain and scale up critical HIV services so that lives are not put at risk, particularly ensuring that interventions with the highest impact on the epidemic are supported. In addition, national governments must increase investment in their own HIV responses and in the implementation of national AIDS strategies.
This study in Mombasa Kenya explored sexual behaviours of people living with HIV (PLHIV) who are not receiving any HIV treatment. Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships. Main risk factors associated with unsafe sex were found to be non-disclosure of HIV status, stigma and the belief that condoms reduce sexual pleasure. In conclusion, high-risk sexual behaviours were found to be common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. The authors urge government to identify and reach this population to provide health services.
In this report, the authors calculate and analyse the fiscal costs of HIV and AIDS for Botswana, South Africa, Swaziland and Uganda, interpreting the HIV and AIDS response as a long-term fiscal commitment, and including certain costs such as specific social grants that are not normally included in HIV and AIDS costing studies. From a microeconomic perspective, the authors calculate, for each country, the fiscal commitment that, under the parameters of the national HIV and AIDS programme, is incurred by a single HIV infection. Similarly, they calculate costs and savings associated with HIV and AIDS-related interventions, concluding that these costs can be substantial, nearly equal to GDP per capita (South Africa) up to 12 times GDP per capita (Uganda). On the macroeconomic level, they aggregate the costs incurred by new infections to track the evolving fiscal burden of HIV and AIDS over time. They found that newly incurred costs are generally lower than current spending, and that the fiscal burden of HIV and AIDS is declining over the projection period, perhaps reflecting a projected decline in HIV incidence. At the same time, the fiscal costs remain large, and increasingly reflect the success or failure of the HIV and AIDS programme in preventing new infections.
Uganda's HIV and AIDS prevalence rate has risen slightly from 6.4% to 6.7% among adults aged between 15 and 49, according to the government’s recently released national AIDS Indicator Survey. HIV prevalence for women stands at 7.7%, with men at 5.6%. The Ministry of Health argues that the increase is small and is due to HIV-positive children growing up and entering the age bracket of 15 to 19 years old. However, activists are concerned that the lack of progress indicated by the new statistics is the result of gaps in the government's HIV prevention programmes, such as lack of supplies like condoms. They are also becoming increasingly concerned about risk compensation as a result of failing HIV prevention messages, especially since the survey found that just 28.1% of women and 31.4% of men aged between 15 and 19 used a condom during their last sexual encounter, dropping to 6.7% and 12.2% respectively among 30- to 39-year-olds. The full report is due for release in June 2012.
This book tracks the progress and pitfalls of the global fight against HIV and AIDS over the past 30 years. The book's strength lies in its methodical documenting of the medical community's response to the virus. Harden also seeks to explain how political and cultural ideas influenced the science of AIDS. In specific instances, such as explaining how stigma about a sexually transmitted disease initially associated with the gay community hampered early research in the United States, she succeeds. But she does not make the same effort to explain later shifts in political perceptions. There is very little discussion of former President George W Bush's decision to launch the President's Emergency Plan for AIDS Relief, for instance, or what impact it had. At a time when the US is projecting a vision of an AIDS-free generation, Harden's history shows that constant monitoring and new perspectives remain critical. She reminds us that the world only arrived at the idea of an AIDS-free generation through constant trial-and-error: first, in determining the causes and later in producing effective therapies to prolong the lives of infected people.
Zimbabwe's ambitious plan to offer an HIV test to every household in the country is not yet under way but is already being met with scepticism by activists who feel this is not a priority for the country, especially with global HIV and AIDS funding on the decline. Zimbabwe Lawyers for Human Rights has warned of the possibility of compromising on informed consent and confidentiality when testing is done on a large scale. If not properly executed, ostracism, violence, stigma and abuse in the home can result from status disclosure. Door-to-door testing was successfully conducted in Uganda between 2005 and 2007, but Lesotho’s proposed door-to-door testing campaign has been criticised by researchers as substandard. Activists ask where additional funding will be found for the campaign, arguing that resources should instead be used for those who have already been identified as HIV positive and who need treatment now. They have also raised concerns about whether the testing campaign will go beyond merely testing people, and whether it will motivate them to change their sexual behaviours and also refer those testing positive to treatment facilities.
Paediatric antiretroviral adherence is difficult to assess, the authors of this paper argue, and subjective measures are affected by reporting bias, which in turn may depend on psychosocial factors such as alcohol use and depression. In this study, they enrolled 56 child caregiver dyads from Cape Town, South Africa, and followed their adherence over one month via various methods. The Alcohol Use Disorder Inventory Tool and Beck Depression Inventory 1 were used to assess participants’ alcohol use and levels of depression and their effect on drug adherence. The median age of the children was four years, and median time on antiretroviral therapy (ART) was 20 months. Increased time on ART was associated with poorer adherence via three-day recall. Alcohol use was inversely associated with adherence. Having a mother as a caregiver and shorter time on highly active antiretroviral therapy (HAART) were significantly associated with better adherence. The authors conclude that paediatric adherence is affected by caregiver alcohol use, but the caregiver’s relationship to the child is most important. This small study suggests that interventions should aim to keep mothers healthy and alive, as well as alcohol-free.
The objective of this study was to report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal, South Africa. Mothers with infants aged ≤16 weeks and fathers or legal guardians with infants aged 4–8 weeks who, between May 2008 and April 2009, attended immunisation clinics in six districts of KwaZulu-Natal were included. Findings indicated that, of the 19,494 mothers investigated, 89•9% reported having had an HIV test in their recent pregnancy. Of the 19,138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7,981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission and suggest that the elimination of paediatric HIV infections is feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.