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.
Equity and HIV/AIDS
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.
Published data on adherence to antiretroviral therapy (ART) in Kenya is limited. This study assessed adherence to ART and identified factors responsible for non-adherence in Nairobi. This is a multiple facility-based cross-sectional study, where 416 patients aged over 18 years were systematically selected and interviewed using a structured questionnaire about their experience taking ART. Additional data was extracted from hospital records. Overall, 403 patients responded: 35% males and 65% females, of whom 18% were non-adherent, and the main (38%) reasons for missing therapy were being busy and forgetting. Accessing ART in a clinic within walking distance from home and difficulty with dosing schedule predicted non-adherence. The study found better adherence to HAART in Nairobi compared to previous studies in Kenya. However, the authors argue that adherence can be improved further by employing fitting strategies to improve patients' ability to fit therapy into their lifestyles and implementing cue-dose training to impact forgetfulness. Further work to determine why patients accessing therapy from ART clinics within walking distance from their residence did not adhere is recommended.
In this study, researchers evaluated the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting in western Kenya. The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High risk express care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of [less than or equal to]100 cells/mm3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of [less than or equal to]100 cells/mm3 were eligible for enrolment into HREC and for analysis. Between March 2007 and March 2009, 4,958 patients initiated cART. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality, and reduced loss to follow up compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up. The researchers conclude that frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.